Publications by authors named "Premila Webster"

43 Publications

Building resilience for the future.

J Public Health (Oxf) 2021 Sep;43(3):435-436

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http://dx.doi.org/10.1093/pubmed/fdab334DOI Listing
September 2021

Adolescent and adult perceptions of the effects of larger size graphic health warnings on conventional and plain tobacco packs in India: A community-based cross-sectional study.

Tob Induc Dis 2019 1;17:70. Epub 2019 Oct 1.

Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.

Introduction: We studied adolescent and adult perceptions of the effects of larger size, 85% versus 40%, Graphic Health Warnings (GHWs) on conventional and plain tobacco packs, in India.

Methods: A cross-sectional survey was conducted with 2121 participants (aged ≥13 years), during the period 2015-16, in Delhi and Telangana, India. Four categories of GHWs on tobacco packs were shown: A - 40% existing (April 2013-April 2016), B - 40% new (April 2016-present), C - 85% new, and D - plain packs (85% new). Regression models tested percentage differences in choice of categories for eight outcomes, adjusted for gender, area of residence, socioeconomic status, age, and tobacco use.

Results: Of the total 2121 participants, 1120 were from Delhi, 1001 from Telangana, 50% were males, 62% were urban residents, 12% were adolescents, and 72% had never used tobacco. Among packs shown, the majority of participants perceived the 85% size GHWs more effective than the 40% size GHWs across all outcomes. The perceived increase in noticeability of GHWs was 45% for category C (p<0.05) and 43.5% for category D (p<0.05) versus category B. In Delhi, participants perceived plain packs to be most effective in motivating quitting, preventing initiation and conveying the health message. In Telangana, adolescents believed GHWs on plain packs were most noticeable, most effective for quitting and preventing initiation.

Conclusions: The larger size 85% GHWs were perceived to be more effective in increasing noticeability of warnings, motivating cessation, preventing initiation, and conveying the intended health message. Support for plain packaging was higher in Delhi and among adolescents in Telangana.
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http://dx.doi.org/10.18332/tid/110677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786002PMC
October 2019

Editorial.

J Public Health (Oxf) 2019 09;41(3):429

University of Nottingham.

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http://dx.doi.org/10.1093/pubmed/fdz109DOI Listing
September 2019

Plain packaging of tobacco products: the logical next step for tobacco control policy in India.

BMJ Glob Health 2018 26;3(5):e000873. Epub 2018 Sep 26.

Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia.

India implemented larger 85% pictorial health warnings on all tobacco products from 1 April 2016. However, to remove the last bit of glamour and attraction from the tobacco packs, it must now embrace plain packaging. Plain packaging prevents tobacco packs from carrying the tobacco industry brand imagery as mobile billboards. Postimplementation of larger 85% pictorial health warnings on all tobacco products, this analysis was undertaken to assess the feasibility of plain packaging as the next logical tobacco control policy measure in India. As part of this analysis, the research team reviewed the available literature on legal and policy challenges to plain packaging as a tobacco control policy initiative for India. Literature from 2010 to 2016 in English language was reviewed, which reveals that, India has taken several preparatory steps implemented by other countries like Australia and the UK that have introduced plain packaging, for example, stronger smoke-free laws, ban on tobacco advertising, promotion and sponsorship, increase in taxes and a report from civil society task force on plain packaging. The trade and investment agreements signed by India are also within the international trade norms relating to public health. A Private Member's Bill on plain packaging is also pending in the Parliament of India. Other potential challenges against such policy decision, for example, freedom of trade, right to property, violation of competition law and other laws including consumer protection laws, were found unsubstantiated by the research team. Plain packaging is the next logical step for tobacco control policy in India.
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http://dx.doi.org/10.1136/bmjgh-2018-000873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6169668PMC
September 2018

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke.

Cochrane Database Syst Rev 2018 01 31;1:CD001746. Epub 2018 Jan 31.

Nuffield Department of Population Health, University of Oxford, Oxford, UK.

Background: Children's exposure to other people's tobacco smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children in child care or educational settings are also at risk of exposure to ETS. Preventing exposure to ETS during infancy and childhood has significant potential to improve children's health worldwide.

Objectives: To determine the effectiveness of interventions designed to reduce exposure of children to environmental tobacco smoke, or ETS.

Search Methods: We searched the Cochrane Tobacco Addiction Group Specialised Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Education Resource Information Center (ERIC), and the Social Science Citation Index & Science Citation Index (Web of Knowledge). We conducted the most recent search in February 2017.

Selection Criteria: We included controlled trials, with or without random allocation, that enrolled participants (parents and other family members, child care workers, and teachers) involved in the care and education of infants and young children (from birth to 12 years of age). All mechanisms for reducing children's ETS exposure were eligible, including smoking prevention, cessation, and control programmes. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

Data Collection And Analysis: Two review authors independently assessed studies and extracted data. Due to heterogeneity of methods and outcome measures, we did not pool results but instead synthesised study findings narratively.

