Childhood mortality in sub-Saharan Africa : cross-sectional insight into small-scale geographical inequalities from Census data

Objectives To estimate and quantify childhood mortality, its spatial correlates and the impact of potential correlates using recent census data from three sub-Saharan African countries (Rwanda, Senegal and Uganda), where evidence is lacking. Design Cross-sectional. Setting Nation-wide census samples from three African countries participating in the 2010 African Census round. All three countries have conducted recent censuses and have information on mortality of children under 5 years. Participants 111 288 children under the age of 5 years in three countries. Primary and secondary outcome measures Under-five mortality was assessed alongside potential correlates including geographical location (where children live), and environmental, bio-demographic and socioeconomic variables. Results Multivariate analysis indicates that in all three countries the overall risk of child death in the first 5 years of life has decreased in recent years (Rwanda: HR=0.04, 95% CI 0.02 to 0.09; Senegal: HR=0.02 (95% CI 0.02 to 0.05); Uganda: HR=0.011 (95% CI 0.006 to 0.018). In Rwanda, lower deaths were associated with living in urban areas (0.79, 0.73, 0.83), children with living mother (HR=0.16, 95% CI 0.15 to 0.17) or living father (HR=0.38, 95% CI 0.36 to 0.39). Higher death was associated with male children (HR=1.06, 95% CI 1.02 to 1.08) and Christian children (HR=1.14, 95% CI 1.05 to 1.27). Children less than 1 year were associated with higher risk of death compared to older children in the three countries. Also, there were significant spatial variations showing inequalities in children mortality by geographic location. In Uganda, for example, areas of high risk are in the south-west and north-west and Kampala district showed a significantly reduced risk. Conclusions We provide clear evidence of considerable geographical variation of under-five mortality which is unexplained by factors considered in the data. The resulting under-five mortality maps can be used as a practical tool for monitoring progress within countries for the Millennium Development Goal 4 to reduce under-five mortality in half by 2015

Factors associated with female genital mutilation in Burkina Faso and its policy implications

Background: Female genital mutilation (FGM) usually undertaken between the ages of 1-9 years and is widely practised in some part of Africa and by migrants from African countries in other parts of the world. Laws prohibit FGM in almost every country. FGM can cause immediate complications (pain, bleeding and infection) and delayed complications (sexual, obstetric, psychological problems). Several factors have been associated with an increased likelihood of FGM. In Burkina Faso, the prevalence of FGM appears to have increased in recent years. Methods: We investigated social, demographic and economic factors associated with FGM in Burkina Faso using the 2003 Demographic Health Survey (DHS). The DHS is a nationally representative cross-sectional survey (multistage stratified random sampling of households) of women of reproductive age (15-49 years). Associations between potential risk factors and the prevalence of FGM were explored using c2 and t-tests and Mann Whitney U-test as appropriate. Logistic regression modelling was used to investigate social, demographic and economic risk factors associated with FGM. Main outcome measures: i) whether a woman herself had had FGM; ii) whether she had one or more daughters with FGM. Results: Data were available on 12,049 women. Response rates by region were at least 90%. Women interviewed were representative of the underlying populations of the different regions of Burkina Faso. Seventy seven percent (9267) of the women interviewed had had FGM. 7336 women had a daughter of whom 2216 (30.2%) had a daughter with FGM and 334 (4.5%) said that they intended that their daughter should have it. Univariate analysis showed that age, religion, wealth, ethnicity, literacy, years of education, household affluence, region and who had responsibility for health care decisions in the household had (RHCD) were all significantly related to the two outcomes (p < 0.01). Multivariate analysis stratified by religion mainly confirmed these findings, however, education is significantly associated with a reduced likelihood of FGM only for Christian women. Conclusions and Policy implications: Factors associated with FGM are varied and complex. Younger women and those from specific groups and religions are less likely to have had FGM. A higher level of education may be protective for women from certain religions. Policies should capitalize on these findings and religious leaders should be involved in continuing programmes of action

Systematic versus opportunistic risk assessment for the primary prevention of cardiovascular disease

