Evaluation of the Healthy Start Voucher Scheme in UK: a natural experiment using the Growing Up in Scotland record linkage study and the Infant Feeding Survey

Background: Having a good start in life during pregnancy and infancy has been shown to be important for living both a healthy life and a longer life. Despite the introduction of many policies for the early-years age group, including voucher schemes, with the aim of improving nutrition, there is limited evidence of their impact on health. Objectives: To assess the effectiveness of the Healthy Start voucher scheme on infant, child and maternal outcomes, and to capture the lived experiences of the Healthy Start voucher scheme for low-income women. Design: This was a natural experiment study using existing data sets, linked to routinely collected health data sets, with a nested qualitative study of low-income women and an assessment of the health economics. Setting: Representative sample of Scottish children and UK children. Participants: Growing Up in Scotland cohort 2 (n = 2240), respondents to the 2015 Infant Feeding Study (n = 8067) and a sample of 40 participants in the qualitative study. Interventions: The Health Start voucher, a means-tested scheme that provides vouchers worth £3.10 per week to spend on liquid milk, formula milk, fruit and vegetables. Main outcome measures: Infant and child outcomes – breastfeeding initiation and duration; maternal outcomes – vitamin use pre and during pregnancy. Results: The exposed group were women receiving the Healthy Start voucher (R), with two control groups: eligible and not claiming the Healthy Start voucher (E) and nearly eligible. There was no difference in vitamin use during pregnancy for either comparison (receiving the Healthy Start voucher, 82%; eligible and not claiming the Healthy Start voucher, 86%; p = 0.10 vs. receiving the Healthy Start voucher, 87%; nearly eligible, 88%; p = 0.43) in the Growing Up in Scotland cohort. Proportions were similar for the Infant Feeding Study cohort (receiving the Healthy Start voucher, 89%; eligible and not claiming the Healthy Start voucher, 86%; p = 0.01 vs. receiving the Healthy Start voucher, 89%; nearly eligible, 87%; p = 0.01); although results were statistically significantly different, these were small effect sizes. There was no difference for either comparison in breastfeeding initiation or breastfeeding duration in months in Growing Up in Scotland, but there was a negative effect of the Healthy Start voucher in the Infant Feeding Survey. This contrast between data sets indicates that results are inconclusive for breastfeeding. The qualitative study found that despite the low monetary value the women valued the Healthy Start voucher scheme. However, the broader lives of low-income women are crucial to understand the constraints to offer a healthy diet. Limitations: Owing to the policy being in place, it was difficult to identify appropriate control groups using existing data sources, especially in the Infant Feeding Study. Conclusions: As the Healthy Start voucher scheme attempts to influence health behaviour, this evaluation can inform other policies aiming to change behaviour and use voucher incentives. The null effect of Healthy Start vouchers on the primary outcomes may be due to the value of the vouchers being insufficient to change the broader lives of low-income women to offer a healthy diet. Future work: The methods developed to undertake an economic evaluation alongside a natural experiment using existing data can be used to explore the cost-effectiveness of the Healthy Start voucher scheme. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 11. See the NIHR Journals Library website for further project information

Can physiological variables and early warning scoring systems allow early recognition of the deteriorating surgical patient?

Objective: Early warning scoring systems are widely used in clinical practice to allow early recognition of the deteriorating patient, but they lack validation. We aimed to test the ability of physiologic variables, either alone or in existing early scoring systems, to predict major deterioration in a patient’s condition and attempt to derive functions with superior accuracy. Design: A comparative cohort study. Setting: A teaching hospital in Scotland. Patients: Two cohorts of general surgical high-dependency patients. The cohorts are a group of surgical high-dependency care patients who did not require intensive care admission and another group of patients who did require admission. Interventions: None. Measurements and Main Results: Prospective physiologic data on consecutive surgical high-dependency unit patients were collected and compared with physiologic data on patients admitted to the intensive care unit from the same surgical high-dependency units. Data were quality checked and summarized, and discriminant analysis and receiver operator curves were used to discriminate between the groups. There were significant physiologic differences between groups with regard to heart rate (p < .001, area under the receiver operating characteristic curve [AUC] 0.7), respiratory rate (p < .001, AUC 0.71), and oxygen saturation (p < .001, AUC 0.78) across time points. This was not present for systolic blood pressure or temperature. Existing early warning scoring systems had good discriminatory power (AUC 0.83–0.86). We derived discriminant functions, which have a high predictive ability to determine differences between groups (p < .0001, AUC 0.86–0.90). We found that heart rate and respiratory rate could detect differences between groups at 6 and 8 hrs before ICU admission, but oxygen saturation and the discriminant function 2 could detect differences 48 hrs before ICU admission. Conclusions: Some commonly used physiologic variables have reasonable power in determining the difference between patients requiring intensive care unit admission, but others are poor. Existing early warning scores have comparatively good discriminatory power. We have derived functions with excellent predictive power in this derivation cohort

An N-of-1 study of daily alcohol consumption following Minimum Unit Pricing implementation in Scotland.

