Orwik

Opportunities and challenges in school-based sex and sexual health education in Nepal.

This article identifies and addresses opportunities for and challenges to current school-based sex and sexual health education in Nepal. Key literature searches were conducted of electronic databases and relevant web-sites, furthermore personal conta... expand abstractct with experts and the hand searching of key journals was included. The review of this literature generated the following challenges: Limitations to teaching including lack of life skill-based and human right-based approach, inappropriate teaching aid and reliance on conventional methods, existing policy and practice, parental/community support, and lack of research into and evaluation of sex education. Diverse methodology in teaching, implementation of peer education programme, partnership with parents, involvement of external agencies and health professionals, capacity building of teachers, access to support and service organisation, and research and evaluation in sex education have been suggested for improving the current practice of sex and sexual health education in Nepalese schools. Key words: Sex education, education, school, adolescence, Nepal. collapse abstract

Sexual and reproductive health status among young peoples in Nepal: opportunities and barriers for sexual health education and services utilization.

This article attempts to summarise the situation of sexual and reproductive health among young people in Nepal. Modernisation and social transformation are occurring rapidly in Nepalese society. Growing expansion of communication and transportation n... expand abstractetworks, urbanisation and in-migration of population to urban areas is creating a different socio-cultural environment, which is conducive to more social interactions between young girls and boys in Nepal. Rising age at marriage has now opened a window of opportunity for pre-marital and unsafe sexual activity among young people in Nepal which creates risks of unwanted pregnancy, STIs/HIV and AIDS. Several socio-economic, demographic and cultural factors have been identified as encouraging factors for risk taking behaviours among young people. Improving access to youth friendly services, implementing peer education programmes for school and out of school going adolescents, developing effective Information, Communication and Education (IEC) materials and curricula have been highly suggested to improve the existing young people's sexual and reproductive health status. collapse abstract

Using a realist approach to evaluate smoking cessation interventions targeting pregnant women and young people.

ABSTRACT: BACKGROUND: This paper describes a study protocol designed to evaluate a programme of smoking cessation interventions targeting pregnant women and young people living in urban and rural locations in Northeast Scotland. The study design was ... expand abstractdeveloped on so-called 'realist' evaluation principles, which are concerned with the implementation of interventions as well as their outcomes. METHODS/DESIGN: A two-phased study was designed based on the Theory of Change (TOC) using mixed methods to assess both process and outcome factors. The study was designed with input from the relevant stakeholders. The mixed-methods approach consists of semi-structured interviews with planners, service providers, service users and non-users. These qualitative interviews will be analysed using a thematic framework approach. The quantitative element of the study will include the analysis of routinely collected data and specific project monitoring data, such as data on service engagement, service use, quit rates and changes in smoking status. DISCUSSION: The process of involving key stakeholders was conducted using logic modelling and TOC tools. Engaging stakeholders, including those responsible for funding, developing and delivering, and those intended to benefit from interventions aimed at them, in their evaluation design, are considered by many to increase the validity and rigour of the subsequent evidence generated. This study is intended to determine not only the components and processes, but also the possible effectiveness of this set of health interventions, and contribute to the evidence base about smoking cessation interventions aimed at priority groups in Scotland. It is also anticipated that this study will contribute to the ongoing debate about the role and challenges of 'realist' evaluation approaches in general, and the utility of logic modelling and TOC approaches in particular, for evaluation of complex health interventions. collapse abstract

Sexual health knowledge, sexual relationships and condom use among male trekking guides in Nepal: a qualitative study.

People in Nepal generally hold fairly traditional views about sex and sexual health, whilst Western tourists often have a more liberal approach towards sex and relationships. There is evidence that significant sexual interaction occurs between male t... expand abstractrekking guides and female travellers and/or local female sex workers in Nepal. This qualitative study explored trekking guides' sexual health knowledge, sexual relationships and condom use with female trekkers and local female sex workers. A total of 21 in-depth interviews were conducted with male trekking guides. Most reported having had sexual relationships with female trekkers and local female sex workers. Explanations for intercourse with female trekkers included: financial support; getting future trekkers through word-of-mouth advertising from the women they have had sex with; and opportunities for emigration. Interestingly, sexual intercourse is reported as more likely to be initiated by female trekkers than by guides, and more so by older women. In contrast, the main reasons for having sex with local female sex workers included: romantic love or sexual excitement and novelty. Awareness regarding sexual health was high among guides, but several factors discouraged the regular use of condoms. Further research with female tourists would help understand the motivations and reasons for their sexual behaviour. collapse abstract

Rural maternity care: can we learn from Wal-Mart?