Background Screening programmes can potentially identify people at high cardiovascular risk and reduce cardiovascular disease (CVD) morbidity and mortality. However, there is currently not enough evidence showing clear clinical or economic benefits of systematic screening-like programmes over the widely practised opportunistic risk assessment of CVD in primary care settings. Objectives The primary objective of this review was to assess the effectiveness, costs and adverse effects of systematic risk assessment compared to opportunistic risk assessment for the primary prevention of CVD. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE, EMBASE on 30 January 2015, and Web of Science Core Collection and additional databases on the Cochrane Library on 4 December 2014. We also searched two clinical trial registers and checked reference lists of relevant articles. We applied no language restrictions. Selection criteria We selected randomised controlled trials (RCTs) that assessed the effects of systematic risk assessment, defined as a screening-like programme involving a predetermined selection process of people, compared with opportunistic risk assessment which ranged from no risk assessment at all to incentivised case finding of CVD and related risk factors. Participants included healthy adults from the general population, including those who are at risk of CVD. Data collection and analysis Two review authors independently selected studies. One review author extracted data and assessed them for risk of bias and a second checked them. We assessed evidence quality using the GRADE approach and present this in a ’Summary of findings’ table. Main results Nine completed RCTs met the inclusion criteria, of which four were cluster-randomised. We also identified five ongoing trials. The included studies had a high or unclear risk of bias, and the GRADE ratings of overall quality were low or very low. The length of follow-up varied from one year in four studies, three years in one study, five or six years in two studies, and ten years in two studies. Eight studies recruited participants from the general population, although there were differences in the age ranges targeted. One study recruited family members of cardiac patients (high risk assessment). There were considerable differences between the studies in the interventions received by the intervention and control groups. There was insufficient evidence to stratify by the types of risk assessment approaches. Limited data were available on all-cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.92 to 1.02; 3 studies,103,571 participants, I² = 0%; low-quality evidence) and cardiovascular mortality (RR 1.00, 95% CI 0.90 to 1.11; 2 studies, 43,955 participants, I² = 0%), and suggest that screening has no effect on these outcomes. Data were also limited for combined non-fatal endpoints; overall, evidence indicates no difference in total coronary heart disease (RR 1.01, 95% CI 0.95 to 1.07; 4 studies, 5 comparisons, 110,168 participants, I² = 0%; low-quality evidence), non-fatal coronary heart disease (RR 0.98, 95% CI 0.89 to 1.09; 2 studies, 43,955 participants, I² = 39%), total stroke (RR 0.99, 95% CI 0.90 to 1.10; 2 studies, 79,631 participants, I² = 0%, low-quality evidence), and non-fatal stroke (RR 1.17, 95% CI 0.94 to 1.47; 1 study, 20,015 participants). Overall, systematic risk assessment appears to result in lower total cholesterol levels (mean difference (MD) -0.11 mmol/l, 95% CI -0.17 to -0.04, 6 studies, 7 comparisons, 12,591 participants, I² = 57%; very low-quality evidence), lower systolic blood pressure (MD -3.05 mmHg, 95% CI -4.84 to -1.25, 6 studies, 7 comparisons, 12,591 participants, I² = 82%; very low-quality evidence) and lower diastolic blood pressure (MD -1.34 mmHg, 95% CI -1.76 to -0.93, 6 studies, 7 comparisons, 12,591 participants, I² = 0%; low-quality evidence). One study assessed adverse effects and found no difference in psychological distress at five years (1126 participants). Authors' conclusions The results are limited by the heterogeneity between trials in terms of participants recruited, interventions and duration of follow-up. Limited data suggest that systematic risk assessment for CVD has no statistically significant effects on clinical endpoints. There is limited evidence to suggest that CVD systematic risk assessment may have some favourable effects on cardiovascular risk factors. The completion of the five ongoing trials will add to the evidence base

Development and preliminary evaluation of a clinical guidance programme for the decision about prophylactic oophorectomy in women undergoing a hysterectomy

