BACKGROUND: Disparities in perinatal health care occur worldwide. If the UN Millennium Development Goals in maternal and child health are to be met, this needs to be addressed. This study was conducted to facilitate our understanding of the changing use of maternity care services in a semi-urban community in Entebbe Uganda and to examine the range of antenatal and delivery services received in health care facilities and at home. METHODS: We conducted a retrospective community survey among women using structured questionnaires to describe the use of antenatal services and delivery care. RESULTS: In total 413 women reported on their most recent pregnancy. Antenatal care attendance was high with 96% attending once, and 69% the recommended four times. Blood pressure monitoring (95%) and tetanus vaccination (91%) were the services most frequently reported and HIV testing (47%), haematinics (58%) and presumptive treatment for malaria (66%) least frequently. Hospital clinics significantly outperformed public clinics in the quality of antenatal service. A significant improvement in the reported quality of antenatal services received was observed by year (p
Muhangi L, Woodburn P, Omara M, Omoding N, Kizito D, Mpairwe H, Nabulime J, Ameke C, Morison LA, Elliott AM (2007) Associations between mild-to-moderate anaemia in pregnancy and helminth, malaria and HIV infection in Entebbe, Uganda, Transactions of the Royal Society of Tropical Medicine and Hygiene 101 (9) pp. 899-907
It is suggested that helminths, particularly hookworm and schistosomiasis, may be important causes of anaemia in pregnancy. We assessed the associations between mild-to-moderate anaemia (haemoglobin >8.0 g/dl and
Freeman EE, Glynn JR, Lagarde E, Ferry B, Lydie N, Hayes R, Morison L, Weiss H, Glynn J, Robinson N (2004) Factors affecting HIV concordancy in married couples in four African cities, AIDS 18 (12) pp. 1715-1721 LIPPINCOTT WILLIAMS & WILKINS
Burns F, Fenton KA, Morison L, Mercer C, Erens B, Field J, Copas AJ, Wellings K, Johnson AM (2005) Factors associated with HIV testing among black Africans in Britain, Sexually Transmitted Infections 81 (6) pp. 494-500
Objective: To describe the factors associated with HIV testing among heterosexual black Africans aged 16-44 years living in Britain. Design: We analysed data from the second British National Survey of Sexual Attitudes and Lifestyles (Natsal 2000)-a stratified national probability sample survey conducted between 1999-2001. Data from Natsal's main and ethnic minority boost (EMB) samples were analysed. Multivariate analysis was performed using complex survey functions to account for the clustered, stratified, and differential selection probabilities inherent within the survey. Results: A total of 385 (216 women and 169 men) black African respondents were included in the study. 44.0% women and 36.4% men reported ever having had an HIV test. In univariate analysis, HIV testing was associated with being born abroad (OR 3.63), having a new partner(s) from abroad in past 5 years (OR 2.88), and attending a GUM clinic (OR 3.27) among men; and educational attainment (OR 3.50), perception of "not very much" personal risk of HIV (OR 2.75), and attending a GUM clinic (OR 2.91) among women. After adjusting for potential confounders, an increased likelihood of HIV testing was associated with being in the United Kingdom less than 5 years relative to being UK born (adjusted OR 9.49), and ever attending a GUM clinic (adj OR 5.53), for men; and educational attainment (adj OR 4.13), and low perception of HIV risk (adj OR 2.77) for women. Conclusions: Black Africans appear to have relatively high rates of HIV testing reflecting, at least partially, awareness of risk behaviours and potential exposure to HIV. Nevertheless, there remains substantial potential for health gain and innovative approaches are required to further increase timely HIV testing.
BACKGROUND: Caring for a baby can provoke or intensify discord between parents, with adverse effects on their own well-being and their parenting. AIM: The aim of this study was to appraise evidence obtained from 450 mothers on the quality of the parents' relationship during the postnatal period and the value of support provided by health visitors in cases of discord. DESIGN: The health visitors were based at nine clinics in an outer London borough, and had been trained on a four-day course (the Brief Encounters course) to screen mothers for relationship problems at the 6-8-week check and to offer support (supportive listening, practical advice, referral) if problems were revealed. Data on relationship quality were obtained by a self-report screening scale completed at the 6-8-week check and again at the 12-week visit for immunizations, when the scale was included in a self-report questionnaire on help received from the health visitor. Intervention records kept by the health visitor showed what form any support had taken. Some 6 weeks later, 25 of the 82 mothers offered support, and their health visitors, were interviewed about their experience of the intervention. RESULTS: One in five mothers were identified as having a relationship problem at the 6-8-week check. Most were offered support. One in five of the 351 mothers who completed a questionnaire at the 12-week visit reported receiving support in improving their relationship. The follow-up interviews showed that most mothers valued this support. Responses to a questionnaire completed by health visitors showed that most were enthusiastic about its benefits. CONCLUSIONS: A four-day training course for health visitors enabled them to screen for relationship problems during the postnatal period and to provide support when required in a way that was valued by mothers. Most health visitors were enthusiastic about the value of the intervention in improving their contribution to family welfare.
O'Farrell N, Morison L, Moodley P, Pillay K, Vanmali T, Quigley M, Sturm AW (2007) High-risk sexual behaviour in men attending a sexually transmitted infection clinic in Durban, South Africa, Sexually Transmitted Infections 83 (7) pp. 530-533
Objectives: A study of men with genital ulcer disease (GUD) in Durban, South Africa, at the start of the local HIV epidemic in 1988/1989 found that 36% of men with GUD continued with sexual intercourse despite symptoms. The aim of this study was to determine whether this high-risk behaviour was still prevalent and to enquire about similar risk behaviours with other sexually transmitted infection (STI)-related problems. Methods: 650 Men attending the main Durban STI clinic with a new complaint were enrolled. A standard questionnaire was administered. Polymerase chain reaction (PCR) tests were performed to diagnose genital herpes from ulcer specimens and gonorrhoea and chlamydia from those with urethral discharge and/or dysuria. Serology tests were performed for HIV, herpes simplex virus type 2 (HSV-2) and syphilis. Results: Sex since the start of symptoms was reported by between 33.3% and 43.9% of men with GUD, herpetic ulcers, gonorrhoea and/or chlamydia or dysuria. The incidence of condom use was very low in all groups having sex despite symptoms. In 87 men with genital ulcers confirmed positive for genital herpes by PCR testing, 30 (34.4%) had had sex since the start of symptoms, 28 (93.3%) of whom had had unprotected sex. Conclusions: There is a high level of risk behaviour in this group of men in whom genital herpes is the most common cause of GUD. This risky sexual behaviour could reflect disinhibition, possibly because so many have already been infected with HSV-2, lack of education or other unknown factors. Syndromic STI management should be strengthened with intensive health education to promote community awareness of both genital ulceration and genital herpes and their role in facilitating HIV transmission. The low level of condom use indicates that condom promotion programmes still have much to achieve.
Whitworth JA, Biraro S, Shafer LA, Morison LA, Quigley M, White RG, Mayanja BN, Ruberantwari A, Van Der Paal L (2007) HIV incidence and recent injections among adults in rural southwestern Uganda, AIDS 21 (8) pp. 1056-1058
Thirty-six incident HIV cases were matched for age, sex and time period with 36 controls to examine associations with recent injections. A significant association between HIV incidence and a history of injections was detected that was not reduced after adjusting for available sexual behaviour variables. This association could either be the result of injections causing HIV infection or, more likely, injections for seroconversion illnesses or other consequences of unsafe sex. © 2007 Lippincott Williams & Wilkins, Inc.
Hargreaves JR, Morison LA, Gear JSS, Makhubele MB, Porter JDH, Busza J, Watts C, Kim JC, Pronyk PM (2007) "Hearing the Voices of the Poor": Assigning Poverty Lines on the Basis of Local Perceptions of Poverty. A Quantitative Analysis of Qualitative Data from Participatory Wealth Ranking in Rural South Africa, World Development 35 (2) pp. 212-229
We applied a mixed-methods approach to participatory wealth ranking (PWR) to identify the number of poor households in eight villages of rural South Africa and describe how poor they are. We generated a household wealth index on the basis of the ranking process and statements made on standard of living. Descriptions from PWR identified households as "very poor," "poor, but a bit better off," or "doing OK." Of 9 671 households, 3 113 (32.2%) could be considered "very poor" or "poor." The paper presents a novel approach to wealth ranking that generates a rich appraisal of poverty. © 2006 Elsevier Ltd. All rights reserved.
Background: Although genital herpes has emerged as the most common cause of genital ulcers in Southern Africa, treatment for herpes is not available routinely in the region. This study was performed to determine the etiology of genital ulcers in men in Durban and assess other sexually transmitted infections-related symptoms, presentation, and treatment patterns in this group. Methods: Polymerase chain reaction (PCR) tests were performed on specimens from consecutive male patients with genital ulcers to detect sexually transmitted pathogens. PCR was also performed for the detection of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis on urethral specimens from consecutive subjects with dysuria or urethral discharge. Antibody tests for syphilis and herpes simplex virus type-2 (HSV-2) and human immunodeficiency virus antibodies were performed. Results: Of 162 patients enrolled with genital ulcers, 77.7% were human immunodeficiency virus-positive and 84.6% had antibodies to HSV-2. PCR results showed the following prevalences: HSV-2 53.7%, lymphogranuloma venereum 13.6%, Treponema pallidum 3.7%, Hemophilus ducreyi 1.2%, mixed infections 6.2%, and no pathogens identified 33.3%. One case of donovanosis was diagnosed clinically. In men with HSV-2 ulcers, delay before attendance recorded for 68 men was 1 to 3 days (24%), 4 to 7 days (47%), 8 to 14 days (12%), 15 to 30 days (12%), and >30 days (6%). History-taking using prompting increased the sensitivity but decreased the specificity and positive predictive value of reported genital ulceration when assessed against ulcers seen on examination. Conclusions: Men at risk of genital ulcers should be asked about relevant symptoms with and without prompting and examined clinically to maximize the likelihood of correct diagnosis and treatment. The finding of a high prevalence of HSV-2 and associated dysuria cautions against providing empirical treatment for gonorrhoea and chlamydia in ulcer patients with dysuria but without urethral discharge. Innovative strategies to limit the burden of HSV-2 infection in this population are required. Copyright © 2008, American Sexually Transmitted Diseases Association.