In many countries rural maternity care is under threat. Consequently rural pregnant women will have to travel further to attend larger maternity units to receive care and deliver their babies. This trend is not dissimilar from the disappearance of ot... expand abstracther rural services, such as village shops, banks, post offices and bus services. We use a comparative approach to draw an analogy with large-scale supermarkets, such as the Wal-Mart and Tesco and their effect on the viability of smaller rural shops, depersonalisation of service and the wider community. The closure of a community-maternity unit leads to women attending a different type of hospital with a different approach to maternity care. Thus small community-midwifery units are being replaced, not by a very similar unit that happens to be further away, but by a larger obstetric unit that operates on different models, philosophy and notions of risk. Comparative analysis allows a fresh perspective on the provision of rural maternity services. We argue that previous discussions focusing on medicalisation and change in maternity services can be enhanced by drawing on experience in other sectors and taking a wider societal lens. collapse abstract

Politicians in apron: case study of rebel health services in Nepal.

This article presents the findings of a systematic review on the health consequences of Nepal's armed conflict waged by the Maoists and the development and trajectory of their health workers. Nepal's decade-long violent conflict resulted in more than... expand abstract 13,000 deaths, the destruction of more than 1000 health posts and poor health services delivery. At present, most of the former rebel health workers live in remote/rural areas and some are running health centers. The review found that the Maoists had trained more than 2000 health workers, who can be categorized into 4 levels. However, there is little evidence on their competencies and career motivation. The Maoists demand restructuring of the Nepalese health sector and the integration of their health workforce into the national health system. However, there has been no national discussion in Nepal of what kind of health reform and integration model is appropriate for a sustainable peace and improved service delivery. collapse abstract

Factors associated with self-reported first sexual intercourse in Scottish adolescents.

BACKGROUND: There is continuing concern about high pregnancy rates and increasing numbers of sexually transmitted infections being detected in Scottish adolescents. Consistent evidence about factors associated with risky sexual behaviours, including ... expand abstractearly first sexual intercourse, may help to identify adolescents at risk and help improve interventions. This study aimed to provide detailed analysis of the evidence of the associations between individual factors and early sexual intercourse using cross-sectional questionnaire data from 4,379 Scottish adolescents who participated in a sexual health intervention evaluation. FINDINGS: Multivariate secondary analysis showed that aspects of family and school life such as decreasing parental monitoring (OR 1.45, 95% CI 1.24-1.70) and decreasing enjoyment of school (OR 2.55, 95% CI 2.15-3.03) were associated with reporting previous sexual intercourse. Furthermore, females were more likely to report previous sexual intercourse than males (OR 1.48, 95% CI 1.14-1.91). Several factors commonly used to inform sexual health intervention design, such as socioeconomic status, self-esteem and religion, were not independently associated. CONCLUSION: These results contribute to the evidence base for the association of several factors with early initiation of sexual activity. The findings suggest that interventions aiming to delay first intercourse may need to consider targeting aspects of individuals' connection to their school and family. Furthermore, the results do not support the need to consider socio-economic background, religion or self-esteem of the individuals in intervention design. collapse abstract

Needs assessment study for community pharmacy travel medicine services.

BACKGROUND: Community pharmacists in the UK currently provide limited travel medicine services. An enhanced service could offer the traveling public general advice, provision of immunizations, and malaria prophylaxis. The assessment of need for a tra... expand abstractvel vaccine service from community pharmacies is key to the decision to develop the service. METHOD: The needs assessment used a questionnaire survey of potential travelers recruited from community pharmacies and the regional travel clinic. RESULTS: In total, 151 completed questionnaires were received (response rate 40%); nearly three times as many replies were from females (74%) than males (26%). Details for 230 different proposed visits abroad and 174 different past visits were analyzed. General medical practice (54.3%) and community pharmacies (36.4%) were rated as providing the most useful advice. Most respondents (76.4%) required advice on vaccines, 53.9% on malaria prophylaxis, and 54.9% on bite prevention. Many (58.9%) agreed, or strongly agreed, that they would use the community pharmacy to provide travel immunizations, while 43% (strongly) agreed that they would be prepared to pay to obtain travel medicine services including immunizations. The median amount that participants were prepared to pay for a full travel assessment was pound 10, pound 13 for the administration of typhoid vaccine, pound 70 for a course of rabies vaccine, and pound 25 for malaria tablets for Kenya. Nearly three quarters (74.8%) agreed, or strongly agreed, that the community pharmacy would provide a convenient location from which to obtain travel services and 70.2% that the pharmacy could provide a one-stop shop for travel medicine services. CONCLUSIONS: Members of the traveling public do visit community pharmacies, and most people are traveling for holiday purposes. The results suggest that travelers would be prepared to use the community pharmacy to provide travel advice and immunizations. collapse abstract

Major problems and key issues in Maternal Health in Nepal.