Objectives: To develop a decision analysis based and computerised clinical guidance programme (CGP) that provides patient specific guidance on the decision whether or not to undergo a prophylactic oophorectomy to reduce the risk of subsequent ovarian cancer and to undertake a preliminary pilot and evaluation. Subjects: Women who had already agreed to have a hysterectomy who otherwise had no ovarian pathology. Setting: Oophorectomy decision consultation at the outpatient or pre-admission clinic. Methods: A CGP was developed with advice from gynaecologists and patient groups, incorporating a set of Markov models within a decision analytical framework to evaluate the benefits of undergoing a prophylactic oophorectomy or not on the basis of quality adjusted life expectancy, life expectancy, and for varying durations of hormone replacement therapy. Sensitivity analysis and preliminary testing of the CGP were undertaken to compare its overall performance with established guidelines and practice. A small convenience sample of women invited to use the CGP were interviewed, the interviews were taped and transcribed, and a thematic analysis was undertaken. Results: The run time of the programme was 20 minutes, depending on the use of opt outs to default values. The CGP functioned well in preliminary testing. Women were able to use the programme and expressed overall satisfaction with it. Some had reservations about the computerised format and some were surprised at the specificity of the guidance given. Conclusions: A CGP can be developed for a complex healthcare decision. It can give evidence-based health guidance which can be adjusted to account for individual risk factors and reflects a patient’s own values and preferences concerning health outcomes. Future decision aids and support systems need to be developed and evaluated in a way which takes account of the variation in patients’ preferences for inclusion in the decision making process

The effects of a UK review of breast cancer screening on uptake : an observational before/after study

Objectives: To measure whether uptake of breast cancer screening was affected by the publication of the Marmot Review and associated press coverage. Setting: Eight NHS breast screening centres in the West Midlands of the UK. Methods: Uptake of breast cancer screening invitations was compared in the week before and after the Marmot review publication. All 12,023 women invited for screening between 23 October 2012 and 5 November 2012 were included. A mixed effects model of the predictors of screening uptake (on date invited, or within 21 days) was created. Predictors considered for inclusion were whether the allocated screening appointment was before or after publication of the review, population factors (age, index of multiple deprivation income domain by quintile, previous attendance), and interaction terms. Results: Uptake decreased after publication of the review from 65% to 62% (OR = 0.87 95%CI = 0.80–0.94), but a similar decrease was seen for the same dates on the previous year (OR = 0.85 95%CI = 0.78–0.93). Odds of attending screening were lower for women in the most deprived (uptake = 49%, OR = 0.54, 95%CI = 0.46–0.62) in comparison with the least deprived quintile (uptake = 71%). Odds of attendance also increased if the woman had ever previously attended (OR 3.9 95% CI 3.5–4.4), and decreased with each year of increasing age (OR 0.96 95% CI 0.96–0.97). There were no interactions between any of the other predictors and whether the appointment was before or after publication of the Marmot review. Conclusion: No change in uptake of breast cancer screening above normal seasonal variation was detected after publication of the Marmot review

Spatial variation of heart failure and air pollution in Warwickshire, UK : an investigation of small scale variation at the ward-level

Objectives To map using geospatial modelling techniques the morbidity and mortality caused by heart failure within Warwickshire to characterise and quantify any influence of air pollution on these risks. Design Cross-sectional. Setting Warwickshire, UK. Participants Data from all of the 105 current Warwickshire County wards were collected on hospital admissions and deaths due to heart failure. Results In multivariate analyses, the presence of higher mono-nitrogen oxide (NOx) in a ward (3.35:1.89, 4.99), benzene (Ben) (31.9:8.36, 55.85) and index of multiple deprivation (IMD; 0.02: 0.01, 0.03), were consistently associated with a higher risk of heart failure morbidity. Particulate matter (Pm; −12.93: −20.41, −6.54) was negatively associated with the risk of heart failure morbidity. No association was found between sulfur dioxide (SO2) and heart failure morbidity. The risk of heart failure mortality was higher in wards with a higher NOx (4.30: 1.68, 7.37) and wards with more inhabitants 50+ years old (1.60: 0.47, 2.92). Pm was negatively associated (−14.69: −23.46, −6.50) with heart failure mortality. SO2, Ben and IMD scores were not associated with heart failure mortality. There was a prominent variation in heart failure morbidity and mortality risk across wards, the highest risk being in the regions around Nuneaton and Bedworth. Conclusions This study showed distinct spatial patterns in heart failure morbidity and mortality, suggesting the potential role of environmental factors beyond individual-level risk factors. Air pollution levels should therefore be taken into account when considering the wider determinants of public health and the impact that changes in air pollution might have on the health of a population