Rasheed F, Karim E, Hawkes S, Morison L, Mabey D, Peeling R, Foster S, De Francisco A (2000) STD research and policy formulation (multiple letters), Lancet 355 (9211) pp. 1275-1276
Heyndrickx L, Janssens W, Zekeng L, Musonda R, Anagonou S, Van der Auwera G, Coppens S, Vereecken K, De Witte K, Van Rampelbergh R, Kahindo M, Morison L, McCutchan FE, Carr JK, Albert J, Essex M, Goudsmit J, Asjö B, Salminen M, Buvé A, van Der Groen G (2000) Simplified strategy for detection of recombinant human immunodeficiency virus type 1 group M isolates by gag/env heteroduplex mobility assay. Study Group on Heterogeneity of HIV Epidemics in African Cities., J Virol 74 (1) pp. 363-370
We developed a heteroduplex mobility assay in the gag gene (gag HMA) for the identification of group M subtypes A to H. The assay covers the region coding for amino acid 132 of p24 to amino acid 20 of p7 (according to human immunodeficiency virus type 1 [HIV-1] ELI, 460 bp). The gag HMA was compared with sequencing and phylogenetic analysis of an evaluation panel of 79 HIV-1 group M isolates isolated from infected individuals from different geographic regions. Application of gag HMA in combination with env HMA on 252 HIV-1- positive plasma samples from Bénin, Cameroon, Kenya, and Zambia revealed a high prevalence of a variety of intersubtype recombinants in Yaoundé, Cameroon (53.8%); Kisumu, Kenya (26.8%); and Cotonou, Bénin (41%); no recombinants were identified among the samples from Ndola, Zambia. The AG(IbNG) circulating recombinant form, as determined by gag HMA, was found to be the most common intersubtype recombinant in Yaoundé (39.4%) and Cotonou (38.5%). Using a one-tube reverse transcriptase PCR protocol, this gag HMA in combination with env HMA is a useful tool for rapidly monitoring the prevalence of the various genetic subtypes as well as of recombinants of HIV-1. Moreover, this technology can easily be applied in laboratories in developing countries.
Hargreaves JR, Bonell CP, Morison LA, Kim JC, Phetla G, Portera JDH, Watts C, Pronyk PA (2007) Explaining continued high HIV prevalence in South Africa: socioeconomic factors, HIV incidence and sexual behaviour change among a rural cohort, 2001-2004, AIDS 21 (S7) pp. S39-S48
LIPPINCOTT WILLIAMS & WILKINS
OBJECTIVES: To estimate HIV incidence and explore evidence for changing sexual behaviour over time among men and women belonging to different socioeconomic groups in rural South Africa. DESIGN AND METHODS: A cohort study conducted between 2001 and 2004; 3881 individuals aged 14-35 years enumerated in eight villages were eligible. At least three household visits were made to contact each eligible respondent at both timepoints. Sexual behaviour data were collected in structured, respondent-focused interviews. HIV serostatus was assessed using an oral fluid enzyme-linked immunosorbent assay at each timepoint. RESULTS: Data on sexual behaviour were available from 1967 individuals at both timepoints. A total of 1286 HIV-negative individuals at baseline contributed to the analysis of incidence. HIV incidence was 2.2/100 person-years among men and 4.9/100 person-years in women, among whom it was highest in the least educated group. Median age at first sex was lower among later birth cohorts. A higher number of previously sexually active individuals reported having multiple partners in the past year in 2004 than 2001. Condom use with non-spousal partners increased from 2001 to 2004. Migrant men more often reported multiple partners. Migrant and more educated individuals of both sexes and women from wealthier households reported higher levels of condom use. DISCUSSION: HIV incidence is high in rural South Africa, particularly among women of low education. Some risky sexual behaviours (early sexual debut, having multiple sexual partners) are becoming more common over time. Condom use is increasing. Existing HIV prevention strategies have only been partly effective in generating population-level behavioural change.
Buvé A, Weiss HA, Laga M, Van Dyck E, Musonda R, Zekeng L, Kahindo M, Anagonou S, Morison L, Robinson NJ, Hayes RJ (2001) The epidemiology of trichomoniasis in women in four African cities., AIDS 15 Sup (SUPPL. 4) pp. S89-S96
OBJECTIVES: To describe the epidemiology of Trichomonas vaginalis infection and its association with HIV infection, in women in four African cities with different levels of HIV infection. DESIGN: Cross-sectional study, using standardized methods, including a standardized questionnaire and standardized laboratory tests, in four cities in sub-Saharan Africa: two with a high prevalence of HIV infection (Kisumu, Kenya and Ndola, Zambia), and two with a relatively low prevalence of HIV (Cotonou, Benin and Yaoundé, Cameroon). METHODS: In each city, a random sample of about 2000 adults aged 15-49 years was taken. Consenting men and women were interviewed about their socio-demographic characteristics and their sexual behaviour, and were tested for HIV, syphilis, herpes simplex virus type 2 (HSV-2), gonorrhoea, chlamydial infection, and (women only) T. vaginalis infection. Risk factor analyses were carried out for trichomoniasis for each city separately. Multivariate analysis, however, was only possible for Yaoundé, Kisumu and Ndola. RESULTS: The prevalence of trichomoniasis was significantly higher in the high HIV prevalence cities (29.3% in Kisumu and 34.3% in Ndola) than in Cotonou (3.2%) and Yaoundé (17.6%). Risk of trichomoniasis was increased in women who reported more lifetime sex partners. HIV infection was an independent risk factor for trichomonas infection in Yaoundé [adjusted odds ratio (OR) = 1.8, 95% confidence interval (CI) = 0.9-3.7] and Kisumu (adjusted OR = 1.7, 95% CI = 1.1-2.7), but not in Ndola. A striking finding was the high prevalence (40%) of trichomonas infection in women in Ndola who denied that they had ever had sex. CONCLUSION: Trichomoniasis may have played a role in the spread of HIV in sub-Saharan Africa and may be one of the factors explaining the differences in levels of HIV infection between different regions in Africa. The differences in prevalence of trichomoniasis between the four cities remain unexplained, but we lack data on the epidemiology of trichomoniasis in men. More research is required on the interaction between trichomoniasis and HIV infection, the epidemiology of trichomoniasis in men, and trichomonas infections in women who deny sexual activity.
The incidence of lameness in herds visited by veterinary practitioners in winter (0.87 cases per 100 cows per month) was greater than in summer (0.71 cases per 100 cows per month). The relative proportions of leg lesions and underrun heel were higher, and those of foul-in-the-foot, interdigital hyperplasia and foreign body in the sole were lower in winter than in summer. In winter, leg lesions and aseptic laminitis were most common in cows housed in cowsheds, white line abscess in cows in strawyards and sole ulcer in cows in either cowsheds or cubicles with concrete yards. The overall incidence of lesions was lower in strawyard accommodation (0.71 cases per 100 cows per month) than in cubicles with yards (0.93 cases per 100 cows per month). Veterinary practitioners saw proportionally fewer cases of foul-in-the-foot but proportionally more cases of sole ulcer in larger than in smaller herds. The animal incidence of lameness ranged from 1.7 to 11.4 per cent among practices; in 20 practices which recorded a total of at least 100 lesions in both summer and winter there was a large variation in the proportions observed of each lesion. A principal component analysis contrasted those practices which tended to see mainly cases of white line abscess, white line separation, foul-in-the-foot and leg lesions with those which saw mainly cases of underrun heel, interdigital hyperplasia, punctured sole with pus and sole ulcer. Twenty-nine per cent of cases of underrun heel and 22 per cent of cases of both deep sepsis and interdigital hyperplasia occurred in conjunction with another lesion.
The incidence of lameness in cows recorded by five veterinary practices over one year and one practice over four years was plotted with rainfall and potential soil moisture deficit. Correlation coefficients calculated between lameness, rainfall and potential soil moisture deficit over two-week periods showed the incidence of lameness in summer to be significantly related to the potential soil moisture deficit in the same two-week period and rainfall in the previous two-week period. Differences in patterns of lameness incidence among practices and years were also partly explained by differences in rainfall and potential soil moisture deficit; however, these effects were small compared with those of other factors that affect lameness incidence such as herd size, age and stage of lactation.