Main Results: Seventy-eight studies met the inclusion criteria, and we assessed all evidence to be of low or very low quality based on GRADE assessment. We judged nine studies to be at low risk of bias, 35 to have unclear overall risk of bias, and 34 to have high risk of bias. Twenty-one interventions targeted populations or community settings, 27 studies were conducted in the well-child healthcare setting and 26 in the ill-child healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether visits were made to well- or ill-children, and another included visits to both well- and ill-children. Forty-five studies were reported from North America, 22 from other high-income countries, and 11 from low- or middle-income countries. Only 26 of the 78 studies reported a beneficial intervention effect for reduction of child ETS exposure, 24 of which were statistically significant. Of these 24 studies, 13 used objective measures of children's ETS exposure. We were unable to pinpoint what made these programmes effective. Studies showing a significant effect used a range of interventions: nine used in-person counselling or motivational interviewing; another study used telephone counselling, and one used a combination of in-person and telephone counselling; three used multi-component counselling-based interventions; two used multi-component education-based interventions; one used a school-based strategy; four used educational interventions, including one that used picture books; one used a smoking cessation intervention; one used a brief intervention; and another did not describe the intervention. Of the 52 studies that did not show a significant reduction in child ETS exposure, 19 used more intensive counselling approaches, including motivational interviewing, education, coaching, and smoking cessation brief advice. Other interventions consisted of brief advice or counselling (10 studies), feedback of a biological measure of children's ETS exposure (six studies), nicotine replacement therapy (two studies), feedback of maternal cotinine (one study), computerised risk assessment (one study), telephone smoking cessation support (two studies), educational home visits (eight studies), group sessions (one study), educational materials (three studies), and school-based policy and health promotion (one study). Some studies employed more than one intervention. 35 of the 78 studies reported a reduction in ETS exposure for children, irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure but rather sought to reduce symptoms of asthma, and found a significant reduction in symptoms among the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

Authors' Conclusions: A minority of interventions have been shown to reduce children's exposure to environmental tobacco smoke and improve children's health, but the features that differentiate the effective interventions from those without clear evidence of effectiveness remain unclear. The evidence was judged to be of low or very low quality, as many of the trials are at a high risk of bias, are small and inadequately powered, with heterogeneous interventions and populations.
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http://dx.doi.org/10.1002/14651858.CD001746.pub4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6491082PMC
January 2018

Management of older adults with hip fractures in India: a mixed methods study of current practice, barriers and facilitators, with recommendations to improve care pathways.

Arch Osteoporos 2017 Dec 2;12(1):55. Epub 2017 Jun 2.

The George Institute for Global Health, University of Sydney, Sydney, Australia.

Evidence-based management can reduce deaths and suffering of older adults with hip fractures. This study investigates the evidence-practice gaps in hip fracture care in three major hospitals in Delhi, potential barriers and facilitators to improving care, and consequently, identifies contextually appropriate interventions for implementing best practice for management of older adults with hip fractures in India.

Purpose: Hip fracture in older adults is a significant public health issue in India. The current study sought to document current practices, identify barriers and facilitators to adopting best practice guidelines and recommend improvements in the management of older adults with hip fractures in Delhi, India.

Methods: This mixed methods observational study collected data from healthcare providers, patients, carers and medical records from three major public tertiary care hospitals in Delhi, India. All patients aged ≥50 years with an X-ray confirmed hip fracture that were admitted to these hospitals over a 10-week period were recruited. Patients' data were collected at admission, discharge and 30 days post-injury. Eleven key informant interviews and four focus group discussions were conducted with healthcare providers. Descriptive data for key quantitative variables were computed. The qualitative data were analysed and interpreted using a behaviour change wheel framework.

Results: A total of 136 patients, 74 (54%) men and 62 women, with hip fracture were identified in the three participating hospitals during the recruitment period and only 85 (63%) were admitted for treatment with a mean age of 66.5 years (SD 11.9). Of these, 30% received surgery within 48 h of hospital admission, 95% received surgery within 39 days of hospital admission and two (3%) had died by 30 days of injury. According to the healthcare providers, inadequate resources and overcrowding prevent adequate caring of the hip fracture patients. They unanimously felt the need for protocol-based management of hip fracture in India.

Conclusion: The development and implementation of national guidelines and standardized protocols of care for older people with hip fractures in India has the potential to improve both care and patient-related outcomes.
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http://dx.doi.org/10.1007/s11657-017-0344-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5486685PMC
December 2017

Protocol-based management of older adults with hip fractures in Delhi, India: a feasibility study.

Pilot Feasibility Stud 2016 9;2:15. Epub 2016 Mar 9.

Global Surgery, The George Institute for Global Health, University of Oxford, Oxford, OX1 3BD UK.

Background: Worldwide hip fractures are projected to increase from 1.7 million in 1990 to 6.3 million in 2050. In India, conservative estimates suggest an annual incidence of 600,000 osteoporotic hip fractures and this is expected to increase significantly due to ageing and increase life expectancy. Protocol-based 'care pathways' for the management of adults, over 60 years of age, with hip fractures in high-income countries has resulted in decreased mortality rates, early hospital discharge, improved quality of life and reduction in healthcare costs. The study objectives are to determine appropriateness, acceptability and feasibility of adopting best-practice guideline or protocol-based care for the management of hip fractures among older adults in India. The study will also identify barriers and facilitators in recruiting patients and retention till the agreed follow-up period.

Methods: This will be a mixed-methods prospective cohort study. The quantitative data collection will involve recruitment of consecutive patients aged >50 years with an X-ray-confirmed hip fracture admitted in four tertiary care hospitals in Delhi, India, over a 2-month period. The quantitative data will be collected at three points: from patients at admission to hospital, from medical records at discharge and by telephone interviews with patients at 30 days post hip fracture. Qualitative data collection will involve key informant interviews, conducted with clinical leads and focus group discussions, conducted with groups of healthcare providers and patients and/or their carers. COM-B theoretical framework (capability, opportunity, motivation and behaviour) will be used to explore healthcare providers' behaviour in order to facilitate development and implementation of appropriate integrated care pathway for management of older adults with hip fractures in India.

