Intelligence and reading abilities in eight year old children who failed to thrive in infancy

The aim of the work reported in this thesis was to investigate intelligence and reading ability at school age in a population based sample of children who failed to thrive in the first two years of life. Weights for an annual cohort of term infants, retrieved from clinic records, were compared with weight expected conditional upon early weight. Those with weights in the lowest 5% in two or more age bands (3, 6, 9, 12 and 18 months) were identified as cases (n =136). Cases were stratified by age, sex and deprivation level of their area of residence at eighteen months of age, and the same number of controls selected from each stratum. Two controls were later omitted as they were found to have been born preterm (< 37 weeks). Between ages 7 and 9 years 79% of cases and 82% of controls were traced and studied. Height, head circumference and weight were measured, and an IQ and reading test administered. Information about socio-economic status, family structure and medical history was gathered during a home visit. The mother's height was measured, the father's being reported by the mothers, and the mother's IQ tested. All testing was carried out blind to the child’s case or control status. The child's medical records were retrieved where admission to a hospital or outpatient clinic was reported and the conditions diagnosed were coded blind for their probable effects on cognitive outcomes or growth. At eight years of age mothers in the case group reported more feeding problems in infancy and more organic conditions. Cases were shorter, lighter, thinner and had a smaller head circumference than controls. These anthropometric differences were all statistically significant and remained so after allowing for parental stature. There were no statistically significant differences in IQ and reading ability either before or after adjusting for maternal IQ, organic condition or the few covariates found to differ between the groups

Cognitive and behavioural outcomes of non-organic failure to thrive

In a study of failure to thrive in 1987-8, 54 children (21%) from an annual cohort attending two clinics in a deprived area of Newcastle Upon Tyne were identified as having fallen across two or more major weight centiles for a month or more during the first 18 months of life. They were studied with 52 normally growing controls selected from the same clinics. Eighty nine per cent of these children were traced for a follow up study at age 6-7 years old. This follow up study is reported in this thesis. IQ was assessed using the Weschler Preschool and Primary Scale of Intelligence. The Teacher's Report Form (Achenbach, 1991) was used to assess behaviour problems in the groups. Testers were unaware of the clinical status of the children. Height was routinely measured at school entry and the original data were analysed to determine age at the lowest centile point and severity of fall in weight gain. In an independent samples analysis, a small but statistically significant difference in height at school entry age was found, but there was no statistically significant difference between the cases and controls in IQ (mean IQ 83.6 and 87 respectively, P=0.16), or ratings of behaviour problems (TRF median problems reported 23 and 14, Mann U=1.05, P=0.297). Teacher ratings did not reach conventional levels of statistical significance in any subsequent analysis. A within case group analysis of growth data was carried out to determine if there was a larger effect on a subset of cases sharing characteristics of growth failure. The effects of chronicity, age at the lowest centile point and severity of failure to thrive were analysed. A significant association was found between IQ and severity of failure to thrive (P=.03).Analysis of weight gains showed that while the screening criterion used was sensitive, identifying a group of children with a median rate of weight gain below the 10th centile for expected weight gain, 6 had fallen no lower than their expected weight gain and 17 were only mildly growth retarded. However, the measure for severity of fall used in this study is not only a sensitive criterion, but can also distinguish between a normal fall in rate of weight gain towards the population mean and an abnormal fall away from the mean and it was this measure that was significantly associated with IQ

Factors shaping initial decision-making to self-test amongst cohabiting couples in urban Blantyre, Malawi.

In sub-Saharan Africa, most new HIV infections occur in stable relationships, making couples testing an important intervention for HIV prevention. We explored factors shaping the decision-making of cohabiting couples who opted to self-test in Blantyre, Malawi. Thirty-four self-tested participants (17 couples) were interviewed. Motivators for HIV self-testing (HIVST) emerged at three main levels. Individual motivations included perceived benefits of access to treatment, and self-checking of serostatus in the hope of having been cured by prolonged treatment or faith-healing. HIVST was considered convenient, confidential, reassuring and an enabling new way to test with one's partner. Partnership motivations included both positive (mutual encouragement) and negative (suspected infidelity) aspects. For women, long-term health and togetherness were important goals that reinforced motivations for couples testing, whereas men often needed persuasion despite finding HIVST more flexible and less onerous than facility-based testing. Internal conflict prompted some partners to use HIVST as a way of disclosing their previously concealed HIV positive serostatus. Thus, the implementation of community-based HIVST should acknowledge and appropriately respond to decision-making processes within couples, which are shaped by gender roles and relationship dynamics

Using research networks to generate trustworthy qualitative public health research findings from multiple contexts