Luxemburger C, McGready R, Kham A, Morison L, Cho T, Chongsuphajaisiddhi T, White NJ, Nosten F (2001) Effects of malaria during pregnancy on infant mortality in an area of low malaria transmission, American Journal of Epidemiology 154 (5) pp. 459-465
Malaria during pregnancy reduces birth weight, and low birth weight is a major determinant of infant mortality. The authors estimated the impact of malaria during pregnancy on infant mortality in a Karen population living in Thailand. Between 1993 and 1996, a cohort of 1,495 mothers and their infants was followed weekly from admission of the mother to antenatal clinics until the first birthday of the infant. Both falciparum malaria and vivax malaria during pregnancy were associated with low birth weight but did not shorten gestation. Febrile illness in the week before delivery was associated with premature birth. Preterm and full-term low birth weight and fever in the week before delivery were associated with neonatal mortality. Maternal fevers close to term were also associated with the deaths of infants aged between 1 and 3 months, whereas no risk factors could be identified for deaths that occurred later in infancy. Thus, malaria during pregnancy increased neonatal mortality by lowering birth weight, whereas fever in the week before birth had a further independent effect in addition to inducing premature birth. The prevention of malaria in pregnancy and, thus, of malaria-attributable low birth weight should increase the survival of young babies.
Hatcher A, de Wet J, Bonell CP, Strange V, Phetla G, Proynk PM, Kim JC, Morison Linda, Porter JDH, Busza J, Watts C, Hargreaves JR (2011) Promoting critical consciousness and social mobilization in HIV/AIDS programmes: lessons and curricular tools from a South African intervention, HEALTH EDUCATION RESEARCH 26 (3) pp. 542-555
OXFORD UNIV PRESS
The development of critical consciousness is seen as a key stage in communities increasing levels of dialogue about priority problems and effecting structural change for health. However, relatively little research identifies concrete methods for programmes to build critical consciousness. We examined how a South African structural intervention used critical consciousness as a tool for prevention of intimate partner violence and HIV infection. We collected qualitative data in the form of in-depth interviews with managers, trainers, and participants of the Intervention with Microfinance for AIDS and Gender Equity intervention (IMAGE) in rural South Africa. The data were analysed through a coding structure developed in QSR NVivo. We draw practical lessons from IMAGE to guide other HIV programmes aiming to promoting critical consciousness and social mobilization. This research suggests that specific curricular tools can work towards critical consciousness and that mobilization efforts in future programmes can be strengthened by including individual and collective efforts by participants.
Wall SR, Scherf CF, Morison L, Hart KW, West B, Ekpo G, Fiander AN, Man S, Gelder CM, Walraven G, Borysiewicz LK (2005) Cervical human papillomavirus infection and squamous intraepithelial lesions in rural Gambia, West Africa: viral sequence analysis and epidemiology, BRITISH JOURNAL OF CANCER 93 (9) pp. 1068-1076
NATURE PUBLISHING GROUP
The development of effective strategies against cervical cancer in Africa requires accurate type specific data on human papillomavirus (HPV) prevalence, including determination of DNA sequences in order to maximise local vaccine efficacy. We have investigated cervical HPV infection and squamous intraepithelial lesions (SIL) in an unselected cohort of 1061 women in a rural Gambian community. Squamous intraepithelial lesions was diagnosed using cytology and histology, HPV was typed by PCR-ELISA of DNA extracts, which were also DNA sequenced. The prevalence of cervical HPV infection was 13% and SIL were observed in 7% of subjects. Human papillomavirus-16 was most prevalent and most strongly associated with SIL. Also common were HPV-18, -33, -58 and, notably, -35. Human papillomavirus DNA sequencing revealed HPV-16 samples to be exclusively African type 1 (Af1). Subjects of the Wolof ethnic group had a lower prevalence of HPV infection while subjects aged 25-44 years had a higher prevalence of cervical precancer than older or younger subjects. This first report of HPV prevalence in an unselected, unscreened rural population confirms high rates of SIL and HPV infection in West Africa. This study has implications for the vaccination of Gambian and other African populations in the prevention of cervical cancer. © 2005 Cancer Research UK.
Morison L, Scherf C, Ekpo G, Paine K, West B, Coleman R, Walraven G (2001) The long-term reproductive health consequences of female genital cutting in rural Gambia: A community-based survey, Tropical Medicine and International Health 6 (8) pp. 643-653
This paper examines the association between traditional practices of female genital cutting (FGC) and adult women's reproductive morbidity in rural Gambia. In 1999, we conducted a cross-sectional community survey of 1348 women aged 15-54 years, to estimate the prevalence of reproductive morbidity on the basis of women's reports, a gynaecological examination and laboratory analysis of specimens. Descriptive statistics and logistic regression were used to compare the prevalence of each morbidity between cut and uncut women adjusting for possible confounders. A total of 1157 women consented to gynaecological examination and 58% had signs of genital cutting. There was a high level of agreement between reported circumcision status and that found on examination (97% agreement). The majority of operations consisted of clitoridectomy and excision of the labia minora (WHO classification type II) and were performed between the ages of 4 and 7 years. The practice of genital cutting was highly associated with ethnic group for two of the three main ethnic groups, making the effects of ethnic group and cutting difficult to distinguish. Women who had undergone FGC had a significantly higher prevalence of bacterial vaginosis (BV) [adjusted odds ratio (OR) = 1.66; 95% confidence interval (CI) 1.25-2.18] and a substantially higher prevalence of herpes simplex virus 2 (HSV2) [adjusted OR = 4.71; 95% CI 3.46-6.42]. The higher prevalence of HSV2 suggests that cut women may be at increased risk of HIV infection. Commonly cited negative consequences of FGC such as damage to the perineum or anus, vulval tumours (such as Bartholin's cysts and excessive keloid formation), painful sex, infertility, prolapse and other reproductive tract infections (RTIs) were not significantly more common in cut women. The relationship between FGC and long-term reproductive morbidity remains unclear, especially in settings where type II cutting predominates. Efforts to eradicate the practice should incorporate a human rights approach rather than rely solely on the damaging health consequences.
Morison L, Buve A, Zekeng L, Heyndrickx L, Anagonou S, Musonda R, Kahindo M, Weiss HA, Hayes RJ, Laga M, Janssens W, van der Groen G (2001) HIV-1 subtypes and the HIV epidemics in four cities in sub-Saharan Africa, AIDS 15 pp. S109-S116
LIPPINCOTT WILLIAMS & WILKINS
To describe the distribution of HIV-1 subtypes in two cities with high HIV prevalence (Kisumu, Kenya and Ndola, Zambia) and two with relatively low prevalence (Cotonou, Benin and Yaoundé, Cameroon), and to examine whether the differences in prevalence of HIV infection could be due to the predominance within the infected populations of subtypes with differing efficiency of heterosexual transmission.
For around 100 randomly selected HIV-positive sera from the general population and 60 from sex workers in each city, the HIV-1 subtype was determined in the env fragment. For between 19 and 52 of the sera from the general population and 20-32 sera from sex workers, the subtype was also determined in the gag fragment.
Over 70% of infections in Cotonou, Yaoundé and Kisumu were with subtype A (by env). However, around one-half of subtype A infections in Cotonou and Yaoundé were found to be the circulating recombinant form CRF02_AG when the gag fragment was also examined. A large number of different HIV strains were found in Yaoundé, including some belonging to group O. Over 20% of infections in Kisumu and around 10% in Yaoundé were with isolated intersubtype recombinant forms. All but a few infections in Ndola were with subtype C and no recombinants were found.
The pattern of distribution of subtypes that we found does not suggest that differences in circulating subtypes play a major role in explaining the differences in prevalence of HIV-1 infection between the four cities. The emergence and spread of recombinants requires close surveillance to adapt testing strategies if needed, to inform vaccine development and to ascertain their role in the future spread of HIV.
The role of social capital in promoting health is now widely debated within international public health. In relation to HIV, the results of previous observational and cross-sectional studies have been mixed. In some settings it has been suggested that high levels of social capital and community cohesion might be protective and facilitate more effective collective responses to the epidemic. In others, group membership has been a risk factor for HIV infection. There have been few attempts to strengthen social capital, particularly in developing countries, and examine its effect on vulnerability to HIV. Employing data from an intervention study, we examined associations between social capital and HIV risk among 1063 14 to 35-year-old male and female residents of 750 poor households from 8 villages in rural Limpopo province, South Africa. We assessed cognitive social capital (CSC) and structural social capital (SSC) separately, and examined associations with numerous aspects of HIV-related psycho-social attributes, risk behavior, prevalence and incidence. Among males, after adjusting for potential confounders, residing in households with greater levels of CSC was linked to lower HIV prevalence and higher levels of condom use. Among females, similar patterns of relationships with CSC were observed. However, while greater SSC was associated with protective psychosocial attributes and risk behavior, it was also associated with higher rates of HIV infection. This work underscores the complex and nuanced relationship between social capital and HIV risk in a rural African context. We suggest that not all social capital is protective or health promotive, and that getting the balance right is critical to informing HIV prevention efforts. © 2008 Elsevier Ltd. All rights reserved.
As part of a community-based reproductive morbidity survey in rural Gambia, the prevalence and association of menstrual disorders with sociodemographic characteristics and other reproductive morbidities, and with knowledge, attitudes, and beliefs concerning menstrual problems were assessed. A questionnaire was administered by a field-worker and by a gynecologist, who also examined the women. Semistructured interviews were conducted to assess knowledge, attitudes, and beliefs in a subsample. Of 607 menstruating women not using hormonal contraceptives, 16 percent complained to the gynecologist of irregular cycles, 14 percent of dysmenorrhea, 8 percent of spotting, and 4 percent of heavy or prolonged bleeding. Each complaint was associated with other reproductive morbidities. A minority of women with menstrual problems had sought health care, and menstruation was revealed to be a highly personal and secretive topic in this population. Menstrual disorders constitute an important unaddressed area of reproductive health service needs in developing countries for which relatively simple and inexpensive therapies are often available. Information, education, and support combined with clinical management of menstrual problems should be core elements of reproductive health programs.