This paper highlights some of the challenges facing maternal health in Nepal and to suggest possible solutions for improvements. Key literature from across the globe is reviewed and discussed in a Nepalese context. Maternal mortality remains one of t... expand abstracthe biggest public health problems in Nepal. Lack of access to basic maternal healthcare, difficult geographical terrain, poorly developed transportation and communication systems, poverty, illiteracy, women's low status in the society, political conflict, shortage of health care professional and under utilization of currently available services are major challenges to improving maternal health in Nepal. In order to effect real improvements in maternal health, attention needs to be focused both on biomedical and social interventions. Improving health facilities, mother's nutrition, women's position in the society such as freedom of movement, providing education to female children, integrating Traditional Birth Attendants into local health services can play a vital role in the improvement of mothers' health. collapse abstract

Clinical governance and research ethics as barriers to UK low-risk population-based health research?

BACKGROUND: Since the Helsinki Declaration was introduced in 1964 as a code of practice for clinical research, it has generally been agreed that research governance is also needed in the field of public health and health promotion research. Recently,... expand abstract a range of factors led to the development of more stringent bureaucratic procedures, governing the conduct of low-risk population-based health research in the United Kingdom. METHODS: Our paper highlights a case study of the application process to medical research ethics committees in the United Kingdom for a study of the promotion of physical activity by health care providers. The case study presented here is an illustration of the challenges in conducting low-risk population-based health research. RESULTS: Our mixed-methods approach involved a questionnaire survey of and semi-structured interviews with health professionals (who were all healthy volunteers). Since our study does not involve the participation of either patients or the general population, one would expect the application to the relevant research ethics committees to be a formality. This proved not to be the case! CONCLUSION: Research ethics committees could be counter-productive, rather than protecting the vulnerable in the research process, they can stifle low-risk population-based health research. Research ethics in health services research is first and foremost the responsibility of the researcher(s), and we need to learn to trust health service researchers again. The burden of current research governance regulation to address the perceived ethical problems is neither appropriate nor adequate. Senior researchers/academics need to educate and train students and junior researchers in the area of research ethics, whilst at the same time reducing pressures on them that lead to unethical research, such as commercial funding, inappropriate government interference and the pressure to publish. We propose that non-invasive low-risk population-based health studies such as face-to-face interviews with health and social care professionals or postal questionnaire studies with patients on non-sensitive topics are given a waiver or a light touch review. We suggest that this can be achieved through a two-staged ethics application process. The first stage starts with a one or two-page outline application which ethics committees can use as the basis to grant a waiver or request a full application. collapse abstract

The use of traditional medicine by Ghanaians in Canada.

BACKGROUND: Research into health and health-care seeking behaviour amongst immigrant populations suggests that culturally-based behaviours change over time towards those prevalent in the host culture. Such acculturation of immigrant groups occurs as ... expand abstractpart of the interaction of immigrants with mainstream culture. This study examined the acculturation of Ghanaian immigrants in Greater Toronto Area (Canada) focusing particularly on attitudes towards and usage of Ghanaian traditional medicine (TRM). METHODS: The study used both quantitative and qualitative methods. Structured questionnaire interviews were conducted with a sample of Ghanaians in active collaboration with the Ghanaian-Canadian Association in the Greater Toronto Area (GTA). A total of 512 questionnaire interviews were conducted. In addition, three focus groups of nine participants each were conducted with a sub-sample of Ghanaians in Canada. RESULTS: Both the questionnaire and the focus groups indicated that nearly 73% of the Ghanaian immigrants in Canada have a positive attitude toward Ghanaian TRM. This is in comparison with less than 30% who have changed their attitude for various reasons. Some of the attraction of TRM lies in its holistic origin. Ghanaians in the GTA have been pursuing 'integration' and 'assimilation' in their acculturation in Canada. Some have given up or modified some of their attitudes and opinions toward TRM to embrace the 'modern' or 'civilized' way of living. CONCLUSION: There is the need for health care providers and other stakeholders to be aware of the influence of religion on African immigrants during their acculturation process. Although modernity is said to be founded on the 'ruthless undermining of tradition', there is no evidence to suggest that Ghanaian traditional religion has been undermined to such an extent that there is a major change in attitudes towards TRM. collapse abstract

Health and lifestyle of Nepalese migrants in the UK.