Discussion: The proposed study will identify gaps in best practice in the management of older people with hip fractures in tertiary care hospitals in Delhi and document barriers and facilitators to the implementation of protocol-based care through recording the contextual realities of the health systems and care-seeking behaviours. Insights into these factors will be used to facilitate the development of protocol-based management of older people with hip fractures that is appropriate, context specific and acceptable by stakeholders in a low- and middle-income country setting, such as India.
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http://dx.doi.org/10.1186/s40814-016-0056-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154050PMC
March 2016

Quantifying the Association Between Physical Activity and Cardiovascular Disease and Diabetes: A Systematic Review and Meta-Analysis.

J Am Heart Assoc 2016 09 14;5(9). Epub 2016 Sep 14.

The British Heart Foundation Center on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, United Kingdom

Background: The relationships between physical activity (PA) and both cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) have predominantly been estimated using categorical measures of PA, masking the shape of the dose-response relationship. In this systematic review and meta-analysis, for the very first time we are able to derive a single continuous PA metric to compare the association between PA and CVD/T2DM, both before and after adjustment for a measure of body weight.

Methods And Results: The search was applied to MEDLINE and EMBASE electronic databases for all studies published from January 1981 to March 2014. A total of 36 studies (3 439 874 participants and 179 393 events, during an average follow-up period of 12.3 years) were included in the analysis (33 pertaining to CVD and 3 to T2DM). An increase from being inactive to achieving recommended PA levels (150 minutes of moderate-intensity aerobic activity per week) was associated with lower risk of CVD mortality by 23%, CVD incidence by 17%, and T2DM incidence by 26% (relative risk [RR], 0.77 [0.71-0.84]), (RR, 0.83 [0.77-0.89]), and (RR, 0.74 [0.72-0.77]), respectively, after adjustment for body weight.

Conclusions: By using a single continuous metric for PA levels, we were able to make a comparison of the effect of PA on CVD incidence and mortality including myocardial infarct (MI), stroke, and heart failure, as well as T2DM. Effect sizes were generally similar for CVD and T2DM, and suggested that the greatest gain in health is associated with moving from inactivity to small amounts of PA.
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http://dx.doi.org/10.1161/JAHA.115.002495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5079002PMC
September 2016

Association between maternal anaemia and pregnancy outcomes: a cohort study in Assam, India.

BMJ Glob Health 2016 7;1(1):e000026. Epub 2016 Apr 7.

NPEU, Nuffield Department of Population Health, University of Oxford, Oxford, UK.

Objectives: To examine the association between maternal anaemia and adverse maternal and infant outcomes, and to assess the feasibility of conducting epidemiological studies through the Indian Obstetric Surveillance System-Assam (IndOSS-Assam).

Design: Retrospective cohort study using anonymised hospital records. Exposure: maternal iron deficiency anaemia; outcomes: postpartum haemorrhage (PPH), low birthweight, small-for-gestational age babies, perinatal death.

Setting: 5 government medical colleges in Assam.

Study Population: 1007 pregnant women who delivered in the 5 medical colleges from January to June 2015.

Main Outcome Measures: ORs with 95% CIs to estimate the association between maternal iron deficiency anaemia and the adverse maternal and infant outcomes. Potential interactive roles of infections and induction of labour on the adverse outcomes were explored.

Results: 35% (n=351) pregnant women had moderate-severe anaemia. Women with severe anaemia had a higher odds of PPH (adjusted OR (aOR) =9.45; 95% CI 2.62 to 34.05), giving birth to low birthweight (aOR=6.19; 95% CI 1.44 to 26.71) and small-for-gestational age babies (aOR=8.72; 95% CI 1.66 to 45.67), and perinatal death (aOR=16.42; 95% CI 4.38 to 61.55). Odds of PPH increased 17-fold among women with moderate-severe anaemia who underwent induction of labour, and 19-fold among women who had infection and moderate-severe anaemia.

Conclusions: Maternal iron deficiency anaemia is a major public health problem in Assam. Maternal anaemia was associated with increased risks of PPH, low birthweight, small-for-gestational age babies and perinatal death. While the best approach is prevention, a large number of women present with severe anaemia late in pregnancy and there is no clear guidance on how these women should be managed during labour and delivery.
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http://dx.doi.org/10.1136/bmjgh-2015-000026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321311PMC
April 2016

IndOSS-Assam: investigating the feasibility of introducing a simple maternal morbidity surveillance and research system in Assam, India.

BMJ Glob Health 2016 7;1(1):e000024. Epub 2016 Apr 7.

National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, UK.

Objective: To assess the feasibility of establishing a simple maternal morbidity surveillance system in Assam (Indian Obstetric Surveillance System-Assam (IndOSS-Assam)) to investigate the incidence and trends in severe maternal complications. This study presents the surveillance platform of IndOSS-Assam.

Design: Four tasks were undertaken: (1) setting up of a steering committee; (2) establishing priorities for the region; (3) mapping of surveillance sites; (4) piloting case-notification systems in selected centres.

Setting: Two government tertiary hospitals in the state.

Study Population: Pregnant women delivering in the hospitals between March and August 2015.

