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.

Addressing the social significance of HIV

George Shirreff

george.shirreff07@ic.ac.uk. Department of Infectious Disease Epidemiology, Imperial College, London

Addressing the social significance of HIV is essential in understanding and preventing its spread and alleviating its impact on the population.

HIV infections are often most prevalent among hard-to-reach populations such as intravenous drug users and commercial sex workers. This creates challenges for identifying and treating individual infections, and it is also difficult to estimate the prevalence of the infection and the effectiveness of interventions. Many with HIV infection experience considerable stigma and this is a barrier both to human well-being and to control of the epidemic. Social reactions to HIV are also important in assessing the impact of changes to behaviour such as condom use or other sexual risk factors. For example, how does condom use change following a test, either with a positive or negative result.

In most cases, the spread of HIV is highly dependent on sex and therefore sexual networks. Network science is an emerging field and is essential to epidemiology of HIV infection. The spread of HIV through sexual networks is dependent on many aspects of the network such as number of partners, heterogeneity of sexual behaviour and concurrency of multiple partnerships. The spread of other sexually transmitted infections is also important as a risk factor for HIV.

In countries where HIV prevalence is extremely high, as in sub-Saharan Africa, the infection devastates the working age population. Large quantities of orphans and a shortage of teachers are among the more direct effects of the premature deaths caused by AIDS.

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.

Policy Decisions and Community Participation in Health: Understanding the public’s view of the National Health Insurance Scheme (NHIS)

Gina Teddy

gt501@york.ac.uk, Department of Social Policy and Social Work, University of York

Background and Aims: Government response to public concerns has been to develop policies to deal with them. Policy makers are increasingly designing strategies to address public needs and problems. With regard to health policies, governments play significant roles in developing them and executing them. Meanwhile, policy recipients tend to have little or no role in the development and measurement of these policies. The public’s understanding of a policy affect how they respond to it and the outcome. Yet little has been done to involve them. This study explored the views and perceptions of community residents on their understanding and experience of the National Health Insurance Policy (NHIP) in Ghana. It tests how much the public knew about the policy, how that affect the response to healthcare use under the scheme, what additional information they require on NHIP and the significance of that knowledge to them, their decisions and reactions to it.

Data and Methods: A qualitative research was employed to explore participants’ views, using nine focus group discussions based on a purposive sampling of three districts with previous experience of community health financing. These discussions were set to include residents of: Dangme West; Kwahu West; and Nkoranza districts. Participants included both scheme and non-scheme members who are 18 years and above from various socio-demographic backgrounds. Each FGD consisted between 8-16 participants.

Results and Conclusion: Findings from the study showed that the public want to be adequately informed of health policies and decisions made at both the national and local levels. They noted that even though the NHIP require their participation at the community level and affect their decision on healthcare, they have very vague information on it. Policies tend to be imposed on them with little or no reference to their individual circumstances. As a result, membership to the scheme is challenged, despite the policy’s aim to improve healthcare access. And this is because the level of information and education about the scheme is very limited. The general public lack information on the NHIP and their place as members, so they tend to rely on uninformed sources. They, therefore, expressed interest in being informed of health policies undertaken locally and nationally. The study concluded that policy recipients must be included more in policy processes, especially, when it has direct impact on them. Policy makers and implementers must employ various means to communicate policy decisions to the best of their ability and beyond the general provision of advertisements.

The Training Needs Analysis of Syrian EFL Secondary School Teachers

Taha Rajab

tr535@york.ac.uk. Department of Educational Studies, The University of York

Background: The last two decades have witnessed a worldwide proliferation of inter-communication pedagogical practices in the field of education. Several studies have showed that the introduction of Communicative Language Teaching (CLT) curriculum in several developing countries is often not preceded by a systematic research-based needs analysis of both teachers and learners. Although such curricula ideally urges teachers to employ inter-communicative approaches, EFL teachers in Syria continue to teach in the grammar-translation approach dominated by: rote learning, recitation, translation, and the transmission of facts through teacher explanation with overwhelming predominance of teacher-fronted explanations and question-answer exchanges. The co-construction of knowledge is a shared responsibility between teachers and learners (Hardman, 2008).

Aim: The research is meant to begin to develop baseline about EFL Syrian secondary teachers: their background and training, their priorities, the problems they face in the classroom and the influence that the new CLT course guidelines have actually had on teaching practice. Also, it will fill a gap in research to date in the Syrian context to investigate how teachers interact with students in English classrooms over time.

It contributes to the world literature on the professional development of language teachers because achieving quality in English teaching necessitates training teachers to use interactive style of teaching.

Methods: A mixed method approach will be taken up. This would involve an array of methods like systematic computerized observation, digitally audio-visual observation, and post-observation interviews with teachers. The participants will be teachers at two Syrian urban schools, one average and one dedicated for the elite students. I will be working with 2 teachers in each school observing 4 lessons of each teacher over 2 or 3 months with the hope of generating a total of 16 observed lessons.

References:

Hardman, F. (2008) The Guided Co-construction of Knowledge. In M. Martin-Jones, A. M. de Mejia and N. H. Hornberger (eds.), Encyclopaedia of Language and Education (3) Discourse and Education, 253-263.

Emotional and Behavioural Problems of Pakistani Adolescents

Nazar Soomro and Jane Clarbour

nhs501@york.ac.uk. Department of Psychology, University of York

Background: Adolescents represent the largest portion of the Pakistani population and many display significant emotional and behavioural problems, which can have serious consequences for them and the wider society such as academic drop-out and failure, delinquency, drug abuse and unemployment.

Aim: The major aim of this study is to present the Emotional Behavioural Scale for Pakistani Adolescents (EBS-PA), a new measure of emotional and behavioural problems in Pakistani adolescents. A further aim of the study was to investigate the association of the new EBS-PA with the Urdu version of Strength and Difficulties Questionnaire (SDQ).

Methods: A cross-sectional research design was used. Data were collected from two private schools in Hyderabad, Sindh, Pakistan. The EBS-PA and SDQ were administered to 109 Year 8 students between 13-16 years. Teachers also rated 56 of these students on the SDQ-Teacher version.

Results/Findings: The EBS-PA subscales were found to be significantly correlated with the SDQ in the expected directions. For example, the EBS-PA Social Anxiety subscale was positively associated with the SDQ emotional symptoms, whereas EBS-PA Malevolent Aggression subscale was significantly correlated with conduct problems and hyperactivity. The EBS-PA Social self-esteem subscale was strongly negatively correlated with SDQ conduct problems.

The correlations between self and teacher ratings SDQ were found to be substantial particularly for the conduct problem and prosocial behaviour subscales. The highest level of difficulties identified with the SDQ were found for the conduct problems, peer problem and emotional problems subscales in the Pakistani adolescents. 21% and 30.4% were rated as abnormal by themselves and teachers respectively.

Discussion: There is a paucity of reliable and valid indigenous questionnaires to assess emotional and behavioural problems in Pakistani adolescents (Ahmer, Faruqui & Aijaz, 2007). Thus, the new EBS-PA scales will be useful to identify children who are in the early stages of developing emotional and behavioural problems for early intervention and support.

Conclusion: A significant number of Pakistani adolescents show emotional and behavioural problems. Thus, EBS-PA will be used for screening purposes in schools as well as in clinical settings. In addition, it will also facilitate to estimate the prevalence of emotional and behavioural problems in Pakistan.

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.