The characteristics of mothers at high risk of obstetric intervention in the Millennium Cohort Study

Holly Nicole Essex

hne100@york.ac.uk, Department of Health Sciences, University of York

Background: The UK has one of the highest rates of caesarean section (CS) in the world, and this has continued to increase over the past decades, with no associated decrease in numbers of instrumental births, and no improvement in perinatal outcomes. CS and other interventions in childbirth represent a psychological risk to mothers, a physiological risk to both mothers and babies and a substantial cost to the NHS. There is a need to understand this trend of increased intervention and reverse it.

Objective: To identify the demographic, psychosocial and clinical characteristics of women who have high rates of intervention at birth.

Methods: The sample consisted of 18,238 natural mothers of infants from the Millennium Cohort Study. Multivariable regression models, stratified by parity, were used to examine socio-demographic, cultural, socio-economic, psychosocial and pregnancy characteristics in relation to mode of birth.

Results: Among primiparous mothers, all types of intervention (instrumental delivery, planned CS and emergency CS) were more likely with increasing maternal age and for mothers who had clinical problems during pregnancy. Instrumental births were more likely for mothers with lower occupational status, and less likely for mothers who were Black, Hindu, closely involved with the father of the baby. Planned CSs were more likely for Pakistani or Bangladeshi origin and for mothers who never saw their own mother, and less likely for Muslim and low income mothers. Emergency CSs were less likely for Pakistani or Bangladeshi mothers, Black mothers and mothers who were closely involved with the father of the baby. Among multiparous mothers, increasing maternal age and clinical problems during pregnancy were more likely for all types of intervention. Instrumental births were also more likely for Indian, mixed race and low income mothers. Planned CSs were more likely for other non-Christian mothers, and less likely for mothers whose parents ever separated. Emergency CSs were more likely for mothers of “other” ethnic background.

Conclusion: Maternal age, ethnic identity, socio-economic status and family relationships were all significantly related to mode of birth. An understanding of the characteristics of women at high risk of intervention is crucial to developing and providing appropriate and high quality maternity services.

My research is interdisciplinary as it is social epidemiology; an investigation into how health, social and psychosocial factors relate to obstetric interventions. Discovering who the women are who are most at risk of intervention in birth will also have the potential to influence policy.

How Acupuncturists Envision Treating IBS

Tracy Stuardi

tls504@york.ac.uk, Department of Health Sciences, University of York

Purpose: The study’s purpose is to relate how acupuncturists envision treating IBS in routine practice to the treatments they actually deliver as part of a pragmatic trial of acupuncture for IBS.

Methods: In-depth interviews based on a flexible topic guide were used to access acupuncturist views on potential treatments. A purposive sample of acupuncturists, with membership in the British Acupuncture Council and a background in traditional Chinese medicine, was invited to participate. Data were analyzed using a thematic framework approach. The second part of the research question – exploring what acupuncturists actually delivered – was addressed using extracted material from acupuncturists’ log books, which was then (or will be) compared to material from the interviews.

Results: Twelve acupuncturists completed an in-depth interview. Acupuncturists acknowledged that patients rarely mention IBS as their primary complaint, but as many as half of their patients have irregular bowel symptoms. Additionally acupuncturists agreed on several commonly encountered diagnoses based on TCM principles and the importance of diagnosis in influencing treatment principle, point selection, use of additional therapies (i.e. moxa), and dissemination of lifestyle advice. The trial of acupuncture for IBS, which will provide results for the second part of the research question, began in October 2008. Since this is a pragmatic trial, we expect treatments to be highly individualized as indicated by the interviews. The treatments themselves may vary from the ones described due to the fact that trial participants will have a known diagnosis of IBS, which is not commonly encountered in routine practice.

Conclusions: Although there was some repetition of diagnoses and points selected, acupuncturists maintained that understanding each individual case was essential to determining the treatment to be delivered. Thus researchers may make generalizations about the treatment of IBS with regard to acupuncture, however each patient will receive a treatment based on his/her needs. Whether this notion correlates with the treatments delivered in the trial is under evaluation.