Main Outcome Measures: Incidence and case fatality rates with 95% CIs.

Results: Local stakeholder ownership and a simple uncomplicated anonymous system for case notification were the key strengths of this project. Cases and deaths were reported for six conditions: eclampsia, postpartum haemorrhage, puerperal sepsis, septic abortion, uterine rupture and anaemic heart failure. Among 10 475 women delivering over 6 months, 402 had one of these conditions and 66 died (case fatality 16%). The incidence of eclampsia was 17 per 1000 deliveries (95% CI 14 to 19), postpartum haemorrhage was 11 per 1000 deliveries (95% CI 10 to 13) and anaemic heart failure was 3 per 1000 deliveries (95% CI 2 to 5). For each of the other three conditions-puerperal sepsis, septic abortion and uterine rupture-the incidence rate was 2 per 1000 deliveries.

Conclusions: IndOSS-Assam was shown to be a feasible and simple system for ongoing surveillance of maternal morbidity that can be used to monitor the trends in the incidence of specific severe life-threatening conditions during pregnancy.
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http://dx.doi.org/10.1136/bmjgh-2015-000024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321309PMC
April 2016

Community level workers: awareness generation for improving children's health.

Indian J Community Health 2015;27(1):60-65

Senior Public Health Specialist, Public Health Foundation of India (PHFI), New Delhi, India.

Background: Routine immunisation and Vitamin A supplementation are two of many services offered by Government of India to reduce child mortality and morbidity. The three groups of community level workers (CLWs) i.e. Auxiliary Nurse Midwives from health department, Anganwadi Workers from women and child development department and Accredited Social Health Activists (ASHAs) are responsible for raising awareness and demand for these services.

Objectives: The paper assesses the knowledge and participation of CLWs in generating awareness about the two services namely immunisation and Vitamin A supplementation among eligible mothers; and mother's knowledge on these two services.

Methods: The study was conducted in 16 villages of two administrative blocks of Udaipur district in Rajasthan. Multistage purposive sampling was used for study area selection. Data collection was done using mixed methods-1) observations of 16 Maternal and Child Health and Nutrition days; 2) questionnaire based survey of 46 CLWs; and 3) questionnaire based survey of 321 programme beneficiaries i.e. infant's mothers.

Results: Limited knowledge of CLWs and their participation in awareness generation activities for the two services was noticed, which was also reflected in the poor knowledge among mothers on the two services.

Conclusion: The study results may partially explain the poor child immunization in Rajasthan. Initiatives to increase CLWs' knowledge of child immunization and Vitamin A supplementation; and increasing their participation in awareness generation activities need serious consideration by the healthcare system to improve immunization coverage.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618305PMC
January 2015

Tackling the social determinants of inequalities in health during Phase V of the Healthy Cities Project in Europe.

Health Promot Int 2015 Jun;30 Suppl 1:i45-i53

Nuffield Department of Population Health, Oxford University, Old Rd, Headington, Oxford OX3 7JZ, UK.

The WHO European Healthy Cities Network has from its inception aimed at tackling inequalities in health. In carrying out an evaluation of Phase V of the project (2009-13), an attempt was made to examine how far the concept of equity in health is understood and accepted; whether cities had moved further from a disease/medical model to looking at the social determinants of inequalities in health; how far the HC project contributed to cities determining the extent and causes of inequalities in health; what efforts were made to tackle such inequalities and how far inequalities in health may have increased or decreased during Phase V. A broader range of resources was utilized for this evaluation than in previous phases of the project. These indicated that most cities were definitely looking at the broader determinants. Equality in health was better understood and had been included as a value in a range of city policies. This was facilitated by stronger involvement of the HC project in city planning processes. Although almost half the cities participating had prepared a City Health Profile, only few cities had the necessary local level data to monitor changes in inequalities in health.
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http://dx.doi.org/10.1093/heapro/dav034DOI Listing
June 2015

Healthy Cities Phase V evaluation: further synthesizing realism.

Health Promot Int 2015 Jun;30 Suppl 1:i118-i125

WHO Healthy Cities Network Belfast Secretariat, Belfast, UK.

In this article we reflect on the quality of a realist synthesis paradigm applied to the evaluation of Phase V of the WHO European Healthy Cities Network. The programmatic application of this approach has led to very high response rates and a wealth of important data. All articles in this Supplement report that cities in the network move from small-scale, time-limited projects predominantly focused on health lifestyles to the significant inclusion of policies and programmes on systems and values for good health governance. The evaluation team felt that, due to time and resource limitations, it was unable to fully exploit the potential of realist synthesis. In particular, the synthetic integration of different strategic foci of Phase V designation areas did not come to full fruition. We recommend better and more sustained integration of realist synthesis in the practice of Healthy Cities in future Phases.
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http://dx.doi.org/10.1093/heapro/dav047DOI Listing
June 2015

Factors affecting the performance of community health workers in India: a multi-stakeholder perspective.

Glob Health Action 2014 13;7:25352. Epub 2014 Oct 13.

Public Health Foundation of India, New Delhi, India.

Background: Community health workers (CHWs) form a vital link between the community and the health department in several countries. In India, since 2005 this role is largely being played by Accredited Social Health Activists (ASHAs), who are village-level female workers. Though ASHAs primarily work for the health department, in a model being tested in Rajasthan they support two government departments. Focusing on the ASHA in this new role as a link worker between two departments, this paper examines factors associated with her work performance from a multi-stakeholder perspective.