BACKGROUND AND AIMS: Within the context of Scotland's policy change to implement a Minimum Unit Price (MUP) per unit of alcohol sold in licenced premises, this study used an N-of-1 design to assess between person differences in the psychological and social factors associated with daily alcohol consumption. DESIGN: A mixed methods approach combined N-of-1 observational studies, comprising daily surveys followed by qualitative social network interviews (not reported here). Peer researchers with lived experience of substance use were involved in the study design and fieldwork. SETTING: Towns and rural areas in the East of Scotland. PARTICIPANTS/CASES: Twenty-five adults with current or recent history of alcohol dependence recruited for three 12-week waves: 11 in wave 1 (pre-MUP), 11 in wave 2 (pre and post MUP) and 3 in wave 3 (post MUP). MEASUREMENTS: Gender, age, alcohol and other drug use history. Daily surveys for 12 weeks captured information about factors in the last 24 hours, e.g., amount and type of alcohol consumed, stress, social contact. FINDINGS: Each participant was in the daily survey for a mean of 64 days (SD=42; median=59), with a response rate of 48%; 15 participants provided sufficient data for analysis. Factors related to daily alcohol consumption differed between individuals. Models suggested some individuals with high initial consumption reduced drinking after MUP, but explanatory factors differed, e.g. changing motivation was important for some while alcohol availability was important for others. CONCLUSIONS: Adapting N-of-1 methods for an observational study uncovered differences in alcohol consumption change before and after minimum unit pricing (MUP) implementation in Scotland, evidence of individual differences in the factors relating to alcohol consumption patterns, and some evidence that post-MUP consumption changes may be related to changing psycho-social factors

The outcome of prenatal identification of sex chromosome abnormalities

Objective: The outcome of a pregnancy following identification of a sex chromosome abnormality (SCA) is unclear. The aims of this study were to ascertain the prevalence of SCA detected prenatally in Scotland and to determine the outcomes for these cases. Design: Following retrospective identification of all prenatal karyotypes performed in Scotland between 2000 and 2012, data linkage was performed to obtain information regarding maternal characteristics and pregnancy outcomes. Detailed outcome data were also collected for all affected offspring in the West of Scotland and Grampian regions within Scotland. Results: Of the 28 145 pregnancies that had a karyotype over the study period, records were available for 27 152 (96%). Karyotype abnormalities were identified in 2139 (8%), with SCA being identified in 321(1%) tests. 45,X was identified as the commonest SCA in 135 pregnancies. Of 121 pregnancies with SCA in the West of Scotland and Grampian, 64 (53%), 52 (43%) and 5 (4%) led to a live birth, termination and intrauterine death, respectively. Of the 64 live births, 21 (33%) had a postnatal karyotype and 35 (54%) received specialist follow-up for the SCA that was identified prenatally. Conclusions: Abnormalities of sex chromosomes are identified in approximately 1% of all pregnancies that undergo a prenatal karyotype. There is a need to review the prenatal as well as postnatal care of the affected mother and offspring

Changes in Non-22-Kilodalton (kDa) Isoforms of Growth Hormone (GH) after Administration of 22-kDa Recombinant Human GH in Trained Adult Males

GH is being used by elite athletes to enhance sporting performance. To examine the hypothesis that exogenous 22-kDa recombinant human GH (rhGH) administration could be detected through suppression of non-22-kDa isoforms of GH, we studied seventeen aerobically trained males (age, 26.9 ± 1.5 yr) randomized to rhGH or placebo treatment (0.15 IU/kg/day for 1 week). Subjects were studied at rest and in response to exercise (cycle-ergometry at 65% of maximal work capacity for 20 min). Serum was assayed for total GH (Pharmacia IRMA and pituitary GH), 22-kDa GH (2 different 2-site monoclonal immunoassays), non-22-kDa GH (22-kDa GH-exclusion assay), 20-kDa GH, and immunofunctional GH. In the study, 3 h after the last dose of rhGH, total and 22-kDa GH concentrations were elevated, reflecting exogenous 22-kDa GH. Non-22-kDa and 20-kDa GH levels were suppressed. Regression of non-22-kDa or 20-kDa GH against total or 22-kDa GH produced clear separation of treatment groups. In identical exercise studies repeated between 24 and 96 h after cessation of treatment, the magnitude of the responses of all GH isoforms was suppressed (P < 0.01), but the relative proportions were similar to those before treatment. We conclude: 1) supraphysiological doses of rhGH in trained adult males suppressed exercise-stimulated endogenous circulating isoforms of GH for up to 4 days; 2) the clearest separation of treatment groups required the simultaneous presence of high exogenous 22-kDa GH and suppressed 20-kDa or non-22-kDa GH concentrations; and 3) these methods may prove useful in detecting rhGH abuse in athletes

International relations in the making of political Islam: interrogating Khomeini's ‘Islamic government’

Eurocentric approaches to political Islam tend to deploy an internalist methodology that theoretically obscures the generative and constitutive role of international relations. This article addresses this problem through a critical application of Leon Trotsky's idea of ‘uneven and combined development’ to Ayatollah Khomeini's invention of the concept of ‘Islamic government’. It argues that this concept was international in its socio-political stimulus and intellectual content, and, crucially, reflected, influenced, and mobilised an emergent liminal sociality that combined Western and Islamic socio-cultural forms. This heterogeneous character of Iran's experience of modernity is, the article argues, theoretically inaccessible to Eurocentric approaches’ homogeneous and unilinear conceptions of history, which, as a result, generate exceptionalist modes of explanations