Lack N, West B, Jeffries D, Ekpo G, Morison L, Soutter WP, Walraven G, Boryseiwicz L (2005) Comparison of non-invasive sampling methods for detection of HPV in rural African women, Sexually Transmitted Infections 81 (3) pp. 239-241
Background: The prevalence of cervical cancer is extremely high in low income countries, primarily because of a lack of cytological screening. The link between human papillomavirus (HPV) and cervical cancer has long been recognised, and it has been suggested that isolated HPV testing in women who do not participate in existing screening programmes may be used to identify women at higher risk of developing cervical cancer. This community based study compares two self administered techniques for detecting HPV (tampons and self administered swabs) with a clinician directed technique, the cervical cytobrush. Methods: 377 rural women were interviewed and of these 210 women had full gynaecological examination, and accepted all three sampling methods for HPV. HPV typing of DNA extracts was performed using polymerase chain reaction and enzyme linked immunosorbent assay techniques. Results: Using the cervical cytobrush as the gold standard, self administered swabs (SAS) showed a sensitivity of 63.9%, and tampons showed a sensitivity of 72.4%. The acceptability of these two tests was 97.1% and 84.6% respectively. When combining acceptability with sensitivity, the SAS detected 61.9% and the tampons detected 60.9% of the true positives. Conclusion: In a setting where women are at a considerable risk of developing cervical cancer, with no access to a formal screening programme, self directed HPV testing could be a useful screening tool in identifying those women at increased risk who may require further investigation.
Binka FN, Kubaje A, Adjuik M, Williams LA, Lengeler C, Maude GH, Armah GE, Kajihara B, Adiamah JH, Smith PG (1996) Impact of permethrin impregnated bednets on child mortality in Kassena-Nankana district, Ghana: A randomized controlled trial, TROPICAL MEDICINE & INTERNATIONAL HEALTH 1 (2) pp. 147-154
BLACKWELL SCIENCE LTD
This study was designed to explore the physical characteristics and child care practices of child care centres as potential risk factors for respiratory infections and diarrhoea in children 3-35 mo of age. A dynamic cohort averaging 667 children from 40 child care centres in Campinas (Brazil) was followed up for 8 mo. Direct structured observations were made to collect information on the centres' physical structure, child activities and child care practices. Despite their good infrastructures, hand washing in the centres was infrequent, and nearly 30% of diaper changes were unhygienic. Risk factors for diarrhoea included the presence of flies during meals, infrequent child hand washing before meals, and infrequent child hand washing after defecation, with relative risks of 1.33, 1.73 and 1.63, respectively. There was 33% less diarrhoea in classes where soap was frequently used during diapering. Contrary to our hypotheses, ventilation, group size and child density were not associated with respiratory infections, as was the case for most other factors studied. Only mixing of groups and a larger classroom area were found to be negatively associated with lower and upper respiratory infections, respectively. The results indicate that improving hygiene practices is the only intervention in child care centre characteristics with good potential to reduce diarrhoea among attendees. For respiratory infections, no modifiable characteristic with intervention potential was identified.
O'Farrell N, Morison L, Chung CK (2007) Low prevalence of penile wetness among male sexually transmitted infection clinic attendees in London, Sexually Transmitted Diseases 34 (6) pp. 408-409
OBJECTIVE: To determine the prevalence of penile wetness among STI clinic attenders in London. STUDY DESIGN: A total of 480 consecutive men were examined clinically to detect whether penile wetness, defined as the clinical observation of a uniform diffuse layer of moisture on the surface of the glans and coronal sulcus, was present. RESULTS: Penile wetness was observed in 30 (6.3%), including 29 (8.3%) of uncircumcised and 1 (0.8%) of circumcised men (Relative risk 10.54 (95% CI 1.45-76.6, P =
Lowndes CM, Alary M, Meda H, Gnintoungbe CAB, Mukenge-Tshibaka L, Adjovi C, Buve A, Morison L, Laourou M, Kanhonou L, Anagonou S (2002) Role of core and bridging groups in the transmission dynamics of HIV and STIs in Cotonu, Benin, West Africa, SEXUALLY TRANSMITTED INFECTIONS 78 (Sup 1) pp. i69-i77
BRITISH MED JOURNAL PUBL GROUP
Hudeson CP, Smith AN, Buvé A, Laga M, Remes P, Padian N, Morison L (2000) Ethics of mass STD treatment  (multiple letters), Lancet 356 (9235) pp. 1115-1116
Elliott AM, Kizza M, Quigley MA, Ndibazza J, Nampijja M, Muhangi L, Morison L, Namujju PB, Muwanga M, Kabatereine N, Whitwortha JAG (2007) The impact of helminths on the response to immunization and on the incidence of infection and disease in childhood in Uganda: Design of a randomized, double-blind, placebo-controlled, factorial trial of deworming interventions delivered in pregnancy and early childhood, Clinical Trials 4 (1) pp. 42-57
Background: Helminths have profound effects on the immune response, allowing long-term survival of parasites with minimal damage to the host. Some of these effects "spill-over", altering responses to non-helminth antigens or allergens. It is suggested that this may lead to impaired responses to immunizations and infections, while conferring benefits against inflammatory responses in allergic and autoimmune disease. These effects might develop in utero, through exposure to maternal helminth infections, or through direct exposure in later life. Purpose: To determine the effects of helminths and their treatment in pregnancy and in young children on immunological and disease outcomes in childhood. Methods: The trial has three randomized, double-blind, placebo-controlled interventions at two times, in two people: a pregnant woman and her child. Pregnant women are randomized to albendazole or placebo and praziquantel or placebo. At age 15 months their children are randomized to three-monthly albendazole or placebo, to continue to age five years. The proposed designation for this sequence of interventions is a 2 × 2(×2) factorial design. Children are immunized with BCG and against polio, Diphtheria, tetanus, Pertussis, Haemophilus, hepatitis B and measles. Primary immunological outcomes are responses to BCG antigens and tetanus toxoid in whole blood cytokine assays and antibody assays at one, three and five years of age. Primary disease outcomes are incidence of malaria, pneumonia, diarrhoea, tuberculosis, measles, vertical HIV transmission, and atopic disease episodes, measured at clinic visits and twice-monthly home visits. Effects on anaemia, growth and intellectual development are also assessed. Conclusion: This trial, with a novel design comprising related interventions in pregnant women and their offspring, is the first to examine effects of helminths and their treatment in pregnancy and early childhood on immunological, infectious disease and allergic disease outcomes. The results will enhance understanding of both detrimental and beneficial effects of helminth infection and inform policy. © Society for Clinical Trials 2007.
Seager M, Morison L, Wilkins D, Haggett A, Sullivan L, Barry J (2014) The hidden mental pain of men, PSYCHOLOGIST 27 (3) pp. 138-139 BRITISH PSYCHOLOGICAL SOC
Hargreaves JR, Morison LA, Chege J, Rutenburg N, Kahindo M, Weiss HA, Hayes R, Buve A (2002) Socioeconomic status and risk of HIV infection in an urban population in Kenya, TROPICAL MEDICINE & INTERNATIONAL HEALTH 7 (9) pp. 793-802 BLACKWELL PUBLISHING LTD
During the second year of the Gambian National Impregnated Bednet Programme (NIBP) charges for insecticide ($0.50 per net) were introduced into the half of the primary health care villages in the country where insecticide have been provided free of charge the previous year. Free insecticide was provided in the remaining villages that had acted as controls during the previous year. In villages where insecticide was provided free, 77% of nets were treated with insecticide. In contrast, in villages where charges were made coverage was only 14%. During the first year of the NIBP, mortality in children was significantly lower in villages where insecticide was provided free than in the control villages. Introduction of a charge for insecticide into the first group of villages and the provision of free insecticide in the latter abolished this difference. The cash income of rural Gambians is very limited and payment of even $2-3 for insecticide treatment for all the bednets in a household represents a substantial outlay. Further education on the benefits of treatment of nets and/or the provision of cheaper insecticide will be required before the full benefits of this powerful new malaria control measure can be fully realised in the Gambia.
Kroeger A, Avila EV, Morison L (2002) Insecticide impregnated curtains to control domestic transmission of cutaneous leishmaniasis in Venezuela: cluster randomised trial, BRITISH MEDICAL JOURNAL 325 (7368) pp. 810-813 BRITISH MED JOURNAL PUBL GROUP
A total of 275 liver biopsies were performed on dairy cows in 6 Friesian and one Guernsey herd during the first 2 weeks after calving. Liver samples were processed by 2 independent histological procedures: (a) formalin-fixed frozen sections were stained with oil-red O (ORO), or (b) samples fixed in glutaraldehyde-osmium tetroxide were embedded in plastic and sections stained with toluidine blue (TOLB). The sections were then subjected to stereological point-counting procedures to assess the quantities of stainable fat present within the liver cells. Estimates of liver cell fat by the 2 techniques were highly correlated, although those obtained by the TOLB method were consistently lower than those obtained by the ORO method. The analytical sampling error was slightly lower in the TOLB method. The simpler ORO method should prove an acceptable alternative in the routine histology laboratory to the tedious and technically demanding TOLB method.
