A qualitative exploratory study: Using medical students’ experiences to review the role of a rural clinical attachment in KwaZulu-Natal

Objectives: There are challenges when it is considered that a main role of a rural clinical attachment for medical students is to encourage students to return after graduation to practise in rural areas. This view may lead to the relative neglect of other potential valuable roles with regard to rural  exposure. This paper draws on the Force Field Model of teacher development to describe medical students’ experiences, illustrate the complexity of interacting factors during rural exposure, caution that experiences cannot be predicted and highlight the positive incentives of a rural clinical attachment.Design: The design was explorative, descriptive and qualitative.Setting: The study setting was a district hospital in rural KwaZulu-Natal.Subjects: The participants were four final-year medical students who had completed a compulsory attachment during their Family Medicine rotation.Outcome measures: Data were collected using photo elicitation and analysed using the Force Field Model.Results: The participants felt that overall the experience was positive. The effect of biography and contextual forces were not as strong as expected. Institutional forces were important and programmatic forces tended to have a negative effect on experiences. The participants particularly enjoyed being acknowledged and felt empathy for the difficult tasks of doctors.Conclusion: The potential role of a clinical attachment may go beyond attracting students to practise in rural areas. The experience can be beneficial, irrespective of where the student decides to practise after graduation. There is a need for a review of the rural attachment curriculum and paedagogy. Caution should be used when screening medical students for suitability to work in rural areas prior to rural exposure.Keywords: rural clinical attachment, family medicine rotation, medical students, experiences, Force Field Mode

A look back on how far to walk: Systematic review and meta-analysis of physical access to skilled care for childbirth in Sub-Saharan Africa.

OBJECTIVES: To (i) summarize the methods undertaken to measure physical accessibility as the spatial separation between women and health services, and (ii) establish the extent to which distance to skilled care for childbirth affects utilization in Sub-Saharan Africa. METHOD: We defined spatial separation as the distance/travel time between women and skilled care services. The use of skilled care at birth referred to either the location or attendant of childbirth. The main criterion for inclusion was any quantification of the relationship between spatial separation and use of skilled care at birth. The approaches undertaken to measure distance/travel time were summarized in a narrative format. We obtained pooled adjusted odds ratios (aOR) from studies that controlled for financial means, education and (perceived) need of care in a meta-analysis. RESULTS: 57 articles were included (40 studied distance and 25 travel time), in which distance/travel time were found predominately self-reported or estimated in a geographic information system based on geographic coordinates. Approaches of distance/travel time measurement were generally poorly detailed, especially for self-reported data. Crucial features such as start point of origin and the mode of transportation for travel time were most often unspecified. Meta-analysis showed that increased distance to maternity care had an inverse association with utilization (n = 10, pooled aOR = 0.90/1km, 95%CI = 0.85-0.94). Distance from a hospital for rural women showed an even more pronounced effect on utilization (n = 2, pooled aOR = 0.58/1km increase, 95%CI = 0.31,1.09). The effect of spatial separation appears to level off beyond critical point when utilization was generally low. CONCLUSION: Although the reporting and measurements of spatial separation in low-resource settings needs further development, we found evidence that a lack of geographic access impedes use. Utilization is conditioned on access, researchers and policy makers should therefore prioritize quality data for the evidence-base to ensure that women everywhere have the potential to access obstetric care

The social practice of sustainable agriculture under audit discipline: initial insights from the ARGOS project in New Zealand

One of the most interesting recent developments in global agri‐food systems has been the rapid emergence and elaboration of market audit systems claiming environmental qualities or sustainability. In New Zealand, as a strongly export‐oriented, high‐value food producer, these environmental market audit systems have emerged as an important pathway for producers to potentially move towards more sustainable production. There have, however, been only sporadic and fractured attempts to study the emerging social practice of sustainable agriculture – particularly in terms of the emergence of new audit disciplines in farming. The ARGOS project in New Zealand was established in 2003 as a longitudinal matched panel study of over 100 farms and orchards using different market audit systems (e.g., organic, integrated or GLOBALG.A.P.). This article reports on the results of social research into the social practice of sustainable agriculture in farm households within the ARGOS projects between 2003‐2009. Results drawn from multiple social research instruments deployed over six years provide an unparalleled level of empirical data on the social practice of sustainable agriculture under audit disciplines. Using 12 criteria identified in prior literature as contributing a significant social dynamic around sustainable agriculture practices in other contexts, the analysis demonstrated that 9 of these 12 dimensions did demonstrate differences in social practices emerging between (or co‐constituting) organic, integrated, or conventional audit disciplines. These differences clustered into three main areas: 1) social and learning/knowledge networks and expertise, 2) key elements of farmer subjectivity – particularly in relation to subjective positioning towards the environment and nature, and 3) the role and importance of environmental dynamics within farm management practices and systems. The findings of the project provide a strong challenge to some older framings of the social practice of sustainable agriculture: particularly those that rely on paradigm‐driven evaluation of social motivations, strong determinism of sustainable practice driven by coherent farmer identity, or deploying overly categorical interpretations of what it means to be ‘organic’ or ‘conventional’. The complex patterning of the ARGOS data can only be understood if the social practice of organic, integrated or (even more loosely) conventional production is understood as being co‐produced by four dynamics: subjectivity/identity, audit disciplines, industry cultures/structure and time. This reframing of how we might research the social practice of sustainable agriculture opens up important new opportunities for understanding the emergence and impact of new audit disciplines in agriculture

