Socioeconomic and physical distance to the maternity hospital as predictors for place of delivery: an observation study from Nepal

BACKGROUND: Although the debate on the safety and women's right of choice to a home delivery vs. hospital delivery continues in the developed countries, an undesirable outcome of home delivery, such as high maternal and perinatal mortality, is documented in developing countries. The objective was to study whether socio-economic factors, distance to maternity hospital, ethnicity, type and size of family, obstetric history and antenatal care received in present pregnancy affected the choice between home and hospital delivery in a developing country. METHODS: This cross-sectional study was done during June, 2001 to January 2002 in an administratively and geographically well-defined territory with a population of 88,547, stretching from urban to adjacent rural part of Kathmandu and Dhading Districts of Nepal with maximum of 5 hrs of distance from Maternity hospital. There were no intermediate level of private or government hospital or maternity homes in the study area. Interviews were carried out on 308 women who delivered within 45 days of the date of the interview with a pre-tested structured questionnaire. RESULTS: A distance of more than one hour to the maternity hospital (OR = 7.9), low amenity score status (OR = 4.4), low education (OR = 2.9), multi-parity (OR = 2.4), and not seeking antenatal care in the present pregnancy (OR = 4.6) were statistically significantly associated with an increased risk of home delivery. Ethnicity, obstetric history, age of mother, ritual observance of menarche, type and size of family and who is head of household were not statistically significantly associated with the place of delivery. CONCLUSIONS: The socio-economic standing of the household was a stronger predictor of place of delivery compared to ethnicity, the internal family structure such as type and size of family, head of household, or observation of ritual days by the mother of an important event like menarche. The results suggested that mothers, who were in the low-socio-economic scale, delivered at home more frequently in a developing country like Nepal

Randomised controlled trial of silk therapeutic garments for the management of atopic eczema in children: the CLOTHES trial

BACKGROUND: Atopic eczema (AE) is a chronic, itchy, inflammatory skin condition that affects the quality of life of children and their families. The role of specialist clothing in the management of AE is poorly understood.OBJECTIVES: To assess the effectiveness and cost-effectiveness of silk garments for the management of AE in children with moderate to severe disease.DESIGN: Parallel-group, observer-blind, randomised controlled trial of 6 months' duration, followed by a 2-month observational period. A nested qualitative study evaluated the beliefs of trial participants, health-care professionals and health-care commissioners about the use of silk garments for AE.SETTING: Secondary care and the community in five UK centres.PARTICIPANTS: Children aged 1-15 years with moderate or severe AE.INTERVENTIONS: Participants were randomised (1 : 1 using online randomisation) to standard care or standard care plus 100% silk garments made from antimicrobially protected knitted sericin-free silk [DermaSilkTM (AlPreTec Srl, San Donà di Piave, Italy) or DreamSkinTM (DreamSkin Health Ltd, Hatfield, UK)]. Three sets of garments were supplied per participant, to be worn for up to 6 months (day and night). At 6 months the standard care group received the garments to use for the remaining 2-month observational period.MAIN OUTCOME MEASURES: Primary outcome - AE severity using the Eczema Area and Severity Index (EASI) assessed at 2, 4 and 6 months, by nurses blinded to treatment allocation. EASI scores were log-transformed for analysis. Secondary outcomes - patient-reported eczema symptoms (Patient Oriented Eczema Measure); global assessment of severity (Investigator Global Assessment); quality of life of the child (Atopic Dermatitis Quality of Life, Child Health Utility - 9 Dimensions), family (Dermatitis Family Impact Questionnaire) and main carer (EuroQoL-5 Dimensions-3 Levels); use of standard eczema treatments (e.g. emollients, topical corticosteroids); and cost-effectiveness. The acceptability and durability of the clothing, and adherence to wearing the garments, were assessed by parental/carer self-report. Safety outcomes - number of skin infections and hospitalisations for AE.RESULTS: A total of 300 children were randomised (26 November 2013 to 5 May 2015): 42% female, 79% white, mean age 5 years. The primary analysis included 282 out of 300 (94%) children (n = 141 in each group). Garments were worn for at least 50% of the time by 82% of participants. Geometric mean EASI scores at baseline, 2, 4 and 6 months were 8.4, 6.6, 6.0, 5.4 for standard care and 9.2, 6.4, 5.8, 5.4 for silk clothing, respectively. There was no evidence of difference between the groups in EASI score averaged over all follow-up visits adjusted for baseline EASI score, age and centre (ratio of geometric means 0.95, 95% confidence interval 0.85 to 1.07; p = 0.43). This confidence interval is equivalent to a difference of -1.5 to 0.5 in the original EASI scale units. Skin infections occurred in 39 out of 141 (28%) and 36 out of 142 (25%) participants for standard care and silk clothing groups, respectively. The incremental cost per QALY of silk garments for children with moderate to severe eczema was £56,811 from a NHS perspective in the base case. Sensitivity analyses supported the finding that silk garments do not appear to be cost-effective within currently accepted thresholds.LIMITATIONS: Knowledge of treatment allocation may have affected behaviour and outcome reporting for some of the patient-reported outcomes.CONCLUSIONS: The addition of silk garments to standard AE care is unlikely to improve AE severity, or to be cost-effective compared with standard care alone, for children with moderate or severe AE. This trial adds to the evidence base to guide clinical decision-making.FUTURE WORK: Non-pharmacological interventions for the management of AE remain a research priority among patients.TRIAL REGISTRATION: Current Controlled Trials ISRCTN77261365.FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 16. See the NIHR Journals Library website for further project information.</p