O'Farrell N, Morison L, Moodley P, Pillay K, Vanmali T, Quigley M, Hayes R, Sturm AW (2007) Acceptability of a penile wipe to promote male genital hygiene, International Journal of STD and AIDS 18 (5)
Background: Aboriginal adolescents are more likely to become pregnant and contract an STI than other Canadian adolescents. This study provides some of the first data on factors associated with these outcomes among Aboriginal adolescents. Methods: A secondary analysis was conducted using 2003 data from a large cross-sectional survey of British Columbia secondary school students. 445 young women and 360 young men who identified as Aboriginal and reported ever having sex were included in analyses. Associations between selfreported pregnancy and STI and 11 exposure variables were examined using logistic regression. Results: Of young women, 10.6% reported a pregnancy; 10.5% of young men reported causing a pregnancy. An STI diagnosis was reported by 4.2% of young women and 3.9% of young men. In multivariate analyses for young men, ever having been sexually abused was the strongest consistent risk factor for causing a pregnancy (AOR=4.30, 95% CI 1.64-11.25) and STI diagnosis (AOR=5.58, 95% CI 1.61-19.37). For young women, abuse was associated with increased odds of pregnancy (AOR=10.37, 95% CI 4.04-26.60) but not STI. Among young women, substance use was the strongest consistent risk factor for both pregnancy (AOR=3.36, 95% CI 1.25-9.08) and STI (AOR=5.27, 95% CI 1.50-18.42); for young men, substance use was associated with higher odds of STI (AOR=4.60, 95% CI 1.11-19.14). Factors associated with decreased risk included community, school and family involvement. Conclusions: Health care professionals, communities and policy-makers must urgently address sexual abuse and substance use. Exploring promotion of school and community involvement and family cohesion may be useful for sexual health interventions with Aboriginal students.
Objective:: To assess effects of a combined microfinance and training intervention on HIV risk behavior among young female participants in rural South Africa. Design:: Secondary analysis of quantitative and qualitative data from a cluster randomized trial, the Intervention with Microfinance for AIDS and Gender Equity study. Methods:: Eight villages were pair-matched and randomly allocated to receive the intervention. At baseline and after 2 years, HIV risk behavior was assessed among female participants aged 14?¬"35 years. Their responses were compared with women of the same age and poverty group from control villages. Intervention effects were calculated using adjusted risk ratios employing village level summaries. Qualitative data collected during the study explored participants responses to the intervention including HIV risk behavior. Results:: After 2 years of follow-up, when compared with controls, young participants had higher levels of HIV-related communication (adjusted risk ratio 1.46, 95% confidence interval 1.01?¬"2.12), were more likely to have accessed voluntary counseling and testing (adjusted risk ratio 1.64, 95% confidence interval 1.06?¬"2.56), and less likely to have had unprotected sex at last intercourse with a nonspousal partner (adjusted risk ratio 0.76, 95% confidence interval 0.60?¬"0.96) . Qualitative data suggest a greater acceptance of intrahousehold communication about HIV and sexuality. Although women noted challenges associated with acceptance of condoms by men, increased confidence and skills associated with participation in the intervention supported their introduction in sexual relationships. Conclusions:: In addition to impacts on economic well being, women empowerment and intimate partner violence, interventions addressing the economic and social vulnerability of women may contribute to reductions in HIV risk behavior. © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins.
West B, Morison L, Van der Loeff MS, Gooding E, Awasana AA, Demba E, Mayaud P (2003) Evaluation of a new rapid diagnostic kit (FemExam) for bacterial vaginosis in patients with vaginal discharge syndrome in the Gambia, SEXUALLY TRANSMITTED DISEASES 30 (6) pp. 483-489 LIPPINCOTT WILLIAMS & WILKINS
Culture medium from bovine peripheral blood mononuclear cells stimulated with the mitogens phytohaemagglutinin (PHA) or Concanavalin A (Con A) was found to maintain the proliferation of Con A blasts in vitro. The factor responsible for this activity was not absorbable with bovine erythrocytes or fresh peripheral blood lymphocytes but was removed by Con A blasts. Production of this factor was dependent on the dose of mitogen used and was greatest after 24 h culture compared to 48 h. Quantitative determinations of factor activity in supernatants were carried out by regression analysis of logit transformed data from assays measuring the maintenance of Con A blast proliferation by supernatants.
Hargreaves JR, Morison Linda, Kim JC, Busza J, Phetla G, Porter JDH, Watts C, Pronyk PM (2009) Characteristics of sexual partnerships, not just of individuals, are associated with condom use and recent HIV infection in rural South Africa, AIDS CARE-PSYCHOLOGICAL AND SOCIO-MEDICAL ASPECTS OF AIDS/HIV 21 (8) pp. 1058-1070
ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD
Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, Busza J, Porter JD (2006) Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial, Lancet 368 (9551) pp. 1973-1983
Background: HIV infection and intimate-partner violence share a common risk environment in much of southern Africa. The aim of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study was to assess a structural intervention that combined a microfinance programme with a gender and HIV training curriculum. Methods: Villages in the rural Limpopo province of South Africa were pair-matched and randomly allocated to receive the intervention at study onset (intervention group, n=4) or 3 years later (comparison group, n=4). Loans were provided to poor women who enrolled in the intervention group. A participatory learning and action curriculum was integrated into loan meetings, which took place every 2 weeks. Both arms of the trial were divided into three groups: direct programme participants or matched controls (cohort one), randomly selected 14-35-year-old household co-residents (cohort two), and randomly selected community members (cohort three). Primary outcomes were experience of intimate-partner violence-either physical or sexual-in the past 12 months by a spouse or other sexual intimate (cohort one), unprotected sexual intercourse at last occurrence with a non-spousal partner in the past 12 months (cohorts two and three), and HIV incidence (cohort three). Analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov, number NCT00242957. Findings: In cohort one, experience of intimate-partner violence was reduced by 55% (adjusted risk ratio [aRR] 0·45, 95% CI 0·23-0·91; adjusted risk difference -7·3%, -16·2 to 1·5). The intervention did not affect the rate of unprotected sexual intercourse with a non-spousal partner in cohort two (aRR 1·02, 0·85-1·23), and there was no effect on the rate of unprotected sexual intercourse at last occurrence with a non-spousal partner (0·89, 0·66-1·19) or HIV incidence (1·06, 0·66-1·69) in cohort three. Interpretation: A combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in programme participants. Social and economic development interventions have the potential to alter risk environments for HIV and intimate-partner violence in southern Africa. © 2006 Elsevier Ltd. All rights reserved.
Paine K, Hart G, Jawo M, Ceesay S, Jallow M, Morison L, Walraven G, McAdam K, Shaw M (2002) 'Before we were sleeping, now we are awake': Preliminary evaluation of the Stepping Stones sexual health programme in The Gambia., African Journal of AIDS Research 1 (1) pp. 39-50
National Inquiry Services Centre (NISC)
Community-based behavioural interventions aimed at reducing risky sexual behaviour have yet to be shown to be effective in the developing world. Stepping Stones is a participatory STI/HIV prevention workshop programme based on empowerment techniques, which has been adapted to an infertility prevention framework for The Gambia. This paper describes a preliminary evaluation in two villages where the intervention was carried out compared to two control villages. Methods used include: participatory evaluation; 84 in-depth interviews; seven focus group discussions; a knowledge, attitudes and practice questionnaire administered to a random sample of 25% of the adult population at three time points; and monitoring of condom supply. The structure of the evaluation is based on the themes derived from the qualitative data. The infertility prevention approach made it possible to overcome resistance to discussing the topics of sexual and reproductive health. An atmosphere of trust was created and men were persuaded to participate in the programme as they felt that their own needs were being addressed. Participants enjoyed the programme and found the content relevant. Knowledge of the modes of transmission of HIV and sexually transmitted infections and levels of risk awareness increased. The value of condoms in particular situations was recognised: for sex before marriage, within marriage (when the woman is breastfeeding) and with non-marital partners. Women reported that they would insist on condom use outside marriage and even ask their husbands to use condoms for non-marital sex. Condom monitoring data suggested that condom uptake had increased. It was reported that there was significant increase in dialogue within marriage with the consequence that there were fewer disagreements and incidents of domestic violence. Diffusion of the messages of Stepping Stones appeared to have taken place with non-participants including children. The evaluation techniques used can now be refined in order to generate further evidence on a larger scale and over a longer period.
In this paper, the ways in which HIV is transmitted and factors facilitating transmission are described, although we still do not fully understand why the HIV epidemic has spread so heterogeneously across the globe. Estimates of HIV prevalence vary in quality but give some idea of trends in different countries and regions. Of all regions in the world, sub-Saharan Africa is the hardest hit by HIV, containing around 70% of people living with HIV/AIDS. There are, however, recent signs of hope in Africa due to a slight reduction in the number of new HIV cases in the year 2000. Most countries in Asia have not seen explosive epidemics in the general population up to now but patterns of injecting drug use (IDU) and sex work are conducive to the spread of HIV so there is no room for complacency. Unpredictable epidemics among IDU in the former Soviet Union have the potential to spread into the general population. Some countries in Central America and the Caribbean have growing HIV epidemics with adult prevalences second only to sub-Saharan Africa. Reductions in morbidity and mortality through the use of highly active antiretroviral therapy are at present limited to high-income and some Latin American countries. Both the cost of these therapies and the poor health care delivery systems in many affected countries need to be addressed before antiretrovirals can benefit the majority of people living with HIV/AIDS.