Design: The study was done in 16 villages from two administrative blocks of Udaipur district in Rajasthan. The findings are based on 63 in-depth interviews with ASHAs, their co-workers and representatives from the two departments. The interviews were conducted using interview guides. An inductive approach with open coding was used for manual data analysis.

Results: This study shows that an ASHA's motivation and performance are affected by a variety of factors that emerge from the complex context in which she works. These include various personal (e.g. education), professional (e.g. training, job security), and organisational (e.g. infrastructure) factors along with others that emerge from external work environment. The participants suggested various ways to address these challenges.

Conclusion: In order to improve the performance of ASHAs, apart from taking corrective actions at the professional and organisational front on a priority basis, it is equally essential to promote cordial work relationships amongst ASHAs and other community-level workers from the two departments. This will also have a positive impact on community health.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197397PMC
http://dx.doi.org/10.3402/gha.v7.25352DOI Listing
June 2015

Impact of mothers' employment on infant feeding and care: a qualitative study of the experiences of mothers employed through the Mahatma Gandhi National Rural Employment Guarantee Act.

BMJ Open 2014 Apr 2;4(4):e004434. Epub 2014 Apr 2.

National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK.

Objective: To explore the experiences of mothers employed through the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) using focus group discussions (FGDs) to understand the impact of mothers' employment on infant feeding and care. The effects of mothers' employment on nutritional status of children could be variable. It could lead to increased household income, but could also compromise child care and feeding.

Setting: The study was undertaken in the Dungarpur district of Rajasthan, India.

Participants: Mothers of infants <12 months of age. Ten FGDs, two in each of the five administrative blocks of the study district were conducted. The groups were composed of a minimum of 5 and maximum of 8 participants, giving a total of 62 mothers. Thematic analysis was conducted to assess patterns and generate emergent themes.

Results: Four major themes were identified-'mothers' employment compromises infant feeding and care', 'caregivers' inability to substitute mothers' care', 'compromises related to childcare and feeding outweigh benefits from MGNREGA' and 'employment as disempowering'. Mothers felt that the comprises to infant care and feeding due to long hours of work, lack of alternative adequate care arrangements, low wages and delayed payments outweighed the benefits from the scheme.

Conclusions: This study provides an account of the trade-off between mothers' employment and child care. It provides an understanding of the household power relationships, societal and cultural factors that modulate the effects of mothers' employment. From the perspective of mothers, it helps to understand the benefits and problems related to providing employment to women with infants in the MGNREGA scheme and make a case to pursue policy changes to improve their working conditions.
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http://dx.doi.org/10.1136/bmjopen-2013-004434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987718PMC
April 2014

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke.

Cochrane Database Syst Rev 2014 Mar 1(3):CD001746. Epub 2014 Mar 1.

Nuffield Department of Population Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, UK, OX3 7LG.

Background: Children's exposure to other people's cigarette smoke (environmental tobacco smoke, or ETS) is associated with a range of adverse health outcomes for children. Parental smoking is a common source of children's exposure to ETS. Older children are also at risk of exposure to ETS in child care or educational settings. Preventing exposure to cigarette smoke in infancy and childhood has significant potential to improve children's health worldwide.

Objectives: To determine the effectiveness of interventions aiming to reduce exposure of children to ETS.

Search Methods: We searched the Cochrane Tobacco Addiction Group Specialized Register and conducted additional searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, EMBASE, CINAHL, ERIC, and The Social Science Citation Index & Science Citation Index (Web of Knowledge). Date of the most recent search: September 2013.

Selection Criteria: Controlled trials with or without random allocation. Interventions must have addressed participants (parents and other family members, child care workers and teachers) involved with the care and education of infants and young children (aged 0 to 12 years). All mechanisms for reduction of children's ETS exposure, and smoking prevention, cessation, and control programmes were included. These include health promotion, social-behavioural therapies, technology, education, and clinical interventions.

Data Collection And Analysis: Two authors independently assessed studies and extracted data. Due to heterogeneity of methodologies and outcome measures, no summary measures were possible and results were synthesised narratively.

Main Results: Fifty-seven studies met the inclusion criteria. Seven studies were judged to be at low risk of bias, 27 studies were judged to have unclear overall risk of bias and 23 studies were judged to have high risk of bias. Seven interventions were targeted at populations or community settings, 23 studies were conducted in the 'well child' healthcare setting and 24 in the 'ill child' healthcare setting. Two further studies conducted in paediatric clinics did not make clear whether the visits were to well or ill children, and another included both well and ill child visits. Thirty-six studies were from North America, 14 were in other high income countries and seven studies were from low- or middle-income countries. In only 14 of the 57 studies was there a statistically significant intervention effect for child ETS exposure reduction. Of these 14 studies, six used objective measures of children's ETS exposure. Eight of the studies had a high risk of bias, four had unclear risk of bias and two had a low risk of bias. The studies showing a significant effect used a range of interventions: seven used intensive counselling or motivational interviewing; a further study used telephone counselling; one used a school-based strategy; one used picture books; two used educational home visits; one used brief intervention and one study did not describe the intervention. Of the 42 studies that did not show a significant reduction in child ETS exposure, 14 used more intensive counselling or motivational interviewing, nine used brief advice or counselling, six used feedback of a biological measure of children's ETS exposure, one used feedback of maternal cotinine, two used telephone smoking cessation advice or support, eight used educational home visits, one used group sessions, one used an information kit and letter, one used a booklet and no smoking sign, and one used a school-based policy and health promotion. In 32 of the 57 studies, there was reduction of ETS exposure for children in the study irrespective of assignment to intervention and comparison groups. One study did not aim to reduce children's tobacco smoke exposure, but rather aimed to reduce symptoms of asthma, and found a significant reduction in symptoms in the group exposed to motivational interviewing. We found little evidence of difference in effectiveness of interventions between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.