BACKGROUND: The health status and lifestyle of migrants is often poorer than that of the general population of their host countries. The Nepalese represent a relatively small, but growing, immigrant community in the UK, about whom very little is know... expand abstractn in term of public health. Therefore, our study examined the health and lifestyle of Nepalese migrants in the UK. METHODS: A cross-sectional survey of Nepalese migrants in UK was conducted in early 2007 using a postal, self-administered questionnaire in England and Scotland (n = 312), and telephone interviews in Wales (n = 15). The total response rate was 68% (327 out of 480). Data were analyzed to establish whether there are associations between socio-economic and lifestyle factors. A multivariate binary logistic regression was applied to find out independent effect of personal factors on health status. RESULTS: The majority of respondents was male (75%), aged between 30 and 45 (66%), married or had a civil partner (83%), had university education (47%) and an annual family income (69%) ranging from pound5,035 to pound33,300. More than one third (39%) of the respondents have lived in the UK for 1 to 5 years and approximately half (46%) were longer-term residents. Most (95%) were registered with a family doctor, but only 38% with a dentist. A low proportion (14%) of respondents smoked but more than half (61%) consumed alcohol. More than half (57%) did not do regular exercises and nearly one fourth (23%) of respondents rated their health as poor. Self reported 'good' health status of the respondents was independently associated with immigration status and doing regular exercise CONCLUSION: The self reported health status and lifestyle, health seeking behaviour of Nepalese people who are residing in UK appears to be good. However, the overall regular exercise and dentist registration was rather poor. Health promotion, especially aimed at Nepalese migrants could help encourage them to exercise regularly and assist them to register with a dentist. collapse abstract

Key health promotion factors among male members of staff at a higher educational institution: a cross-sectional postal survey.

BACKGROUND: Men's lifestyles are generally less healthy than women's. This study identifies associations between health-related behaviour in different groups of men working in a Higher Education (HE) institution. In addition, men were asked whether t... expand abstracthey regarded their health-related behaviours as a concern. This article highlights smoking, consumption of alcohol and physical activity as most common men's health-related lifestyle behaviours. METHODS: A descriptive cross-sectional survey was conducted among all male staff employed by a Higher Education institute in Scotland using a postal self-completed questionnaire. A total of 1,335 questionnaires were distributed and 501 were returned completed (38% return rate). The data were analysed using SPSS 13.0 for Windows. RESULTS: Less than 10% currently smoked and almost 44% of these smokers were light smokers. Marital status, job title, consumption of alcohol and physical activity level were the major factors associated with smoking behaviour. Men in manual jobs were far more likely to smoke. Nearly all (90%) consumed alcohol, and almost 37% had more than recommended eight units of alcohol per day at least once a week and 16% had more than 21 units weekly. Younger men reported higher amount of units of alcohol on their heaviest day and per week. Approximately 80% were physically active, but less than 40% met the current Government guidelines for moderate physical activity. Most men wanted to increase their activity level. CONCLUSION: There are areas of health-related behaviour, which should be addressed in populations of this kind. Needs assessment could indicate which public health interventions would be most appropriately aimed at this target group. However, the low response rate calls for some caution in interpreting our findings. collapse abstract

A systematic review of school-based sexual health interventions to prevent STIHIV in sub-Saharan Africa.