Willingness to participate in future HIV prevention studies among gay and bisexual men in Scotland, UK: a challenge for intervention trials

This article examines willingness to participate in future HIV prevention research among gay and bisexual men in Scotland, UK. Anonymous, self-complete questionnaires and Orasure Gäó oral fluid samples were collected in commercial gay venues. 1,320 men were eligible for inclusion. 78.2% reported willingness to participate in future HIV prevention research; 64.6% for an HIV vaccine, 57.4% for a behaviour change study, and 53.0% for a rectal microbicide. In multivariate analysis, for HIV vaccine research, greater age, minority ethnicity, and not providing an oral fluid sample were associated with lower willingness; heterosexual orientation and not providing an oral fluid sample were for microbicides; higher education and greater HIV treatment optimism were for behaviour change. STI testing remained associated with being more willing to participate in microbicide research and frequent gay scene use remained associated with being more willing to participate in behaviour change research. Having an STI in the past 12 months remained significantly associated with being willing to participate in all three study types. There were no associations between sexual risk behaviour and willingness. Although most men expressed willingness to participate in future research, recruitment of high-risk men, who have the potential to benefit most, is likely to be more challenging

Trends in the lifetime risk of developing cancer in Great Britain: comparison of risk for those born from 1930 to 1960

BACKGROUND: Typically, lifetime risk is calculated by the period method using current risks at different ages. Here, we estimate the probability of being diagnosed with cancer for individuals born in a given year, by estimating future risks as the cohort ages. METHODS: We estimated the lifetime risk of cancer in Britain separately for men and women born in each year from 1930 to 1960. We projected rates of all cancers (excluding non-melanoma skin cancer) and of all cancer deaths forwards using a flexible age-period-cohort model and backwards using age-specific extrapolation. The sensitivity of the estimated lifetime risk to the method of projection was explored. RESULTS: The lifetime risk of cancer increased from 38.5% for men born in 1930 to 53.5% for men born in 1960. For women it increased from 36.7 to 47.5%. Results are robust to different models for projections of cancer rates. CONCLUSIONS: The lifetime risk of cancer for people born since 1960 is >50%. Over half of people who are currently adults under the age of 65 years will be diagnosed with cancer at some point in their lifetime

Why not? Understanding the spatial clustering of private facility-based delivery and financial reasons for homebirths in Nigeria.

BACKGROUND: In Nigeria, the provision of public and private healthcare vary geographically, contributing to variations in one's healthcare surroundings across space. Facility-based delivery (FBD) is also spatially heterogeneous. Levels of FBD and private FBD are significantly lower for women in certain south-eastern and northern regions. The potential influence of childbirth services frequented by the community on individual's barriers to healthcare utilization is under-studied, possibly due to the lack of suitable data. Using individual-level data, we present a novel analytical approach to examine the relationship between women's reasons for homebirth and community-level, health-seeking surroundings. We aim to assess the extent to which cost or finance acts as a barrier for FBD across geographic areas with varying levels of private FBD in Nigeria. METHOD: The most recent live births of 20,467 women were georeferenced to 889 locations in the 2013 Nigeria Demographic and Health Survey. Using these locations as the analytical unit, spatial clusters of high/low private FBD were detected with Kulldorff statistics in the SatScan software package. We then obtained the predicted percentages of women who self-reported financial reasons for homebirth from an adjusted generalized linear model for these clusters. RESULTS: Overall private FBD was 13.6% (95%CI = 11.9,15.5). We found ten clusters of low private FBD (average level: 0.8, 95%CI = 0.8,0.8) and seven clusters of high private FBD (average level: 37.9, 95%CI = 37.6,38.2). Clusters of low private FBD were primarily located in the north, and the Bayelsa and Cross River States. Financial barrier was associated with high private FBD at the cluster level - 10% increase in private FBD was associated with + 1.94% (95%CI = 1.69,2.18) in nonusers citing cost as a reason for homebirth. CONCLUSIONS: In communities where private FBD is common, women who stay home for childbirth might have mild increased difficulties in gaining effective access to public care, or face an overriding preference to use private services, among other potential factors. The analytical approach presented in this study enables further research of the differentials in individuals' reasons for service non-uptake across varying contexts of healthcare surroundings. This will help better devise context-specific strategies to improve health service utilization in resource-scarce settings

Altered SMRT levels disrupt vitamin D3 receptor signalling in prostate cancer cells.