Authors' Conclusions: While brief counselling interventions have been identified as successful for adults when delivered by physicians, this cannot be extrapolated to adults as parents in child health settings. Although several interventions, including parental education and counselling programmes, have been used to try to reduce children's tobacco smoke exposure, their effectiveness has not been clearly demonstrated. The review was unable to determine if any one intervention reduced parental smoking and child exposure more effectively than others, although seven studies were identified that reported motivational interviewing or intensive counselling provided in clinical settings was effective.
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http://dx.doi.org/10.1002/14651858.CD001746.pub3DOI Listing
March 2014

Effect of the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) on malnutrition of infants in Rajasthan, India: a mixed methods study.

PLoS One 2013 25;8(9):e75089. Epub 2013 Sep 25.

National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.

Objectives: Analyse the effect of the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA), a wage-for-employment policy of the Indian Government, on infant malnutrition and delineate the pathways through which MGNREGA affects infant malnutrition.

Hypothesis: MGNREGA could reduce infant malnutrition through positive effects on household food security and infant feeding.

Method: Mixed methods using cross-sectional study and focus group discussions conducted in Dungarpur district, Rajasthan, India.

Participants: Infants aged 1 to <12 months and their mothers/caregivers. Final sample 528 households with 1056 participants, response rate 89.6%. Selected households were divided into MGNREGA-households and non-MGNREGA-households based on participation in MGNREGA between August-2010 and September-2011.

Outcomes: Infant malnutrition measured using anthropometric indicators - underweight, stunting, and wasting (WHO criteria).

Results: We included 528 households with 1,056 participants. Out of 528, 281 households took part in MGNREGA between August'10, and September'11. Prevalence of wasting was 39%, stunting 24%, and underweight 50%. Households participating in MGNREGA were less likely to have wasted infants (OR 0·57, 95% CI 0·37-0·89, p = 0·014) and less likely to have underweight infants (OR 0·48, 95% CI 0·30-0·76, p = 0·002) than non-participating households. Stunting did not differ significantly between groups. We did 11 focus group discussions with 62 mothers. Although MGNREGA reduced starvation, it did not provide the desired benefits because of lower than standard wages and delayed payments. Results from path analysis did not support existence of an effect through household food security and infant feeding, but suggested a pathway of effect through low birth-weight.

Conclusion: Participation in MGNREGA was associated with reduced infant malnutrition possibly mediated indirectly via improved birth-weight rather than by improved infant feeding. Addressing factors such as lack of mothers' knowledge and inappropriate feeding practices, over and above the social and economic policies, is key in efforts to reduce infant malnutrition.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0075089PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783470PMC
July 2014

Prevention of diabetes in rural India with a telemedicine intervention.

J Diabetes Sci Technol 2012 Nov 1;6(6):1355-64. Epub 2012 Nov 1.

Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, WHO Collaborating Centre for Non-communicable Diseases Prevention & Control, IDF Centre for Education, Gopalapuram, Chennai, India.

Background: Diabetes care is not presently available, accessible, or affordable to people living in rural areas in developing countries, such as India. The Chunampet Rural Diabetes Prevention Project (CRDPP) was conceived with the aim of implementing comprehensive diabetes screening, prevention, and treatment using a combination of telemedicine and personalized care in rural India.

Methods: This project was undertaken in a cluster of 42 villages in and around the Chunampet village in the state of Tamil Nadu in southern India. A telemedicine van was used to screen for diabetes and its complications using retinal photography, Doppler imaging, biothesiometry, and electrocardiography using standardized techniques. A rural diabetes center was set up to provide basic diabetes care.

Results: Of the total 27,014 adult population living in 42 villages, 23,380 (86.5%) were screened for diabetes, of which 1138 (4.9%) had diabetes and 3410 (14.6%) had prediabetes. A total of 1001 diabetes subjects were screened for complications (response rate of 88.0%). Diabetic retinopathy was detected in 18.2%, neuropathy in 30.9%, microalbuminuria in 24.3%, peripheral vascular disease in 7.3%, and coronary artery disease in 10.8%. The mean hemoglobin A1c levels among the diabetes subjects in the whole community decreased from 9.3 ± 2.6% to 8.5 ± 2.4% within 1 year. Less than 5% of patients needed referral for further management to the tertiary diabetes hospital in Chennai.

Conclusions: The Chunampet Rural Diabetes Prevention Project is a successful model for screening and for delivery of diabetes health care and prevention to underserved rural areas in developing countries such as India.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570875PMC
http://dx.doi.org/10.1177/193229681200600614DOI Listing
November 2012

Health professionals' migration in emerging market economies: patterns, causes and possible solutions.

J Public Health (Oxf) 2013 Mar 24;35(1):157-63. Epub 2012 Oct 24.

Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford OX3 7LF, UK.