O'Farrell N, Oula R, Morison L, Van CTB (2006) Periodic presumptive treatment for cervical infections in service women in 3 border provinces of Laos, Sexually Transmitted Diseases 33 (9) pp. 558-564
OBJECTIVES: The objectives of this study were to determine whether periodic presumptive treatment (PPT) for sexually transmitted infections (STIs) in service women could be implemented in 3 border provinces of Laos and whether its implementation was associated with a reduction in the prevalence of cervical infections. STUDY DESIGN: Four hundred forty-two service women were interviewed using a standardized questionnaire in 3 border provinces at baseline (day 1) and 419 3 months (day 90) later. Azithromycin at a dosage of 1 g was administered at monthly intervals over 3 months in Khammouane province, on days 1, 30, and 90 in Oudomxai and days 1, 60, and 90 in Savannakhet. Urine samples were collected at baseline and day 90 for gonorrhea and chlamydia testing. RESULTS: Baseline samples showed very high levels of both gonorrhea and/or chlamydia of 42.7% in Oudomxai, 39.9% in Khammouane, and 22.7% in Savannakhet. At day 90, after 2 or 3 rounds of PPT, these were, respectively, 12.3%, 21.9%, and 17.0%. Overall, the prevalence of any cervical infection decreased by 45% from 32.4% (95% confidence interval [CI] = 28.1-36.9) at day 1 to 18.0% (95% CI = 14.5-22.1) at day 90 (P
O'Farrell N, Morison L, Moodley P, Pillay K, Vanmali T, Quigley M, Hayes R, Sturm AW (2006) Association between HIV and subpreputial penile wetness in uncircumcised men in South Africa, Journal of Acquired Immune Deficiency Syndromes 43 (1) pp. 69-77
OBJECTIVES: To describe the prevalence and characteristics of subpreputial penile wetness and to investigate the association between current levels of penile wetness and HIV infection. METHODS: Male attenders at a sexually transmitted infections clinic in Durban, South Africa were enrolled and treated for their presenting sexually transmitted infection complaint. They were asked to return after 14 days when a structured questionnaire was administered, and the degree of wetness of the glans penis and coronal sulcus was assessed clinically. RESULTS: Six hundred and fifty men were enrolled, and 488 (75%) returned. Three hundred eighty-six uncircumcised men were included for statistical analysis of whom 215 (56%) were HIV positive. One hundred ninety-six (50.8%) had no penile wetness, and 190 (49.2%) had penile wetness. In the adjusted analysis, penile wetness was associated with younger age, low level of attained education, low income, higher lifetime numbers of sexual partners, and not washing after sex. The prevalence of HIV was greater in those with penile wetness 126 of 190 (66.3%) compared with 90 of 196 (45.9%) with no penile wetness, crude prevalence odds ratio 2.32 (95% confidence interval [CI], 1.54-3.50, P =
Zimmerman C, Hossain M, Yun K, Gajdadziev V, Guzun N, Tchomarova M, Ciarrocchi RA, Johansson A, Kefurtova A, Scodanibbio S, Motus MN, Roche B, Morison L, Watts C (2008) The health of trafficked women: A survey of women entering posttrafficking services in Europe, American Journal of Public Health 98 (1) pp. 55-59
American Public Health Association
Morison L, Trigeorgis C, John M (2014) Are mental health services inherently feminised?, PSYCHOLOGIST 27 (6) pp. 414-416 BRITISH PSYCHOLOGICAL SOC
OBJECTIVE: To examine the association between age on arrival in Britain and experiences and attitudes relating to female circumcision among young, single Somalis living in London. DESIGN: The study population consisted of single male and female Somalis aged 16-22 years living in the Greater London area. Quantitative data were collected using a cross-sectional survey based on snowball sampling aiming to obtain data on 100 males and 100 females. Qualitative data were collected from 10 males and 10 infibulated females. RESULTS: Quantitative data were obtained for 94 females and 80 males. Living in Britain from a younger age was associated with increased assimilation in terms of language, dress and socialising. Seventy per cent of the females reported being circumcised with two-thirds of operations being infibulation. Those who were living in Britain before the usual age range for circumcision (before age six) were less likely to be circumcised (42%) than those who arrived after the usual age range for circumcision (11 or older) (91%). During in-depth interviews, health and sexual problems due to female circumcision were described with great emotion and interviewees acknowledged the association between the importance of virginity for marriage and circumcision. Half of males who arrived aged 11 or older wanted a circumcised wife compared with less than a quarter of those who arrived at a younger age. Eighteen per cent of female respondents and 43% of males intended to circumcise any daughters. Females were less likely than males to agree with the assumptions about sexuality and religion that underpin the practice. Substantial proportions of respondents perceived that their parents' expectations in terms of marriage and circumcision were more traditional than their own. CONCLUSION: Living in Britain from a younger age appears to be associated with abandonment of female circumcision and with changes in the underlying beliefs on sexuality, marriage and religion that underpin it. Groups identified with more traditional views towards female circumcision include males, older generations, new arrivals and those who show few signs of social assimilation.
Hatcher AM, de Wet J, Bonell C, Phetla G, Strange V, Pronyk P, Kim J, Morison LA, Watts C, Porter J, Hargreaves JR (2016) Is Microfinance Coupled with Gender Training Empowering for Women? Lessons from the IMAGE Process Evaluation in Rural South Africa, In: Dworkin S, Ghandi M, Passano P (eds.), Women's Empowerment and Global Health; A Twenty-First-Century Agenda 9 pp. 210-231
University of California Press
What is women?s empowerment, and how and why does it matter for women?s health? Despite the rise of a human rights?based approach to women?s health and increasing awareness of the synergies between women?s health and empowerment, a lack of consensus remains as to how to measure empowerment and successfully intervene in ways that improve health. Women?s Empowerment and Global Health presents thirteen multidisciplinary case studies that demonstrate how science and advocacy can be creatively merged to enhance the agency and status of women. The content is enriched by ancillary videos that give background about programs in India, the United States, Mexico, Nicaragua, Zimbabwe, and South Africa. Women?s Empowerment and Global Health provides the next generation of researchers and practitioners, as well as students in global and public health, sociology, anthropology, women?s studies, law, business, and medicine, with cutting-edge and inspirational examples of programs that point the way toward achieving women?s equality and fulfilling the right to health.
Do the gains in confidence and economic well being that can come from participation in a microfinance programme reduce clients' vulnerability to HIV infection? Until now practical experience and an evidence base relating to such activities have been limited. This article reviews the evidence supporting an enhanced role for microfinance in HIV prevention activities. It describes the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) - a South African case study that has been specifically designed to explore these relationships. The paper discusses the operational integration of microfinance and HIV prevention - high-lighting challenges, emerging lessons and limitations in the light of international best practice and several years of field experience.
Buvé A, Caraël M, Hayes RJ, Auvert B, Ferry B, Robinson NJ, Anagonou S, Kanhonou L, Laourou M, Abega S, Akam E, Zekeng L, Chege J, Kahindo M, Rutenberg N, Kaona F, Musonda R, Sukwa T, Morison L, Weiss HA, Laga M (2001) The multicentre study on factors determining the differential spread of HIV in four African cities: summary and conclusions., AIDS 15 Sup (SUPPL. 4) pp. S127-S131
In all regions of sub-Saharan Africa, the predominant mode of transmission of HIV is sexual intercourse between men and women, but there are large variations in the rate and extent of the spread of HIV in different populations. We set out to try and identify factors that could explain why HIV has spread more rapidly in some parts of Africa than in others. To approach this question, we used a study design that combined ecological comparisons across populations with individual-level analyses within populations. The ecological analysis allowed us to explore the population-level effects of risk factor profiles that may be difficult to identify from individual-level analysis.
Galloway R, Dusch E, Elder L, Achadi E, Grajeda R, Hurtado E, Favin M, Kanani S, Marsaban J, Meda N, Mona Moore K, Morison L, Raina N, Rajaratnam J, Rodriquez J, Stephen C (2002) Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries, Social Science and Medicine 55 (4) pp. 529-544
The World Health Organization estimates that 58% of pregnant women in developing countries are anemic. In spite of the fact that most ministries of health in developing countries have policies to provide pregnant women with iron in a supplement form, maternal anemia prevalence has not declined significantly where large-scale programs have been evaluated. During the period 1991-98, the MotherCare Project and its partners conducted qualitative research to determine the major barriers and facilitators of iron supplementation programs for pregnant women in eight developing countries. Research results were used to develop pilot program strategies and interventions to reduce maternal anemia. Across-region results were examined and some differences were found but the similarity in the way women view anemia and react to taking iron tablets was more striking than differences encountered by region, country or ethnic group. While women frequently recognize symptoms of anemia, they do not know the clinical term for anemia. Half of women in all countries consider these symptoms to be a priority health concern that requires action and half do not. Those women who visit prenatal health services are often familiar with iron supplements, but commonly do not know why they are prescribed. Contrary to the belief that women stop taking iron tablets mainly due to negative side effects, only about one-third of women reported that they experienced negative side effects in these studies. During iron supplementation trials in five of the countries, only about one-tenth of the women stopped taking the tablets due to side effects. The major barrier to effective supplementation programs is inadequate supply. Additional barriers include inadequate counseling and distribution of iron tablets, difficult access and poor utilization of prenatal health care services, beliefs against consuming medications during pregnancy, and in most countries, fears that taking too much iron may cause too much blood or a big baby, making delivery more difficult. Facilitators include women's recognition of improved physical well being with the alleviation of symptoms of anemia, particularly fatigue, a better appetite, increased appreciation of benefits for the fetus, and subsequent increased demand for prevention and treatment of iron deficiency and anemia. © 2002 Elsevier Science Ltd. All rights reserved.