We hypothesized that key antiproliferative target genes for the vitamin D receptor (VDR) were repressed by an epigenetic mechanism in prostate cancer cells resulting in apparent hormonal insensitivity. To explore this possibility, we examined nuclear receptor corepressor expression in a panel of nonmalignant and malignant cell lines and primary cultures, and found frequently elevated SMRT corepressor mRNA expression often associated with reduced sensitivity to 1alpha,25-dihydroxyvitamin D(3) (1alpha,25(OH)2D3). For example, PC-3 and DU-145 prostate cancer cell lines had 1.8-fold and twofold increases in SMRT mRNA relative to normal PrEC cells (P<0.05). Similarly, 10/15 primary tumour cultures (including three matched to normal cells from the same donors) had elevated SMRT mRNA levels; generally NCoR1 and Alien were not as commonly elevated. Corepressor proteins often have associated histone deacetylases (HDAC) and reflectively the antiproliferative action of 1alpha,25(OH)2D3 can be restored by cotreatment with low doses of HDAC inhibitors such as trichostatin A (TSA, 15 nM) to induce apoptosis in prostate cancer cell lines. To decipher the transcriptional events that lead to these cellular responses, we undertook gene expression studies in PC-3 cells after cotreatment of 1alpha,25(OH)2D3 plus TSA after 6 h. Examination of known VDR target genes and cDNA microarray analyses revealed cotreatment of 1alpha,25(OH)2D3 plus TSA cooperatively upregulated eight (out of 1176) genes, including MAPK-APK2 and GADD45alpha. MRNA and protein time courses and inhibitor studies confirmed these patterns of regulation. Subsequently, we knocked down SMRT levels in PC-3 cells using a small interfering RNA (siRNA) approach and found that GADD45alpha induction by 1alpha,25(OH)2D3 alone became very significantly enhanced. The same distortion of gene responsiveness, with repressed induction of GADD45alpha was found in primary tumour cultures compared and to matched peripheral zone (normal) cultures from the same donor. These data demonstrate that elevated SMRT levels are common in prostate cancer cells, resulting in suppression of target genes associated with antiproliferative action and apparent 1alpha,25(OH)2D3-insensitivity. This can be targeted therapeutically by combination treatments with HDAC inhibitors

Molecular Evolutionary Characterization of a V1R Subfamily Unique to Strepsirrhine Primates

Vomeronasal receptor genes have frequently been invoked as integral to the establishment and maintenance of species boundaries among mammals due to the elaborate one-to-one correspondence between semiochemical signals and neuronal sensory inputs. Here, we report the most extensive sample of vomeronasal receptor class 1 (V1R) sequences ever generated for a diverse yet phylogenetically coherent group of mammals, the tooth-combed primates (suborder Strepsirrhini). Phylogenetic analysis confirms our intensive sampling from a single V1R subfamily, apparently unique to the strepsirrhine primates. We designate this subfamily as V1Rstrep. The subfamily retains extensive repertoires of gene copies that descend from an ancestral gene duplication that appears to have occurred prior to the diversification of all lemuriform primates excluding the basal genusDaubentonia (the aye-aye). We refer to the descendent clades as V1Rstrep-a and V1Rstrep-b. Comparison of the two clades reveals different amino acid compositions corresponding to the predicted ligand-binding site and thus potentially to altered functional profiles between the two. In agreement with previous studies of the mouse lemur (genus, Microcebus), the majority of V1Rstrep gene copies appear to be intact and under strong positive selection, particularly within transmembrane regions. Finally, despite the surprisingly high number of gene copies identified in this study, it is nonetheless probable that V1R diversity remains underestimated in these nonmodel primates and that complete characterization will be limited until high-coverage assembled genomes are available

Shorter Food Chain Length in Ancient Lakes: Evidence from a Global Synthesis

Food webs may be affected by evolutionary processes, and effective evolutionary time ultimately affects the probability of species evolving to fill the niche space. Thus, ecosystem history may set important evolutionary constraints on community composition and food web structure. Food chain length (FCL) has long been recognized as a fundamental ecosystem attribute. We examined historical effects on FCL in large lakes spanning >6 orders of magnitude in age. We found that food chains in the world’s ancient lakes (n = 8) were significantly shorter than in recently formed lakes (n = 10) and reservoirs (n = 3), despite the fact that ancient lakes harbored much higher species richness, including many endemic species. One potential factor leading to shorter FCL in ancient lakes is an increasing diversity of trophic omnivores and herbivores. Speciation could simply broaden the number of species within a trophic group, particularly at lower trophic levels and could also lead to a greater degree of trophic omnivory. Our results highlight a counter-intuitive and poorly-understood role of evolutionary history in shaping key food web properties such as FCL