Why this study has relevance interdisciplinary: This study is directly relevant to the health sciences because it explores the delivery of a treatment modality for IBS. Additionally this study is relevant to the social sciences because it explores what influences the acupuncturists’ decisions and actions regarding treatment.

Comparing economic and non-economic outcome measurements in the evaluation of drug misuse intervention

Stacey Ching-Wen Chang

cc544@york.ac.uk. Department of Health Sciences, University of York

Background

In current cost-effectiveness analysis of drug misuse intervention there are a number of different outcome measurements that are carried out independently of one another. It is not clear the extent to which these are related to and compliment each other or are measuring independent domains.

Aim

The aim of this research is to explore the relationship between economic outcomes and non-economic outcomes and examine the implications for drug misuse policy.

Method

The research consists of a systematic review and secondary data analysis of existing studies. Both economic outcomes and non-economic outcomes are examined.

The WHO’s International Classification of Functioning, Disability and Health (ICF) is used as the classification system to identify the different constructs of outcome measurements. This involves considering how at a theoretical level the different constructs that are used are related and then analysing whether the measurements that are used reflect and illustrate these relationships.

Results

The results show that some ICF concepts are measured both in economic and non-economic outcomes, particularly in the body function category and activities and participation category.

Most questionnaire items that are categorised in the same ICF concepts are correlated. Items from the Social Satisfaction Questionnaire are not correlated with items from other outcome measurements, due to the different approaches for determining the outcome.

Conclusion

That existing research on drug intervention may not necessarily be measuring adequate outcomes because it fails to take into account certain relationships between outcome domains. The relationships between the different individual outcome domains that are measured should be considered in a research. This research has interdisciplinary relevance across economic and psychological theories, and the results carry important implications for health policy.

A systematic review of randomised controlled trials of interventions to change maladaptive illness beliefs in patients with coronary heart disease

Lucy Goulding

lg529@york.ac.uk. Department of Health Sciences, University of York

Background: Many people with coronary heart disease (CHD) report poor functional and psychological status. An increasing body of evidence suggests that some of these difficulties may arise as a result of maladaptive illness beliefs such as ‘exercise is bad for CHD, I must rest and take it easy’. The effectiveness of interventions which are designed to change maladaptive beliefs in people with CHD is unknown.

Aims: The purpose of the systematic review was to investigate whether interventions to change maladaptive illness beliefs are effective in changing beliefs and other behavioural, functional and psychological outcomes in people with CHD, and thus to establish which types of intervention are most effective.

Methods: A systematic review was conducted in order to assimilate the results of RCTs of interventions to change maladaptive illness beliefs in people with CHD using a transparent method which minimises bias.

Results: Thirteen randomised controlled trials met the inclusion criteria. These studies varied in terms of participants, interventions, outcome measures, outcomes and study quality. Due to this heterogeneity, quantitative synthesis was not practicable, thus descriptive synthesis was undertaken.

Conclusions: Descriptive synthesis of the results suggested that it is possible to devise interventions to change maladaptive illness beliefs in people with CHD. Cognitive behavioural interventions may be particularly effective and counselling and / or educational interventions can be effective in some circumstances. The review was not able to reveal whether interventions to change maladaptive cognitions result in positive behaviour change or improved functional or psychological outcomes in people with CHD. The quality of studies that have been conducted in this area is mixed. The poor quality of some of the included trials in addition to unreliable outcome measures mean that the results included in the present review may be subject to methodological bias. There may also be publication bias due to lack of a search for studies not written in English. It is therefore important to interpret the results of the review with caution. Perhaps the most important finding of the present review is that there is a lack of good quality randomised controlled trials investigating the efficacy of maladaptive belief change interventions for people with CHD.

Can rich areas be bad for the health of the poor? The protective effect of living amongst one’s own.