Buvé A, Caraël M, Hayes RJ, Auvert B, Ferry B, Robinson NJ, Anagonou S, Kanhonou L, Laourou M, Abega S, Akam E, Zekeng L, Chege J, Kahindo M, Rutenberg N, Kaona F, Musonda R, Sukwa T, Morison L, Weiss HA, Laga M (2001) Multicentre study on factors determining differences in rate of spread of HIV in sub-Saharan Africa: methods and prevalence of HIV infection., AIDS 15 Sup (SUPPL. 4) pp. S5-14
OBJECTIVE: The objective of this study was to explore whether the differences in rate of spread of HIV in different regions in sub-Saharan Africa could be explained by differences in sexual behaviour and/or factors influencing the probability of HIV transmission during sexual intercourse. METHODS: A cross-sectional, population-based study was conducted in two cities with a high HIV prevalence (Kisumu in Kenya and Ndola in Zambia) and two cities with a relatively low HIV prevalence (Cotonou in Benin and Yaoundé in Cameroon). In each of these cities, approximately 1000 men and 1000 women, aged 15-49 years, were randomly selected from the general population. Consenting men and women were interviewed and were tested for HIV, syphilis, herpes simplex virus type 2 (HSV-2), gonorrhoea, chlamydial infection and trichomoniasis (the latter for women only). In addition, a survey was conducted on a random sample of 300 sex workers in each city. The research instruments, including the questionnaires and the laboratory procedures, were standardized to permit comparison of results. RESULTS: The numbers of men interviewed were 1021 in Cotonou, 973 in Yaoundé, 829 in Kisumu, and 720 in Ndola. The corresponding figures for women were 1095, 1116, 1060 and 1130. In Yaoundé, Kisumu and Ndola, the response rates for men were lower than for women due to failure to make contact with eligible men. The proportion of eligible women who were interviewed was 86% in Yaoundé, and 89% in Kisumu and Ndola. In Yaoundé, 76% of eligible men were interviewed, along with 82% in Kisumu and 75% in Ndola. The prevalence of HIV infection in men was 3.3% in Cotonou, 4.1% in Yaoundé, 19.8% in Kisumu and 23.2% in Ndola. For women, the respective figures were 3.4, 7.8, 30.1 and 31.9%. The prevalence of HIV infection among women aged 15-19 years was 23.0% in Kisumu and 15.4% in Ndola. Among women in Kisumu who had their sexual debut 5 years before the interview, the prevalence of HIV infection was 46%; in Ndola, it was 59%. Among sex workers, the prevalence of HIV infection was 57.5% in Cotonou, 34.4% in Yaoundé, 74.7% in Kisumu and 68.7% in Ndola. CONCLUSIONS: The HIV prevalence rates in the general population confirmed our preliminary assessment of the level of HIV infection in the four cities, which was based on estimates of HIV prevalence from sentinel surveillance among pregnant women. The very high prevalence of HIV infection among young women in Kisumu and Ndola calls for urgent intervention.
Lagarde E, Auvert B, Carael M, Laourou M, Ferry B, Akam E, Sukwa T, Morison L, Maury B, Chege J, N'Doye I, Buve A (2001) Concurrent sexual partnerships and HIV prevalence in five urban communities of sub-Saharan Africa, AIDS 15 (7) pp. 877-884
LIPPINCOTT WILLIAMS & WILKINS
Objective: To estimate parameters of concurrent sexual partnerships in five urban populations in sub-Saharan Africa and to assess their association with levels of HIV infection and other sexually transmitted infections (STI).
Methods: Data were obtained from a multicentre study of factors which determine the differences in rate of spread of HIV in five African cities. Consenting participants were interviewed on sexual behaviour and at four of the five sites also provided a blood and a urine sample for testing for HIV and other STI. Data on sexual behaviour included the number of partnerships in the 12 months preceding the interview as well as the dates of the start and end of each partnership. Summary indices of concurrent sexual partnerships - some of which were taken from the literature, while others were newly developed - were computed for each city and compared to HIV and STI prevalence rates.
Results: A total of 1819 adults aged 15-49 years were interviewed in Dakar (Senegal), 2116 in Cotonou (Benin), 2089 in Yaounde (Cameroon), 1889 in Kisumu (Kenya) and 1730 in Ndola (Zambia). Prevalence rates of HIV infection were 3.4% for Cotonou, 5.9% for Yaounde, 25.9% for Kisumu and 28.4% for Ndola, and around 1% for Dakar. The estimated fraction of sexual partnerships that were concurrent at the time of interview (index k) was relatively high in Yaounde (0.98), intermediate in Kisumu (0.44) and Cotonou (0.33) and low in Ndola (0.26) and in Dakar (0.18). An individual indicator of concurrency (iic) was developed which depends neither on the number of partners nor on the length of the partnerships and estimates the individual propensity to keep (positive values) or to dissolve (negative values) on-going partnership before engaging in another one. This measure iic did not discriminate between cities with high HIV infection levels and cities with low HIV infection levels. In addition, iic did not differ significantly between HIV-infected and uninfected people in the four cities where data on HIV status were collected.
Conclusion: We could not find evidence that concurrent sexual partnerships were a major determinant of the rate of spread of HIV in five cities in sub-Saharan Africa. HIV epidemics are the result of many factors, behavioural as well as biological, of which concurrent sexual partnerships are only one.
Morison L, Scherf C (2004) Erratum: The association between female genital cutting and correlates of sexual and gynaecological morbidity in Edo State, Nigeria (BJOG: An International Journal of Obstetrics and Gynaecology (2003) 110 (1137)), BJOG: An International Journal of Obstetrics and Gynaecology 111 (10)
Stewart H, Morison L, White R (2002) Determinants of coital frequency among married women in Central African Republic: the role of female genital cutting., J Biosoc Sci 34 (4) pp. 525-539
This paper examines determinants of one aspect of sexual behaviour--coital frequency--among 2,188 married women in the Central African Republic using a secondary analysis of data from the Demographic and Health Survey of 1994-95. Female genital cutting (or circumcision) is practised in the Central African Republic and self-reported circumcision status was included in the questionnaire enabling it to be examined as a possible determinant of coital frequency. Multiple logistic regression was used to find a subset of factors independently associated with coital frequency. Decreased coital frequency was found in those who had longer duration of marriage, those who were not the most recent wife in a polygamous marriage and those who had more surviving children. Coital frequency was higher in more educated women and those not contracepting because they wanted to get pregnant. After adjusting for confounders no association between female genital cutting and coital frequency was found. The extent to which women can control coital frequency in this culture is not known and fertility desires may override any negative effects of circumcision on sexual pleasure. It was therefore not possible to draw conclusions about how female genital cutting affects a woman's desire for sexual intercourse and consequently there is a need to develop research methods further to investigate this question.
Halton K, Ratcliffe AA, Morison L, West B, Shaw M, Bailey R, Walraven G (2003) Herpes simplex 2 risk among women in a polygynous setting in rural West Africa, AIDS 17 (1) pp. 97-103
Objectives: To determine risk factors for herpes simplex 2 (HSV2) infection in women in a polygynous rural Gambian population. Methods: Data from women who participated in a cross-sectional survey of reproductive health were matched to their own and, for women who had been or were married (ever-married), their spouses' data collected in a cross-sectional survey of fertility interests, including information on marital histories. Results: Data were available on 150 never-married and 525 ever-married women. HSV2 prevalence was 16% amongst never-married women and 36% amongst ever-married women. For ever-married women, their own personal characteristics (age, ethnicity and genital cutting status) and events from their husbands' marriage history were important determinants of HSV2 infection. Women whose husbands married for the first time over age 35 were at greater risk than women whose husbands married by age 24 [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.20-6.10]. Women whose husband reported interest in a new marriage were more likely to be HSV2 positive (OR 1.91, 95% CI 1.18-3.09). Women whose husbands were currently monogamous but had had previous marriages (OR 2.76, 95% CI 1.30-5.88) and women in currently polygynous marriages (OR 2.88, 95% CI 1.66-5.01) were three times as likely to be HSV2 positive as women who were their husband's only wife ever. Conclusion: Much transmission of HSV2 in this setting occurs within marriage where opportunity for personal protection is limited. High levels of transmission within marriage may undermine the impact of sexual behaviour change programmes aiming to reduce HSV2 and HIV incidence and complicate their evaluation. © 2003 Lippincott Williams & Wilkins.
Tann CJ, Mpairwe H, Morison L, Nassimu K, Hughes P, Omara M, Mabey D, Muwanga M, Grosskurth H, Elliott AM (2006) Lack of effectiveness of syndromic management in targeting vaginal infections in pregnancy in Entebbe, Uganda., Sex Transm Infect 82 (4) pp. 285-289
OBJECTIVES: To measure the prevalence of reproductive tract infections (RTIs) during pregnancy in Entebbe, Uganda, and to evaluate the current syndromic diagnosis and management approach in effectively targeting infections, such as bacterial vaginosis (BV) and trichomoniasis, that are associated with low birth weight and prematurity among newborns. METHODS: We enrolled 250 antenatal clinic attenders. Vaginal swabs and diagnostic tests were performed for BV, Trichomonas vaginalis (TV), candida, Neisseria gonorrhoeae, Chlamydia trachomatis and for HIV-1 and active (TPHA+/RPR+) syphilis infection. Same day treatment was offered for symptoms according to syndromic management guidelines. The treatment actually provided by healthcare workers was documented. Sensitivity, specificity, positive and negative predictive values were used to assess the effectiveness of syndromic management guidelines and practice. RESULTS: The prevalence of infections were: BV 47.7%, TV 17.3%, candida 60.6%, gonorrhoea 4.3%, chlamydia 5.9%, syphilis 1.6%, and HIV 13.1%. In total, 39.7% of women with BV and 30.2% of those with TV were asymptomatic. The sensitivity of syndromic management as applied by health workers in targeting BV and TV was 50.0% and 66.7%, respectively. This would have increased to 60.3% (BV) and 69.8% (TV) had the algorithm been followed exactly. CONCLUSIONS: The prevalence of BV and TV seen in this and other African populations is high. High rates of asymptomatic infection and a tendency of healthcare workers to deviate from management guidelines by following their own personal clinical judgment imply that many vaginal infections remain untreated. Alternative strategies, such as presumptive treatment of BV and TV in pregnancy, should be considered.