Selenium supplementation for the primary prevention of cardiovascular disease

Background: Selenium is a key component of a number of selenoproteins which protect against oxidative stress and have the potential to prevent chronic diseases including cardiovascular disease (CVD). However, observational studies have shown inconsistent associations between selenium intake and CVD risk; in addition, there is concern around a possible increased risk of type 2 diabetes with high selenium exposure. Objectives: To determine the effectiveness of selenium only supplementation for the primary prevention of CVD and examine the potential adverse effect of type 2 diabetes. Search methods: The following electronic databases were searched: the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 10 of 12, October 2012) on The Cochrane Library; MEDLINE (Ovid) (1946 to week 2 October 2012); EMBASE Classic + EMBASE (Ovid) (1947 to 2012 Week 42); CINAHL (EBSCO) (to 24 October 2012); ISI Web of Science (1970 to 24 October 2012); PsycINFO (Ovid) (1806 to week 3 October 2012); Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database and Health Economics Evaluations Database (Issue 4 of 4, October 2012) on The Cochrane Library. Trial registers and reference lists of reviews and articles were searched and experts in the field were approached. No language restrictions were applied. Selection criteria: Randomised controlled trials on the effects of selenium only supplementation on major CVD end-points, mortality, changes in CVD risk factors, and type 2 diabetes were included both in adults of all ages from the general population and in those at high risk of CVD. Trials were only considered where the comparison group was placebo or no intervention. Only studies with at least three months follow-up were included in the meta-analyses, shorter term studies were dealt with descriptively. Data collection and analysis: Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Main results: Twelve trials (seven with duration of at least three months) met the inclusion criteria, with 19,715 participants randomised. The two largest trials that were conducted in the USA (SELECT and NPC) reported clinical events. There were no statistically significant effects of selenium supplementation on all cause mortality (RR 0.97, 95% CI 0.88 to 1.08), CVD mortality (RR 0.97, 95% CI 0.79 to 1.2), non-fatal CVD events (RR 0.96, 95% CI 0.89 to 1.04) or all CVD events (fatal and non-fatal) (RR 1.03, 95% CI 0.95 to 1.11). There was a small increased risk of type 2 diabetes with selenium supplementation but this did not reach statistical significance (RR 1.06, 95% CI 0.97 to 1.15). Other adverse effects that increased with selenium supplementation, as reported in the SELECT trial, included alopecia (RR 1.28, 95% CI 1.01 to 1.62) and dermatitis grade 1 to 2 (RR 1.17, 95% CI 1.0 to 1.35). Selenium supplementation reduced total cholesterol but this did not reach statistical significance (WMD - 0.11 mmol/L, 95% CI - 0.3 to 0.07). Mean high density lipoprotein (HDL) levels were unchanged. There was a statistically significant reduction in non-HDL cholesterol (WMD - 0.2 mmol/ L, 95% CI - 0.41 to 0.00) in one trial of varying selenium dosage. None of the longer term trials examined effects on blood pressure. Overall, the included studies were regarded as at low risk of bias. Authors’ conclusions: The limited trial evidence that is available to date does not support the use of selenium supplements in the primary prevention of CVD

It’s hard to play ball:A qualitative study of knowledge exchange and silo effects in public health

Background Partnerships in public health form an important component of commissioning and implementing services, in England and internationally. In this research, we examine the views of staff involved in a City-wide health improvement programme which ran from 2009 to 2013 in England. We examine the practicalities of partnership work in community settings, and we describe some of barriers faced when implementing a large, multi-organisation health improvement programme. Methods Qualitative, semi-structured interviews were performed. Purposive sampling was used to identify potential participants in the programme: programme board of directors, programme and project managers and intervention managers. Interviews were conducted one-to-one. We conducted a thematic analysis using the ‘one sheet of paper’ technique. This involved analysing data deductively, moving from initial to axial coding, developing categories and then identifying emerging themes. Results Fifteen interviews were completed. Three themes were identified. The first theme reflects how poor communication approaches hindered the ability of partnerships to deliver their aims and objectives in a range of ways and for a range of reasons. Our second theme reflects how a lack of appropriate knowledge exchange hindered decision-making, affected trust and contributed to protectionist approaches to working. This lack of shared, and communicated, understanding of what type of knowledge is most appropriate and in which circumstance made meaningful knowledge exchange challenging for decision-making and partnership-working in the City-wide health improvement programme. Theme three demonstrates how perceptions about silos in partnership-working could be problematic, but silos themselves were at times beneficial to partnerships. This revealed a mismatch between rhetoric and a realistic understanding of what components of the programme were functional and which were more hindrance than help. Discussion There were high expectations placed on the concept of what partnership work was, or how it should be done. We found our themes to be interdependent, and reflective of the ‘dynamic fluid process’ discussed within the knowledge mobilisation literature. We contend that reframing normal and embedded processes of silos and silo-working already in use might ease resistance to some knowledge exchange processes and contribute to better long-term functioning of public health partnerships