Christo Albor [1], Dimitris Ballas [2], Richard Wilkinson [3], and Kate Pickett [1].

ca533@york.ac.uk 1Department of Health Sciences, University of York; 2Department of Geography, University of Sheffield, UK;  3Division of Epidemiology and Community Health, University of Nottingham Medical School

Aim: To find whether poor mothers and their infants have better or worse health in richer areas.

Health Outcomes: Self-rated health, limiting long-term illness (LLI), low birthweight (LBW), and preterm delivery.

Design: Analysis of 14,465 white mothers in the UK. Neighbourhood ‘poor’ density was measured by area-level measures of income: for the UK, neighbourhood income ranks from the index of multiple deprivation; for subset of 7,288 mothers in England, raw neighbourhood income scores. Analyses were stratified by poor (<£10,400) and non-poor households. Age, marital status, parity, urban status, and duration at address were controlled for. Further models additionally adjusted for occupation and education.

Results: For poor mothers, odds for LBW and LLI increased for every decile of area income, by 9% and 8%. For non-poor mothers – odds decreased 6% and 5% (LLI non-sig.). In the subset analysis, for poor mothers, the area income relationship with LLI and LBW remained positive but LBW lost significance. Self-rated health did not vary significantly for poor mothers. For non-poor mothers, better self-rated health was associated in richer areas. Odds of preterm delivery decreased for poor mothers by 7% per decile, but this was not significant in further models. No preterm delivery models were significant for non-poor mothers.

Conclusion: Except preterm delivery, the health of non-poor mothers improve when living in richer areas. This is not the case for poor mothers, who do not have better self-rated health and have worse odds for LBW and LLI in richer areas.

These findings support a psycho-social explanation mediated by neighbourhood socio-economic density. Understanding the underlying mechanisms require input across biological, psychological and sociological fields. Through collaboration, intermediate pathways such as social engagement and socio-relational stress could be more effectively tested.

Knowledge of HIV among multidisciplinary community-clinic workers in Chile: Disparities by occupational risk and educational level

Baltica Cabieses [1], Lilian Ferrer [2], Kathleen Norr [3], Helena Tunstall [4], Kate E. Pickett [1] & Christo Albor [1]

bbcv500@york.ac.uk. 1Department of Health Sciences, University of York, UK; 2School of Nursing, Pontificia Universidad Católica, Chile; 3College of Nursing, University of Illinois, Chicago, US.

Background: HIV is a growing health problem in Chile and no particular prevention strategy has been targeted to multidisciplinary primary-care setting.

Aim: To analyse the level of knowledge of HIV by occupational risk and educational level of community-clinic workers in Chile.

Methods: Cross-sectional survey of 720 community-clinic workers in Santiago.

Outcome: Knowledge of HIV; Educational level.

Exposures: Occupational risk of HIV

Controls: age, marital status and religion.

Descriptive analysis was conducted through proportions/averages estimation and association analysis through Chi-square tests and logistic regression.

Results: Community-clinic workers showed significant differences in knowledge of HIV by educational level (p<0.001), with a higher level of knowledge among those with higher levels of education (OR=2.5, 95% CI=1.7-3.4).

When stratifying knowledge by occupational risk of HIV, 63.8% of those at risk showed an adequate level of knowledge, in contrast to 36.1% of those not at risk (OR=3.3, 95%CI=2.2-5.0, p<0.0001). However, within the group occupationally at risk, most dental/health care assistants and cleaners reported an inadequate level of knowledge, while most in professional occupations had adequate level (p<0.0001).

Discussion: Level of knowledge of HIV among community-clinic workers in Chile varied significantly. Community-clinic workers educated up to high-school level and with occupational risk of HIV should be urgently trained to increase their knowledge and reduce their potential risk.

Conclusions: The interpretation and application of our findings would benefit from inter-disciplinary collaboration. They provide further understanding of the reasons for the disparity in HIV knowledge across occupations. However, determining practical and effective educational strategies still require a deeper assessment of other socio-political and economic dimensions.