BACKGROUND: The HIV/AIDS epidemic remains of global significance and there is a need to target (a) the adolescent age-groups in which most new infections occur; and (b) sub-Saharan Africa where the greatest burden of the epidemic lies. A focused syst... expand abstractematic review of school-based sexual health interventions in sub-Saharan Africa to prevent HIV/AIDS and Sexually Transmitted Infections (STI) in this age group was therefore conducted. METHODS: Searches were conducted in Medline, Embase, Cinahl and PsychINFO according to agreed a priori criteria for studies published between 1986 and 2006. Further searches were conducted in UNAIDS and WHO (World Health Organization) websites, and 'Google'. Relevant journals were hand-searched and references cited in identified articles were followed up. Data extraction and quality assessment was carried out on studies selected for full text appraisal, and results were analysed and presented in narrative format. RESULTS: Some 1,020 possible titles and abstracts were found, 23 full text articles were critically appraised, and 12 articles (10 studies) reviewed, reflecting the paucity of published studies conducted relative to the magnitude of the HIV epidemic in sub-Saharan Africa. Knowledge and attitude-related outcomes were the most associated with statistically significant change. Behavioural intentions were more difficult to change and actual behaviour change was least likely to occur. Behaviour change in favour of abstinence and condom use appeared to be greatly influenced by pre-intervention sexual history. CONCLUSION: There is a great need in sub-Saharan Africa for well-evaluated and effective school-based sexual health interventions. collapse abstract

Utilisation of postnatal care among rural women in Nepal.

BACKGROUND: Postnatal care is uncommon in Nepal, and where it is available the quality is often poor. Adequate utilisation of postnatal care can help reduce mortality and morbidity among mothers and their babies. Therefore, our study assessed the uti... expand abstractlisation of postnatal care at a rural community level. METHODS: A descriptive, cross-sectional study was carried out in two neighbouring villages in early 2006. A total of 150 women who had delivered in the previous 24 months were asked to participate in the study using a semi-structured questionnaire. RESULTS: The proportion of women who had received postnatal care after delivery was low (34%). Less than one in five women (19%) received care within 48 hours of giving birth. Women in one village had less access to postnatal care than women in the neighbouring one. Lack of awareness was the main barrier to the utilisation of postnatal care. The woman's own occupation and ethnicity, the number of pregnancies and children and the husband's socio-economic status, occupation and education were significantly associated with the utilisation of postnatal care. Multivariate analysis showed that wealth as reflected in occupation and having attended antenatal are important factors associated with the uptake of postnatal care. In addition, women experiencing health problems appear strongly motivated to seek postnatal care. CONCLUSION: The postnatal care has a low uptake and is often regarded as inadequate in Nepal. This is an important message to both service providers and health-policy makers. Therefore, there is an urgent need to assess the actual quality of postnatal care provided. Also there appears to be a need for awareness-raising programmes highlighting the availability of current postnatal care where this is of sufficient quality. collapse abstract

Dutch women's decision-making in pregnancy and labour as seen through the eyes of their midwives.

OBJECTIVE: a national study of midwives' perceptions of women's decision-making in the technical interventions in the birth process. DESIGN: questionnaire survey of women and their midwives. Midwives completed a maternity record for each woman in the... expand abstract study after the birth, and the women completed a demographic questionnaire at to 20-24 weeks gestation. SETTING: a stratified sample of 25 Dutch midwifery practices based on rural or urban location. Each of these 25 independent practices agreed to approach 25 eligible consecutive pregnant women on a randomly assigned day. PARTICIPANTS: in total 637 women were invited and 625 participated (response rate 98%). FINDINGS AND KEY CONCLUSIONS: midwives reported that they had a large influence in the decision to refer a woman to an obstetrician, but far and far less so when it comes to decisions around taking pharmaceutical pain relief. Midwives felt women had least say in the decision around augmentation of labour and most in the decision to sweep the membranes, whilst obstetricians had most input in the decision around primary induction of labour and least in the decision to refer from primary to secondary care. Our analysis indicated that midwives saw younger women (29 and younger) as having more influence in the decision-making process than old ones. Our analysis suggests there might be a tension between midwives own professional ideology and their non-interventionist focus and women's choice, which leads to an increase in medicalisation of childbirth. collapse abstract

Importance of piloting a questionnaire on sexual health research.

Decentred comparative research: Context sensitive analysis of maternal health care.

Cross-national comparison is an important tool for health care research, but too often those who use this method fail to consider important inter-national differences in the social organisation of health care and in the relationship between health ca... expand abstractre practices and social experience. In this article we make the case for a context-sensitive and reflexive analysis of health care that allows researchers to understand the important ways that health care systems and practices are situated in time and place. Our approach--decentred comparative research--addresses the often unacknowledged ethnocentrism of traditional comparative research. Decentred cross-national research is a method that draws on the socially situated and distributed expertise of an international research team to develop key concepts and research questions. We used the decentred method to fashion a multilevel framework that used the meso level of organisation (i.e., health care organisations, professional groups and other concrete organisations) as an analytical starting point in our international study of maternity care in eight countries. Our method departs from traditional comparative health systems research that is most often conducted at the macro level. Our approach will help researchers develop new and socially robust knowledge about health care. collapse abstract

Inconsistent grading of evidence across countries: a review of low back pain guidelines.

