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This study investigated the beliefs held by survivors of a heart attack about the causes of heart attacks. A survey of survivors was carried out in six coronary care units involved in the Anglo-Scandinavian Study of Early Thrombolysis (ASSET). The results were based on 1283 returned questionnaires. Stress or worry were nominated by most people (66 per cent). Only 22 per cent of all patients named smoking as a cause of heart attacks (28 per cent among smokers). Smokers who named smoking as a cause were not significantly more likely to stop smoking within a month than smokers who did not nominate it (78 per cent versus 73 per cent, respectively). The findings were compared to those from a survey of the general population; knowledge of established risk factors was poor in both populations. Smokers were more aware of smoking as a cause than non-smokers in both populations but this knowledge did not appear to affect smoking behaviour soon after the heart attack in the survivors. There were substantial differences in the level of knowledge of some risks in those from lower social classes in the survivor group. Health promotion activity in survivors need not be substantially different from that delivered to the general population but needs to impart more than just knowledge of risk factors to be effective. Survivors who are in lower social classes may have a poorer knowledge base and present a particular challenge. [ABSTRACT FROM AUTHOR]

Background: Delays seeking care worsen the burden of tuberculosis and cost of care for patients, families and the public health system. This study investigates costs of tuberculosis diagnosis incurred by patients, escorts and the public health system in 10 districts of Ethiopia., Methods: New pulmonary tuberculosis patients > or = 15 years old were interviewed regarding their health care seeking behaviour at the time of diagnosis. Using a structured questionnaire patients were interviewed about the duration of delay at alternative care providers and the public health system prior to diagnosis. Costs incurred by patients, escorts and the public health system were quantified through patient interview and review of medical records., Results: Interviews were held with 537 (58%) smear positive patients and 387 (42%) smear negative pulmonary patients. Of these, 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. The mean (median) days elapsed for consultation at alternative care providers and public health facilities prior to tuberculosis diagnosis was 5 days (0 days) and 3 (3 days) respectively. The total median cost incurred from first consultation to diagnosis was $27 per patient (mean = $59). The median costs per patient incurred by patient, escort and the public health system were $16 (mean = $29), $3 (mean = $23) and $3 (mean = $7) respectively. The total cost per patient diagnosed was higher for women, rural residents; those who received government food for work support, patients with smear negative pulmonary tuberculosis and patients who were not screened for TB in at least one district diagnostic centers., Conclusions: The costs of tuberculosis diagnosis incurred by patients and escorts represent a significant portion of their monthly income. The costs arising from time lost in seeking care comprised a major portion of the total cost of diagnosis, and may worsen the economic position of patients and their families. Getting treatment from alternative sources and low index of suspicion public health providers were key problems contributing to increased cost of tuberculosis diagnosis. Thus, the institution of effective systems of referral, ensuring screening of suspects across the district public health system and the involvement of alternative care providers in district tuberculosis control can reduce delays and the financial burden to patients and escorts.

Background: Little is known about the quality of tuberculosis (TB) service delivery in public health facilities in Ethiopia and its association with patients' non-adherence to TB treatment. This study assessed the organization, management and processes of TB care delivery, and their effects on patients' adherence to TB treatment., Methods: The quality of TB care was investigated in 44 public health facilities from three perspectives: structure, processes of TB care delivery and patient treatment outcome. Quality of care was determined by adherence to national TB guidelines. On-site observations of TB service delivery and interviews with health providers were conducted to evaluate structural factors. Patients (n = 237) in the health facilities were interviewed prospectively at completion of their treatment to determine the quality of tuberculosis care delivered. Three measures of treatment adherence [treatment interruption (>or=2 weeks), availability of unused TB drugs and treatment default] were quantified from a review of patient treatment registers and an audit of unused TB drugs at patients' homes. Effects were identified of poor quality structures and processes of service delivery on these three measures of adherence., Results: TB care providers were untrained in 18 (44%) of 44 facilities and daily outpatient TB care was not given in 13 of 44 (25%). Among the 237 patients, 43% interrupted treatment for >or=15 days and 30% had at least 1 day's dose of TB drugs unused. Patients tended to interrupt and default from treatment when their care provider had been inadequately supervised by district TB control experts and was incapable of dealing with patients' minor illnesses. Unavailability of daily TB care in health facilities was associated with missing daily doses., Conclusion: Better training of TB care providers and district supervisory support could be important interventions to improve the quality of care delivery and patient adherence to treatment.