Background: Qualitative research networks (QRNs) bring together researchers from diverse contexts working on multi-country studies. The networks may themselves form a consortium or may contribute to a wider research agenda within a consortium with colleagues from other disciplines. The purpose of a QRN is to ensure robust methods and processes that enable comparisons across contexts. Under the Self-Testing Africa (STAR) initiative and the REACHOUT project on community health systems, QRNs were established, bringing together researchers across countries to coordinate multi-country qualitative research and to ensure robust methods and processes allowing comparisons across contexts. QRNs face both practical challenges in facilitating this iterative exchange process across sites and conceptual challenges interpreting findings between contexts. This paper distils key lessons and reflections from both QRN experiences on how to conduct trustworthy qualitative research across different contexts with examples from Bangladesh, Ethiopia, Kenya, Indonesia, Malawi, Mozambique, Zambia and Zimbabwe. Methods: The process of generating evidence for this paper followed a thematic analysis method: themes initially identified were refined during several rounds of discussions in an iterative process until final themes were agreed upon in a joint learning process. Results: Four guiding principles emerged from our analysis: a) explicit communication strategies that sustain dialogue and build trust and collective reflexivity; b) translation of contextually embedded concepts; c) setting parameters for contextualizing, and d) supporting empirical and conceptual generalisability. Under each guiding principle, we describe how credibility, dependability, confirmability and transferability can be enhanced and share good practices to be considered by other researchers. Conclusions: Qualitative research is often context-specific with tools designed to explore local experiences and understandings. Without efforts to synthesise and systematically share findings, common understandings, experiences and lessons are missed. The logistical and conceptual challenges of qualitative research across multiple partners and contexts must be actively managed, including a shared commitment to continuous ‘joint learning’ by partners. Clarity and agreement on concepts and common methods and timelines at an early stage is critical to ensure alignment and focus in intercountry qualitative research and analysis processes. Building good relationships and trust among network participants enhance the quality of qualitative research findings. Keywords: Qualitative research, Research networks, trustworthiness, Generalisable research, Research guiding principles, Research good practice

Measuring sexual behaviour in Malawi: a triangulation of three data collection instruments

BACKGROUND: There is a need for valid approaches to measure sexual interactions to assess the impact of behavioural interventions and to predict the impact of behaviour changes. Different methods of asking about sexual behaviour often yield conflicting answers and men often report higher levels of heterosexual activity than women. To better understand self-reported sexual behaviour data and how best to collect it, we analyzed data collected as part of a larger project (ST IMPACTS) on the social and behavioural impact of introducing community-level HIV self-testing (HIVST) with counseling (semi-supervised with pre- and generic post-test counseling provided on delivery or collection of test kits) in an urban Malawian setting. METHODS: Information on sexual behaviour was collected from HIV self-testers over a three-month period. Three different methods were used: retrospective face-to-face interviews (FTFI); audio computer assisted self-interviews (ACASI) and a prospective coital diary. Both retrospective instruments were used before and after the three-month study period. Frequency and cross-tabulation, as well as scatterplots, were used for exploratory analyses. Chi-square tests were used to test for differences in proportions. Spearman's correlation coefficient was used to explore associations between both continuous and ordinal variables and Wilcoxon's paired sample and Mann-Whitney test was used to test for differences in such variables or between variables. RESULTS: There was reasonable agreement between the two retrospective methods although both yielded inconsistent answers e.g. with lower reported numbers of life-time sexual partners at the end than at the beginning of the study period. The diary method elicited higher reported levels of sex with multiple partners than both retrospective instruments which may be due to inadequate recall. Over the study period 37.4% of men and 19.7% of women reported multiple sexual partners using the diary. There was no clear relationship between reported sexual behaviour and HIV status (prevalence 9.6%). CONCLUSIONS: Diaries may therefore have higher validity for sensitive behaviour reporting and thus be the preferred method in similar African contexts in measuring sexual behaviours

Improving the reach of vaccines to low-resource regions, with a needle-free vaccine delivery device and long-term thermostabilization

Dry-coated microprojections can deliver vaccine to abundant antigen-presenting cells in the skin and induce efficient immune responses and the dry-coated vaccines are expected to be thermostable at elevated temperatures. In this paper, we show that we have dramatically improved our previously reported gas-jet drying coating method and greatly increased the delivery efficiency of coating from patch to skin to from 6.5% to 32.5%, by both varying the coating parameters and removing the patch edge. Combined with our previous dose sparing report of influenza vaccine delivery in a mouse model, the results show that we now achieve equivalent protective immune responses as intramuscular injection (with the needle and syringe), but with only 1/30th of the actual dose. We also show that influenza vaccine coated microprojection patches are stable for at least 6 months at 23 degrees C. inducing comparable immunogenicity with freshly coated patches. The dry-coated microprojection patches thus have key and unique attributes in ultimately meeting the medical need in certain low-resource regions with low vaccine affordability and difficulty in maintaining "cold-chain" for vaccine storage and transport. (C) 2011 Elsevier B.V. All rights reserved