Outreach programmes for health improvement of Traveller Communities: a synthesis of evidence

Background: The term ‘Traveller Communities’ refers to a complex population group encompassing Romani Gypsies, Irish Travellers, Welsh Travellers, Scottish Travellers, Roma, New Travellers, Travelling Showpeople, Circus People and Boat Dwellers. A lack of reliable demographic data combined with nomadic lifestyles leads to potential invisibility in health service planning and results in unmet needs.Outreach has been utilised as a key strategy to engage Traveller Communities in health improvement interventions. Aim: To synthesise the evidence on outreach programmes to improve the health of Traveller Communities. Design: Scoping, economic and realist reviews were employed with the following objectives: (1) to quantify and classify the evidence concerning Traveller Communities’ health; (2) to estimate the costs of different types of outreach and determine which might be considered cost-effective and (3) to develop explanations of how, for whom and in what circumstances outreach works best. Methods: Comprehensive searches of electronic databases and grey literature were undertaken using a broad search strategy to identify publications relevant to Traveller Communities and health. The following databases were searched: Web of Knowledge, MEDLINE, The British Library’s Electronic Table of Contents (Zetoc), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA), Social Services Abstracts, British Humanities Index, PsycArticles, Allied and Complementary Medicine Database (AMED), ProQuest Nursing and Allied Health Source, International Bibliography of the Social Sciences (IBSS) and Sociological Abstracts. Searches were conducted between August 2011 and November 2011. No restrictions on inclusion were imposed according to type of journal, publication date (up to the date of searching) or country of research or practice. Foreign-language publications were excluded. This formed a core literature base to be drawn on by the different arms of thereview. Expert hearings involving Traveller Community members and outreach workers were also undertaken to refine and validate emerging findings. Findings: Two hundred and seventy-eight articles were included in the scoping review, which highlighted the emergent nature of the evidence on outreach interventions for Traveller Communities. While much research describes the needs of Traveller Communities, as yet there has been little response to this in the form of discussion and evaluation of outreach and other interventions that might improve their health. From an economic perspective, the data available suggest that the cost of providing mobile services to travellers is high; improving accessibility of services and signposting Traveller Communities is cheaper and may be equally effective. The realist synthesis generated an explanatory framework of why outreach might lead to certain outcomes depending on the particular circumstances. The extent to which workers are trusted by the Community and whether or not the intervention focus is negotiated both have clear impacts on intervention success. Individuals engage differentially with outreach interventions, leading to participation, behaviour change or social capital improvement outcomes. Conclusions: Outreach workers need clarity about the purpose of their intervention, in terms of degrees of engagement (leading to the three outcome categories above). Where outreach aims to promote attendance at one-off events such as screening, the worker may not need to have long-established links with the Community. Changing behaviour or developing social capital, on the other hand, is a challenge that needs to build explicitly on long-established, trusting relationships. Any flexibility built into the intervention in terms of negotiating intervention topic can contribute significantly to the outcome. While true engagement with an issue must not be assumed from participation at an event, these events can be used as part of longer-term trust-building strategies. These synthesis approaches offer maximum translational potential for other marginalised groups. There is a need for more theoretically informed evaluations of engagement initiatives, in order to develop transferable lessons around how and for whom interventions work in different contexts. Further research is needed to test the explanatory potential of the framework in other socially excluded groups. Funding: The National Institute for Health Research Public Health Research programme