Background: Delays seeking care increase transmission of pulmonary tuberculosis and hence the burden of tuberculosis, which remains high in developing countries. This study investigates patterns of health seeking behavior and determines risk factors for delayed patient consultation at public health facilities in 10 districts of Ethiopia., Methods: New pulmonary TB patients >or= 15 years old were recruited at 18 diagnostic centres. Patients were asked about their health care seeking behaviour and the time from onset of symptoms to first consultation at a public health facility. First consultation at a public health facility 30 days or longer after onset of symptoms was regarded as prolonged patient delay., Results: Interviews were held with 924 pulmonary patients. Of these, 537 (58%) were smear positive and 387 (42%) were smear negative; 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. Prior to their first consultation at a public health facility, patients received treatment from a variety of informal sources: the Orthodox Church, where they were treated with holy water (24%); private practitioners (13%); rural drug vendors (7%); and traditional healers (3%). The overall median patient delay was 30 days (mean = 60 days). Fifty three percent [95% Confidence Intervals (CI) (50%, 56%)] of patients had delayed their first consultation for >or= 30 days. Patient delay for women was 54%; 95% CI (54%, 58%) and men 51%; 95% CI (47%, 55%). The delay was higher for patients who used informal treatment (median 31 days) than those who did not (15 days). Prolonged patient delay (>or= 30 days) was significantly associated with both patient-related and treatment-related factors. Significant patient-related factors were smear positive pulmonary disease [Adjusted Odds Ratio (AOR) 1.4; 95% CI (1.1 to 1.9)], rural residence [AOR 1.4; 95% CI (1.1 to 1.9)], illiteracy [AOR 1.7; 95% CI (1.2 to 2.4)], and lack of awareness/misperceptions of causes of pulmonary TB. Significant informal treatment-related factors were prior treatment with holy water [AOR 3.5; 95% CI (2.4 to 5)], treatment by private practitioners [AOR 1.7; 95% CI (1.1 to 2.6)] and treatment by drug vendors [AOR 1.9; 95% CI (1.1 to 3.5)]., Conclusion: Nearly half of pulmonary tuberculosis patients delayed seeking health care at a public health facility while getting treatment from informal sources. The involvement of religious institutions and private practitioners in early referral of patients with pulmonary symptoms and creating public awareness about tuberculosis could help reduce delays in starting modern treatment.

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

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

Objective: To determine the effectiveness of extended trained ambulance personnel (paramedics) for the management of out of hospital cardiac arrest., Methods: A retrospective cohort study of patients who suffered a cardiac arrest between 1 January 1992 and 31 July 1994, and who were transported to their local accident and emergency (A&E) department. Data were collected on basic demography, operational time intervals, and ambulance crew status. Further clinical data were collected, and outcome measures included status on arrival at A&E, status on leaving A&E (hospital admission), and status on leaving hospital. The data were analysed using univariate and multivariate techniques., Results: Univariate analysis showed the likelihood of arriving in A&E with a return of spontaneous circulation was more than doubled among patients attended by a paramedic crew compared with those attended by technicians (relative risk = 2.48, 95% confidence interval 1.34 to 4.60). The likelihood of successful hospital admission was also significantly increased (RR = 1.92, 95% CI 1.13 to 3.27); however, beyond this point, further survival benefits appeared to be much smaller. Similar findings were revealed using multivariate analysis. Second level modelling revealed further possible differences between paramedic and technician crews according to type of incident. Patients successfully admitted to hospital who died before discharge remained severely disabled between admission and death., Conclusions: There are marked short term survival advantages after cardiac arrest associated with paramedic care, but these probably diminish rapidly over time.