OBJECTIVE: The aim of this study was to report clinical treatment recommendations for low back pain (LBP) based on 5 international guidelines and best evidence from the Cochrane database of systematic reviews. METHODS: Five LBP guidelines available i... expand abstractn English language were appraised, including 4 studies published since the seminal work by Koes et al (Spine 2001;26:2504-5213). The guidelines were examined for treatment recommendations concerning nonspecific LBP and guideline quality with application of the Appraisal of Guidelines for Research and Evaluation instrument. Secondly, a systematic literature search for reviews and randomized controlled trials was conducted using a modified version of the search strategy recommended by the Cochrane Back Review Group. Two systematic reviews were identified. RESULTS: According to best evidence from review of the Cochrane database of systematic reviews, there remains a lack of consensus regarding reported efficacy of spinal manipulative therapy for the treatment of nonspecific LBP. Furthermore, the guidelines reviewed in the present study have not changed significantly with respect to treatment recommendations for nonspecific LBP since the original review, and there is inconsistency between the guidelines regarding optimal time to introduce spinal manipulation to treat nonspecific LBP. CONCLUSION: Treatment recommendations for nonspecific LBP, particularly spinal manipulation, remain inconclusive. Guideline developers need to consider guidelines in neighboring countries and reach consensus on how evidence is graded and incorporated into guidelines. Guidelines should continue to be regularly updated to incorporate new evidence and methods of grading the evidence. collapse abstract

A qualitative study of an integrated maternity, drugs and social care service for drug-using women.

BACKGROUND: The care of drug-using pregnant women is a growing health and social care concern in many countries. A specialist clinic was established offering multidisciplinary care and advice to pregnant drug users in and around Aberdeen (UK) in 1997... expand abstract. The majority of women stabilise and reduce their drug use. By determining the needs and views of the women more appropriate services and prevention strategies may be developed. There has been little research conducted in this area and none in Scotland. METHODS: This is a qualitative study that aimed to gain an understanding of the experiences of women drug users, seeking and receiving prenatal care and drug services from a specialist clinic. Twelve women participated in semi-structured one-to-one interviews. RESULTS: The women preferred the multidisciplinary clinic (one-stop shop) to traditional prenatal care centred within General Practice. The relationships of the clients to the range of Clinic professionals and in hospital were explored as well as attitudes to Clinic care. The study participants attributed success in reducing their drug use to the combination of different aspects of care of the multi-agency clinic, especially the high level prenatal support. It is this arrangement of all aspects of care together that seem to produce better outcomes for mother and child than single care elements delivered separately. Some women reported that their pregnancy encouraged them to rapidly detoxify due to the guilt experienced. The most important aspects of the Clinic care were found to be non-judgemental attitude of staff, consistent staff, high level of support, reliable information and multi-agency integrated care. CONCLUSION: There is an impetus for women drug users to change lifestyle during pregnancy. The study highlighted a need for women to have access to reliable information on the effects of drugs on the baby. Further research is required to determine whether positive outcomes related to clinic attendance in the prenatal period are sustained in the postnatal period. Early referral to a specialist clinic is of benefit to the women, as they reported to receive more appropriate care, especially in relation to their drug use. A greater awareness of needs of the pregnant drug user could help the design of more effective prevention strategies. collapse abstract

Avoidance as a strategy of (not) coping: qualitative interviews with carers of Huntington's Disease patients.

BACKGROUND: Since Huntington's Disease (HD) is a familial disease with an average onset in the mid-thirties, one might expect that spousal carers are concerned with providing care for off-spring who may turn out to be affected. METHODS: This study in... expand abstractvolved ten face-to-face interviews with carers of spouses affected by HD in Northeast Scotland. Carers were recruited through two channels: a genetic clinic and the Scottish Huntington's Association (SHA). Interviews were conducted in carers' own homes. A thematic analysis of the transcripts was conducted. RESULTS: Although carers did worry about their children, they did not envisage being involved in their care. Many avoided talking about the disease, both within and outwith their family; this may have greatly reduced the level of support provided by family members. Conversely, avoidance was often accompanied by symptom-spotting. For example, several people had given up driving, before they were incapable of doing so. The explanation appears to be that they avoided getting into situations in which HD may express itself. Support meetings seem to be valued amongst patients with other serious diseases and their carers, however, although all participants had had contact with the SHA, only one regularly attended meetings. It was felt that seeing others with HD provided a constant reminder of the possible effect of HD on the wider family, which seemed to outweigh the benefit of attending. Overall, the analysis highlighted 'avoidance' as a key theme. CONCLUSION: Many denied symptoms of HD in their spouses, pre-diagnosis. All had pretended at some point that it was not happening, through ignoring early signs and 'obvious' symptoms. Some partners had refused to go to the doctor until it was no longer possible to deny symptoms. Formal health and social care seemed to play a very small role compared to informal care arrangements. collapse abstract