Background: About a third of the countries affected by shortage of human resources for health are the emerging market economies (EMEs). The greatest shortage in absolute terms was found to be in India and Indonesia leading to health system crisis. This review identifies the patterns of migration of health workers, causes and possible solutions in these EMEs.

Methods: A qualitative synthesis approach based on the 'critical review' and 'realist review' approaches to the literature review was used.

Results: The patterns of migration of health professionals' in the EMEs have led to two types of discrepancies between health needs and healthcare workers: (i) within country (rural-urban, public-private or government healthcare sector-private sector) and (ii) across countries (south to north). Factors that influence migration include lack of employment opportunities, appropriate work environment and wages in EMEs, growing demand in high-income countries due to demographic transition, favourable country policies for financial remittances by migrant workers and medical education system of EMEs. A range of successful national and international initiatives to address health workforce migration were identified.

Conclusions: Measures to control migration should be country specific and designed in accordance with the push and pull factors existing in the EMEs.
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http://dx.doi.org/10.1093/pubmed/fds087DOI Listing
March 2013

Managing priorities.

Med Educ 2012 Aug;46(8):733-5

Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford OX3 7LF, UK.

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http://dx.doi.org/10.1111/j.1365-2923.2012.04308.xDOI Listing
August 2012

Is early age at menarche a risk factor for endometriosis? A systematic review and meta-analysis of case-control studies.

Fertil Steril 2012 Sep 22;98(3):702-712.e6. Epub 2012 Jun 22.

Department of Public Health, University of Oxford, Oxford, United Kingdom.

Objective: To review published studies evaluating early menarche and the risk of endometriosis.

Design: Systematic review and meta-analysis of case-control studies.

Setting: None.

Patient(s): Eighteen case-control studies of age at menarche and risk of endometriosis including 3,805 women with endometriosis and 9,526 controls.

Intervention(s): None.

Main Outcome Measure(s): Medline and Embase databases were searched from 1980 to 2011 to locate relevant studies. Results of primary studies were expressed as effect sizes of the difference in mean age at menarche of women with and without endometriosis. Effect sizes were used in random effects meta-analysis.

Result(s): Eighteen of 45 articles retrieved met the inclusion criteria. The pooled effect size in meta-analysis was 0.10 (95% confidence interval -0.01-0.21), and not significantly different from zero (no effect). Results were influenced by substantial heterogeneity between studies (I(2) = 72.5%), which was eliminated by restricting meta-analysis to studies with more rigorous control of confounders; this increased the pooled effect size to 0.15 (95% confidence interval 0.08-0.22), which was significantly different from zero. This represents a probability of 55% that a woman with endometriosis had earlier menarche than one without endometriosis if both were randomly chosen from a population.

Conclusion(s): There is a small increased risk of endometriosis with early menarche. The potential for disease misclassification in primary studies suggests that this risk could be higher.
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http://dx.doi.org/10.1016/j.fertnstert.2012.05.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502866PMC
September 2012

Trends in social inequalities for premature coronary heart disease mortality in Great Britain, 1994-2008: a time trend ecological study.

BMJ Open 2012 18;2(3). Epub 2012 Jun 18.

Department of Public Health, University of Oxford, Oxford, UK.

Objective: To compare trends in metrics of socioeconomic inequalities in premature coronary heart disease (CHD) mortality in Great Britain.

Design: Time trend ecological study with area-level deprivation as exposure.

Setting: Great Britain, 1994-2008.

Participants: Men and women aged younger than 75 years. No lower age limit.

Interventions: None.

Main Outcome Measures: CHD mortality rates.

Results: There has been a decrease in socioeconomic inequalities in CHD mortality in absolute terms but an increase in relative terms. CHD mortality rates in men aged younger than 75 years fell by 69 per 100 000 (95% CIs 64 to 74) in the least deprived quintile and by 92 per 100 000 (95% CI 86 to 98) in the most deprived quintile (p for trend: <0.001). Mortality rate ratios comparing the most deprived quintile to the least deprived quintile increased in women aged younger than 75 years from 1.77 (95% CI 1.68 to 1.86) to 2.32 (95% CI 2.14 to 2.52). There was a weak negative association between the average decline of relative rates and area deprivation.

Conclusions: It could either be said that inequalities in premature mortality from CHD between affluent and deprived areas have widened or narrowed between 1994 and 2008 depending on the measurement technique. In the context of falling CHD mortality rates, narrowing of absolute inequalities is to be expected, but increases in relative inequalities are a cause for concern.
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http://dx.doi.org/10.1136/bmjopen-2011-000737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3378944PMC
October 2012

Healthy Cities indicators--a suitable instrument to measure health?

J Urban Health 2013 Oct;90 Suppl 1:52-61

Department of Public Health, University of Oxford, Oxford, OX3 7LF, UK,

The evidence-base for a health strategy should include information on the determinants of health and how they link together if it is to influence the health of the population. The WHO European Healthy Cities Network developed a set of 53 healthy city indicators (HCIs), to describe the health of its citizens and capture a range of local initiatives addressing the wider dimensions of health. This was the first systematic effort to collect and analyze a range of data from European cities. The analysis provided important insights into the interpretation, availability, and feasibility of collecting data, resulting in the development of a revised set of 32 indicators with improved definitions. An analysis of the revised indicators showed that this data was more complete and feasible to collect. It provided useful information to cities contributing to developing a description of health and thus helping to identify health problems. It also highlighted issues about the importance of collecting qualitative as well as quantitative data, the number of indicators and the appropriateness of using the indicators to compare different cities. HCIs facilitated the collection of routinely available health data in a systematic manner. The introduction of HCIs has encouraged cities to adopt a structured process of collecting information on the health of their citizens and build on this information by collecting appropriate local data for developing a city health profile to underpin a city health plan that would set out strategies and interventions to improve health and provide the evidence-base for health plans.
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http://dx.doi.org/10.1007/s11524-011-9643-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3764266PMC
October 2013

Differences in coronary heart disease, stroke and cancer mortality rates between England, Wales, Scotland and Northern Ireland: the role of diet and nutrition.