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

Background: The role of psychosocial factors in the aetiology of coronary heart disease continues to be debated. Despite public perception of a major role for their effect, scientific opinion on their relevance remains divided. This paper reviews the literature on the influence of social support and life stress on coronary heart disease incidence and mortality., Methods: Observational studies published in English, based on over 100 human subjects from the general population, investigating life stress or social support were considered. Fourteen studies derived from MEDLINE searches on MeSH headings: coronary disease; stress, psychological; social support; social isolation; life change events. An equivalent search of BIDS and studies referenced by papers identified using these sources was carried out., Results and Conclusions: The review concludes that both life stress and social support were found to have an influence on coronary heart disease, social support more so than stress. Both have a stronger influence on coronary heart disease mortality than on initial incidence of clinical disease. Measures of the quality of support, in particular emotion support, show the largest effects. The review highlights problems in drawing conclusions from the available literature; in particular, the inconsistency in measures used to define the psychosocial factors. Further studies are needed to investigate interrelationships between stress and social support, and a recommendation is made to adopt pragmatic measures in future studies, which if proven to have an effect, may be open to modification.

Background: The elderly residents of nursing and old people's homes are at substantially increased risk from influenza and its complications. Annual vaccination is therefore strongly recommended by the UK Departments of Health. However, few data exist on the uptake of influenza vaccine in this setting; this was last estimated to be 45 percent in 1988-1989. A major epidemic of influenza A occurred in 1989-1990 which may have changed vaccination behaviours., Methods: A structured interview survey was conducted in 49 old people's homes in Nottingham to determine practices and policies for influenza vaccine. The medical records of 151 randomly selected elderly residents were examined to determine vaccine uptake in the 1992-1993 season., Results: Twenty-five homes (52.1 percent) claimed to operate a policy for influenza immunization but only 3 (12.0 percent) were written down and none set targets. Methods of vaccine promotion were generally weak. Accordingly, vaccine uptake was only 39.6% percent (95 percent confidence interval 33.2-46.0)., Conclusions: In contrast to other high-risk groups living in the open community, no improvement in influenza vaccine uptake has occurred in nursing and old people's homes since the late 1980s. Future attempts to increase vaccine uptake in this setting should focus on developing joint policies between general practitioners and home staff to facilitate better co-ordinated programmes of vaccine promotion and administration.

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

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

The prognostic importance psychosocial factors after acute myocardial infarction (AMI) is still debated. A fourfold increase in risk of mortality after AMI was reported for participants in the beta Blocker Heart Attack Trial who were described as being socially isolated and having high levels of life stress. This study was designed to determine the influence of social isolation and/or life stress on mortality after AMI in an English population. It was a follow-up study of a subset of patients recruited for the Anglo-Scandinavian Study of Early Thrombolysis (ASSET), between November 1986 and February 1988. The study group comprised 1,376 patients with suspected AMI (1,073 men and 303 women), from coronary care units in six English hospitals. Patients who were alive at 7 days and had completed a psychosocial questionnaire within seven days post-infarction were followed up for a median time of three years, the sole outcome measure being death from all causes. All deaths were notified by the National Health Service Central Registry (NHSCR). Cox's regression was used to allow for independent clinical prognostic factors such as age-group, previous documented infarct, complications in hospital, history of diabetes and history of hypertension. Socially isolated patients (in terms of lack of membership of any club or religious group or lack of contact with family and friends) were 49% more likely to die after an infarction than patients classified as not being socially isolated. While this statistic is of borderline significance it does suggest that such patients are at an increased risk of death after AMI. No associations with mortality risk were found with life-stress level, type A behaviour pattern or depression.

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

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

The outcome of 140 pregnancies complicated by unexplained abdominal pain was compared with that in a comparison group of 280 women who gave birth at the same time. The two groups were comparable for maternal age and parity but the study group contained a significantly higher proportion of smokers, unmarried women, and women whose partners were unemployed (P less than 0.001). All the pregnancies resulted in livebirths. There were no statistically significant differences in birthweight, gestational age at delivery or mode of delivery between the two groups.