Understanding the social organisation of maternity care systems: midwifery as a touchstone.

Theories of professions and healthcare organisation have difficulty in explaining variation in the organisation of maternity services across developed welfare states. Four countries - the United Kingdom, Finland, the Netherlands and Canada - serve as... expand abstract our case examples. While sharing several features, including political and economic systems, publicly-funded universal healthcare and favourable health outcomes, these countries nevertheless have distinct maternity care systems. We use the profession of midwifery, found in all four countries, as a 'touchstone' for exploring the sources of this diversity. Our analysis focuses on three key dimensions: (1) welfare state approaches to legalising midwifery and negotiating the role of the midwife in the division of labour; (2) professional boundaries in the maternity care domain; and (3) consumer mobilisation in support of midwifery and around maternity issues. collapse abstract

Family communication about genetic risk: the little that is known.

Although family communication is important in clinical genetics only a small number of studies have specifically explored the passing on of genetic knowledge to family members. In addition, many of these present exploratory or tentative findings base... expand abstractd upon small sample sizes, or data collected only a short time after testing. Nevertheless, if health professionals are to develop effective strategies to help patients' deal with communication issues, we need to know more about what actually happens in families. The aim of this commentary is to identify factors which appear to influence whether patients share information about genetic risk with relatives who are unaware of that risk, with whom they share it and how they go about it. The paper draws upon evidence and thinking from the disciplines of psychology (including family therapy), sociology, medicine and genetic counselling. It is presented under the following headings: disease factors, individual factors, family factors and sociocultural factors. It concludes by highlighting a number of key issues which are relevant for health professionals. collapse abstract

Economic and social implications of multiple birth.

This paper provides the background statistics and trends on multiple births. It highlights a number of factors that influence parents with multiples, including social situation, psychological adjustment and economic circumstances. It is often assumed... expand abstract that these areas of concern arise only after the babies have been born, but clinicians should be aware that many are seen in the antenatal period as well. Apart from the socioeconomic cost to individual families, multiple births also carry a cost to society. A number of self-help groups and voluntary organisations can assist parents of multiples. This is especially important if parents find that family and friends cannot or will not come forward. collapse abstract

Does a pregnant woman's intended place of birth influence her attitudes toward and occurrence of obstetric interventions?

BACKGROUND: A home confinement with midwifery care is still an integral part of Dutch maternity care. It has been argued that the existence of home birth itself influences the course of the birth process positively, which is why obstetric interventio... expand abstractns are low in comparison with neighboring countries. This study examined the impact of women's intended place of birth (home or hospital) and the course of pregnancy and labor when attended by midwives. METHODS: This is a prospective study of 625 low-risk pregnant women, gestation 20 to 24 weeks, enrolled in 25 independently working midwifery practices. The course of labor was measured by the frequency of interventions by midwives and obstetricians. RESULTS: A more non-technological approach to childbirth was observed within the women opting for a home birth compared with the women opting for a hospital birth. Data showed a relationship between interventions and planned birth site: sweeping membranes and amniotomy by midwives were more likely to be conducted in women opting for a home birth. Multiparas opting for hospital birth were more likely to experience consultations and referrals. Within the group of multiparas referred for obstetrician care, women intending to have a home birth experienced fewer interventions (e.g., induction, augmentation, pharmacologic pain relief, assisted delivery, cesarean section) compared with those who had opted for a hospital birth. CONCLUSIONS: A large proportion of women desire a home birth. The impact of that choice demonstrated a smoother course of the birth process, compared with women who desired to deliver in the hospital, as measured by fewer obstetric interventions. We suggest that psychological factors (expectation and perceptions) influence both a woman's decision of birthplace and the actual birth process. collapse abstract