BMJ Open 2011 Nov 3;1(1):e000263. Epub 2011 Nov 3.

British Heart Foundation Health Promotion Research Group, Department of Public Health, University of Oxford, Oxford, UK.

Introduction It is unclear how much of the geographical variation in coronary heart disease (CHD), stroke and cancer mortality rates within the UK is associated with diet. The aim of this study is to estimate how many deaths from CHD, stroke and cancer would be delayed or averted if Wales, Scotland and Northern Ireland adopted a diet equivalent in nutritional quality to the English diet. Methods Mortality data for CHD, stroke and 10 diet-related cancers for 2007-2009 were used to calculate the mortality gap (the difference between actual mortality and English mortality rates) for Wales, Scotland and Northern Ireland. Estimates of mean national consumption of 10 dietary factors were used as baseline and counterfactual inputs in a macrosimulation model (DIETRON). An uncertainty analysis was conducted using a Monte Carlo simulation with 5000 iterations. Results The mortality gap in the modelled scenario (achieving the English diet) was reduced by 81% (95% credible intervals: 62% to 108%) for Wales, 40% (33% to 51%) for Scotland and 81% (67% to 99%) for Northern Ireland, equating to approximately 3700 deaths delayed or averted annually. For CHD only, the mortality gap was reduced by 88% (69% to 118%) for Wales, 58% (47% to 72%) for Scotland, and 88% (70% to 111%) for Northern Ireland. Conclusion Improving the average diet in Wales, Scotland and Northern Ireland to a level already achieved in England could have a substantial impact on reducing geographical variations in chronic disease mortality rates in the UK. Much of the mortality gap between Scotland and England is explained by non-dietary risk factors.
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http://dx.doi.org/10.1136/bmjopen-2011-000263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3227806PMC
November 2011

Career choices for public health: cohort studies of graduates from UK medical schools.

J Public Health (Oxf) 2011 Dec 12;33(4):616-23. Epub 2011 Sep 12.

Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK.

Background: The aim of this paper is to describe UK-trained doctors' early intentions about seeking careers in public health and their eventual speciality destinations.

Methods: Analysis of longitudinal studies of medical graduates from all UK medical schools in selected year-of-qualification cohorts from 1974 to 2008; data collected by postal questionnaires at various times after qualifying; and selection, for this paper, of doctors who expressed an early preference for a career in public health and/or who eventually practised in it.

Results: Of all doctors eventually practising in public health, for whom we had early choices, public health had been the unreserved first choice of 8% (10/125) in their first post-qualification year, 27% (33/122) in their third year and 59% (51/86) in their fifth year. Including first choices for public health 'tied' with an equal preference for a different speciality, and doctors' second and third choices for public health, 19% (24/125) of practising public health doctors had considered public health as a possible career in their first post-graduation year, 41% (50/122) in the third and 83% (71/86) in the fifth year.

Conclusions: Comparisons with other specialities show that doctors in public health chose their speciality relatively late after qualification.
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http://dx.doi.org/10.1093/pubmed/fdr067DOI Listing
December 2011

Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries.

Fertil Steril 2011 Aug 30;96(2):366-373.e8. Epub 2011 Jun 30.

Department of Public Health, University of Oxford, Oxford, UK.

Objective: To assess the impact of endometriosis on health-related quality of life (HRQoL) and work productivity.

Design: Multicenter cross-sectional study with prospective recruitment.

Setting: Sixteen clinical centers in ten countries.

Patient(s): A total of 1,418 premenopausal women, aged 18-45 years, without a previous surgical diagnosis of endometriosis, having laparoscopy to investigate symptoms or to be sterilized.

Intervention(s): None.

Main Outcome Measure(s): Diagnostic delay, HRQoL, and work productivity.

Result(s): There was a delay of 6.7 years, principally in primary care, between onset of symptoms and a surgical diagnosis of endometriosis, which was longer in centers where women received predominantly state-funded health care (8.3 vs. 5.5 years). Delay was positively associated with the number of pelvic symptoms (chronic pelvic pain, dysmenorrhoea, dyspareunia, and heavy periods) and a higher body mass index. Physical HRQoL was significantly reduced in affected women compared with those with similar symptoms and no endometriosis. Each affected woman lost on average 10.8 hours (SD 12.2) of work weekly, mainly owing to reduced effectiveness while working. Loss of work productivity translated into significant costs per woman/week, from US$4 in Nigeria to US$456 in Italy.

Conclusion(s): Endometriosis impairs HRQoL and work productivity across countries and ethnicities, yet women continue to experience diagnostic delays in primary care. A higher index of suspicion is needed to expedite specialist assessment of symptomatic women. Future research should seek to clarify pain mechanisms in relation to endometriosis severity.
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http://dx.doi.org/10.1016/j.fertnstert.2011.05.090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3679489PMC
August 2011
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