Citation classics in systematic reviews and meta-analyses : who wrote the top 100 most cited articles?

Background: Systematic reviews of the literature occupy the highest position in currently proposed hierarchies of evidence. The aims of this study were to assess whether citation classics exist in published systematic review and meta-analysis (SRM), examine the characteristics of the most frequently cited SRM articles, and evaluate the contribution of different world regions. Methods: The 100 most cited SRM were identified in October 2012 using the Science Citation Index database of the Institute for Scientific Information. Data were extracted by one author. Spearman’s correlation was used to assess the association between years since publication, numbers of authors, article length, journal impact factor, and average citations per year. Results: Among the 100 citation classics, published between 1977 and 2008, the most cited article received 7308 citations and the least-cited 675 citations. The average citations per year ranged from 27.8 to 401.6. First authors from the USA produced the highest number of citation classics (n=46), followed by the UK (n=28) and Canada (n=15). The 100 articles were published in 42 journals led by the Journal of the American Medical Association (n=18), followed by the British Medical Journal (n=14) and The Lancet (n=13). There was a statistically significant positive correlation between number of authors (Spearman’s rho=0.320, p=0.001), journal impact factor (rho=0.240, p=0.016) and average citations per year. There was a statistically significant negative correlation between average citations per year and year since publication (rho = -0.636, p=0.0001). The most cited papers identified seminal contributions and originators of landmark methodological aspects of SRM and reflect major advances in the management of and predisposing factors for chronic diseases. Conclusions: Since the late 1970s, the USA, UK, and Canada have taken leadership in the production of citation classic papers. No first author from low or middle-income countries (LMIC) led one of the most cited 100 SRM

The barriers and facilitators to the implementation of clinical guidance in elective orthopaedic surgery : a qualitative study protocol

Background: Clinical guidelines in orthopaedic surgery aim to improve the efficiency, quality and outcomes of patient care by ensuring that treatment recommendations are based on the best available evidence. The simple provision of guidelines, however, does not ensure fidelity or guarantee their uptake and use in surgical practice. Research exploring the factors that affect surgeons’ use of evidence and guidelines has focused on understanding what evidence exists for current clinical decisions. This narrowed scope emphasises the technical, educational and accessibility issues but overlooks wider factors that help explain how and why guidelines are not implemented and used in surgery. It is also important to understand how we can encourage the implementation processes in practice. By taking a social science perspective to examine orthopaedic surgery, we move beyond the narrow focus and explore how and why clinical guidelines struggle to achieve full uptake. We aim to explore guideline uptake to discover the factors that contribute to, or complicate, appropriate implementation in this field. We need to go beyond traditional views and experimental methods to examine the barriers and facilitators of implementation in real-life NHS surgical practice. These could be multifactorial, linked to individual, organisational or contextual influences, which act on the guideline implementation process. Methods/design: We will use ethnographic methods to conduct case studies in three English NHS hospitals. Within each case, we will conduct observations, interviews and analysis of key documents to understand experiences, complex processes and decisions made and the role of clinical guidance and other sources of evidence within orthopaedic surgery. The data will be transcribed and analysed thematically. Comparisons will be made within cases and across cases. Discussion: Guidelines are a fundamental part of clinical practice, and various factors must be considered when preparing for their successful implementation into organisations. Understanding the views and experiences of a range of surgical, clerical and managerial staff across multiple orthopaedic departments will capture the complexity and variety of factors that can influence surgical decisions. The findings of our study will identify the specific features of orthopaedic practice to help guide the development of strategies to facilitate guideline uptake in everyday surgical work