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study

ABSTRACT Background Despite the widespread use of accreditation in many countries, and prevailing beliefs that accreditation is associated with variables contributing to clinical care and organisational outcomes, little systematic research has been conducted to examine its validity as a predictor of healthcare performance. Objective To determine whether accreditation performance is associated with self-reported clinical performance and independent ratings of four aspects of organisational performance. Design Independent blinded assessment of these variables in a random, stratified sample of health service organisations. Settings Acute care: large, medium and small healthservice organisations in Australia. Study participants Nineteen health service organisations employing 16 448 staff treating 321 289 inpatients and 1 971 087 non-inpatient services annually, representing approximately 5% of the Australian acute care health system. Main measures Correlations of accreditation performance with organisational culture, organisational climate, consumer involvement, leadership and clinical performance. Results Accreditation performance was significantly positively correlated with organisational culture (rho¼0.618, p¼0.005) and leadership (rho¼0.616, p¼0.005). There was a trend between accreditation and clinical performance (rho¼0.450, p¼0.080). Accreditation was unrelated to organisational climate (rho¼0.378, p¼0.110) and consumer involvement (rho¼0.215, p¼0.377). Conclusions Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted

Medical Student Professionalism Narratives: A Thematic Analysis and Interdisciplinary Comparative Investigation

<p>Abstract</p> <p>Background</p> <p>Professionalism development is influenced by the informal and hidden curriculum. The primary objective of this study was to better understand this experiential learning in the setting of the Emergency Department (ED). Secondarily, the study aimed to explore differences in the informal curriculum between Emergency Medicine (EM) and Internal Medicine (IM) clerkships.</p> <p>Methods</p> <p>A thematic analysis was conducted on 377 professionalism narratives from medical students completing a required EM clerkship from July 2008 through May 2010. The narratives were analyzed using established thematic categories from prior research as well as basic descriptive characteristics. Chi-square analysis was used to compare the frequency of thematic categories to prior research in IM. Finally, emerging themes not fully appreciated in the established thematic categories were created using grounded theory.</p> <p>Results</p> <p>Observations involving interactions between attending physician and patient were most abundant. The narratives were coded as positive 198 times, negative 128 times, and hybrid 37 times. The two most abundant narrative themes involved <it>manifesting respect </it>(36.9%) and <it>spending time </it>(23.7%). Both of these themes were statistically more likely to be noted by students on EM clerkships compared to IM clerkships. Finally, one new theme regarding <it>cynicism </it>emerged during analysis.</p> <p>Conclusions</p> <p>This analysis describes an informal curriculum that is diverse in themes. Student narratives suggest their clinical experiences to be influential on professionalism development. Medical students focus on different aspects of professionalism depending on clerkship specialty.</p

Changes in the socio-demographic patterning of late adolescent health risk behaviours during the 1990s: analysis of two West of Scotland cohort studies

Background: Substance use and sexual risk behaviour affect young people's current and future health and wellbeing in many high-income countries. Our understanding of time-trends in adolescent health-risk behaviour is largely based on routinely collected survey data in school-aged adolescents (aged 15 years or less). Less is known about changes in these behaviours among older adolescents. Methods: We compared two cohorts from the same geographical area (West of Scotland), surveyed in 1990 and 2003, to: describe time-trends in measures of smoking, drinking, illicit drug use, early sexual initiation, number of opposite sex sexual partners and experience of pregnancy at age 18-19 years, both overall and stratified by gender and socioeconomic status (SES); and examine the effect of time-trends on the patterning of behaviours by gender and SES. Our analyses adjust for slight between-cohort age differences since age was positively associated with illicit drug use and pregnancy. Results: Rates of drinking, illicit drug use, early sexual initiation and experience of greater numbers of sexual partners all increased significantly between 1990 and 2003, especially among females, leading to attenuation and, for early sexual initiation, elimination, of gender differences. Most rates increased to a similar extent regardless of SES. However, rates of current smoking decreased only among those from higher SES groups. In addition, increases in 'cannabis-only' were greater among higher SES groups while use of illicit drugs other than cannabis increased more in lower SES groups. Conclusion: Marked increases in female substance use and sexual risk behaviours have implications for the long-term health and wellbeing of young women. More effective preventive measures are needed to reduce risk behaviour uptake throughout adolescence and into early adulthood. Public health strategies should reflect both the widespread prevalence of risk behaviour in young people as well as the particular vulnerability to certain risk behaviours among those from lower SES groups