In the largest survey of smoking in pregnancy to date in the United Kingdom, 3882 women attending the two antenatal clinics in Nottingham during July and August 1986, were asked about their smoking habits. Thirty-seven per cent of pregnant women were smoking and only one in four of these was successful at stopping at some point during pregnancy. However, 55 per cent of the mothers who smoked at the start of pregnancy claimed to smoke less during pregnancy. No change was reported in the habits of one-quarter of the mothers who smoked during pregnancy and this proportion may represent an 'irreducible minimum'. Mothers were more likely to continue to smoke if younger (14-20 years), single, living with a partner who smoked, who left school at 16 years and were from manual working families. Those who succeeded in giving up smoking during pregnancy were more likely to be from professional and managerial families. Antenatal booklets about the dangers of smoking were the source of information cited most frequently. Half of the smoking mothers claimed not to have received advice from their family practitioners about the hazards of smoking nor information about how to give up the habit. Even fewer received such advice from hospital doctors, or midwives. This represents a major challenge to professional training in health education.

An epidemiological study was carried out in the current Nottingham health district to determine changes in both neonatal unit workload and in the infants requiring neonatal care during two study periods. All admissions for 1977 and again for the 12 months 1 April 1983 to 31 March 1984 were reviewed. Total numbers of admissions have shown roughly a 50% reduction because of a more rigorous admission policy locally. The admissions of infants of 33 weeks' gestation or less have shown a significant increase, while the overall survival of infants less than 33 weeks' gestation has improved.

This study aimed to record the main reasons given by pregnant women for smoking and to observe how these varied by age, education, marital status, social class and level of tobacco consumption. The study involved 498 smoking mothers who were all new antenatal clinic attenders. Data were collected by self-completed questionnaire containing closed and open response items. The participation rate was 95%. Main reasons given for smoking in pregnancy included those related to mood control (i.e. to relax, calm down, enjoyment, out of boredom) and addiction. Pregnant women were more likely to smoke to control their mood if they were older and smoked less than ten cigarettes per day. They were more likely to give addiction as their reason for smoking if they were older. Pregnant women were also more likely to smoke due to boredom if they were single, especially divorced or separated, from unskilled or semi-skilled occupational groups and if their husband or partner was unemployed. The implications of the findings for health education are discussed.

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

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

A retrospective cohort study based on obstetric records was performed, to compare the use of analgesia/anaesthesia during labour by consultants and general practitioners. The episiotomy rates for the two groups were also compared. 111 general practitioner patients were identified and these were matched with 111 consultant patients. No difference was found between the two groups for duration of stages I or II. The rates for episiotomy, 1 degree or 2 degrees tear or intact perineum were the same in each group. Women delivered under consultant supervision used more entonox than women delivered under general practitioner care, but this was counterbalanced by an increased use of pethidine in the latter group. No difference was found between the two groups with regard to the use of epidurals. There was an increased use of local anaesthetic by general practitioners. This was due to general practitioners preferring to use local anaesthetic for suturing after an epidural had worn off, whereas hospital doctors preferred to top-up the epidural to provide anaesthesia for suturing. This study supports the view that women delivered under the care of their own general practitioner in a hospital obstetric unit fare no worse than similar women delivered under consultant supervision. The former group have the advantage of continuity of care from their general practitioner.

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

This further study of wartime gas-mask workers who were exposed to asbestos dust has shown that among those who worked with crocidolite there is a considerable excess of cases of mesothelioma, a more modest excess of bronchial carcinoma, but no excess of any other type of malignant disease. A dose-response relationship is established in the mesothelioma and bronchial carcinoma patients. It is not possible to base any conclusions on the limited data available for the small number of people exposed to chrysotile for a maximum period of five months. We believe that the identification and measurement of fibres in autoptic lung tissue from patients with accurately known occupational histories of asbestos dust exposure is useful, and a similar study on a population exclusively exposed to chrysotile would be of considerable interest.

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

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

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

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

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

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

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

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

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