Hargreaves J, Hatcher A, Strange V, Phetla G, Busza J, Kim J, Watts C, Morison Linda, Porter J, Pronyk P, Bonell C (2010) Process evaluation of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in rural South Africa, HEALTH EDUCATION RESEARCH 25 (1) pp. 27-40
OXFORD UNIV PRESS
The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) combines microfinance, gender/HIV training and community mobilization (CM) in South Africa. A trial found reduced intimate partner violence among clients but less evidence for impact on sexual behaviour among clients' households or communities. This process evaluation examined how feasible IMAGE was to deliver and how accessible and acceptable it was to intended beneficiaries during a trial and subsequent scale-up. Data came from attendance registers, financial records, observations, structured questionnaires (378) and focus group discussions and interviews (128) with clients and staff. Gender/HIV training and CM were managed initially by an academic unit ('linked' model) and later by the microfinance institution (MFI) ('parallel' model). Microfinance and gender/HIV training were feasible to deliver and accessible and acceptable to most clients. Though participation in CM was high for some clients, others experienced barriers to collective action, a finding which may help explain lack of intervention effects among household/community members. Delivery was feasible in the short term but both models were considered unsustainable in the longer term. A linked model involving a MFI and a non-academic partner agency may be more sustainable and is being tried. Feasible models for delivering microfinance and health promotion require further investigation.
Biraro S, Morison LA, Nakiyingi-Miiro J, Whitworth JAG, Grosskurth H (2007) The role of vertical transmission and health care-related factors in HIV infection of children: A community study in rural Uganda, Journal of Acquired Immune Deficiency Syndromes 44 (2) pp. 222-228
OBJECTIVES: To determine the probable route of transmission of HIV to children aged 12 years or younger in a rural area of Uganda from 1999 through 2000 and to examine associations between HIV infection and health care-related variables. METHODS: The HIV infections status for 6991 children was determined from 1 round of an ongoing population surveillance system, and the reported numbers of injections in the past year and blood transfusions were determined for 5922 of these children based on a medical questionnaire. Data from the surveillance system and from an additional survey were used to assess the potential for vertical infection from a mother to her child. RESULTS: The HIV prevalence among children was 0.4%. Of 23 definite and 4 probable cases of HIV infection in children, vertical transmission was not possible for 1 case, not likely for another case, and possibly not vertical for another case. The population-attributable fraction for vertical transmission was between 90% and 94%. Large numbers of injections in the past year and ever having a blood transfusion were only associated with HIV infection in children exposed to vertical transmission. CONCLUSIONS: Up to 10% of HIV infections in children in the study area were not attributable to vertical transmission, and thus were possibly attributable to iatrogenic transmission. Associations seen between health care-related variables and HIV were likely to be attributable to treatment for AIDS-related illness in children infected vertically. © 2007 Lippincott Williams & Wilkins, Inc.
Reid IM, Dew AM, Williams LA (1984) Haematology of subclinical fatty liver in dairy cows., Res Vet Sci 37 (1) pp. 63-65
The relationship between liver fat content and haematology was investigated in 369 cows from eight herds sampled in the second week after calving. High levels of fat in the liver were associated with a depression in total white cell count and in neutrophils, eosinophils and lymphocytes. There was no correlation between liver fat content and the percentage of E rosetting lymphocytes, packed cell volume or haemoglobin concentration. The changes in peripheral white cell counts may be related to the increased incidence of post parturient disease in cows with fatty liver.
OBJECTIVE: To examine whether commercial sex transactions were more common and/or transmission between sex workers and clients more efficient in two African cities with high HIV prevalence (Kisumu, Kenya and Ndola, Zambia) compared with two with relatively low HIV prevalence (Cotonou, Benin and Yaoundé, Cameroon). METHODS: Data on sexual behaviour, HIV and sexually transmitted infections were collected from representative samples of around 300 female sex workers in each city. Sexual behaviour data from a population-based study of around 1000 men aged 15-49 in each city were used to estimate the extent of contact with sex workers. RESULTS: The number of sex workers per 1000 males was highest in Kisumu and Ndola, but other estimates of the extent or characteristics of sex work contact showed no consistent differences between high or low prevalence cities. HIV prevalence among sex workers was 75% in Kisumu, 69% in Ndola, 55% in Cotonou and 34% in Yaoundé. The prevalence of genital ulceration and trichomoniasis was higher among sex workers in Kisumu and Ndola but no clear pattern was seen for the other sexually transmitted infections. Around 70% of sex workers in Cotonou reported use of a condom with the last client, markedly higher than in the other cities. CONCLUSIONS: Although sex work is likely to have played an important role in the spread of HIV in all four cities, differences in present patterns of sex work do not appear to explain the differential spread of HIV. However, high levels of condom use among sex workers may have slowed the spread from sex workers to the general population in Cotonou, highlighting the importance of interventions among sex workers and their clients.
Jan S, Ferrari G, Watts CH, Hargreaves JR, Kim JC, Phetla G, Morison LA, Porter JD, Barnett T, Pronyk PM (2010) Economic evaluation of a combined microfinance and gender training intervention for the prevention of intimate partner violence in rural South Africa., Health Policy and Planning 26 (5) pp. 366-372
Oxford University Press
OBJECTIVE Assess the cost-effectiveness of an intervention combining microfinance with gender and HIV training for the prevention of intimate partner violence (IPV) in South Africa. METHODS We performed a cost-effectiveness analysis alongside a cluster-randomized trial. We assessed the cost-effectiveness of the intervention in both the trial and initial scale-up phase. RESULTS We estimated the cost per DALY gained as US$7688 for the trial phase and US$2307 for the initial scale-up. The findings were sensitive to the statistical uncertainty in effect estimates but otherwise robust to other key assumptions employed in the analysis. CONCLUSIONS The findings suggest that this combined economic and health intervention was cost-effective in its trial phase and highly cost-effective in scale-up. These estimates are probably conservative, as they do not include the health and development benefits of the intervention beyond IPV reduction.
Hargreaves JR, Morison LA, Gear JS, Kim JC, Makhubele MB, Porter JD, Watts C, Pronyk PM (2007) Assessing household wealth in health studies in developing countries: a comparison of participatory wealth ranking and survey techniques from rural South Africa., Emerg Themes Epidemiol 4
BACKGROUND: Accurate tools for assessing household wealth are essential for many health studies in developing countries. Household survey and participatory wealth ranking (PWR) are two approaches to generate data for this purpose. METHODS: A household survey and PWR were conducted among eight villages in rural South Africa. We developed three indicators of household wealth using the data. One indicator used PWR data only, one used principal components analysis to combine data from the survey, while the final indicator used survey data combined in a manner informed by the PWR. We assessed internal consistency of the indices and assessed their level of agreement in ranking household wealth. RESULTS: Food security, asset ownership, housing quality and employment were important indicators of household wealth. PWR, consisting of three independent rankings of 9671 households, showed a high level of internal consistency (intraclass correlation coefficient 0.81, 95% CI 0.79-0.82). Data on 1429 households were available from all three techniques. There was moderate agreement in ranking households into wealth tertiles between the two indicators based on survey data (spearman rho = 0.69, kappa = 0.43), but only limited agreement between these techniques and the PWR data (spearman rho = 0.38 and 0.31, kappa = 0.20 and 0.17). CONCLUSION: Both PWR and household survey can provide a rapid assessment of household wealth. Each technique had strengths and weaknesses. Reasons for differences might include data inaccuracies or limitations in the methods by which information was weighted. Alternatively, the techniques may measure different things. More research is needed to increase the validity of measures of socioeconomic position used in health studies in developing countries.
Bates CJ, Matthews N, West B, Morison L, Walraven G (2002) Plasma carotenoid and vitamin E concentrations in women living in a rural West African (Gambian) community, INTERNATIONAL JOURNAL FOR VITAMIN AND NUTRITION RESEARCH 72 (3) pp. 133-141 VERLAG HANS HUBER
Whitworth JA, Biraro S, Shafer LA, Morison LA, Quigley M, White RG, Mayanja BN, Ruberantwari A, Van Der Paal L (2007) Confusing association with causation?, A response to Brewer et al., 'Valid evaluation of iatrogenic and sexual HIV transmission requires proof' , AIDS 21 (18) pp. 2558-2559
Hawkes S, Morison L, Chakraborty J, Gausia K, Ahmed F, Islam SS, Alam N, Brown D, Mabey D (2002) Reproductive tract infections: prevalence and risk factors in rural Bangladesh, BULLETIN OF THE WORLD HEALTH ORGANIZATION 80 (3) pp. 180-188 WORLD HEALTH ORGANIZATION
Buvé A, Weiss HA, Laga M, Van Dyck E, Musonda R, Zekeng L, Kahindo M, Anagonou S, Morison L, Robinson NJ, Hayes RJ (2001) The epidemiology of gonorrhoea, chlamydial infection and syphilis in four African cities., AIDS 15 Sup (SUPPL. 4) pp. S79-S88
OBJECTIVES: To compare the epidemiology of gonorrhoea, chlamydial infection and syphilis in four cities in sub-Saharan Africa; two with a high prevalence of HIV infection (Kisumu, Kenya and Ndola, Zambia), and two with a relatively low HIV prevalence (Cotonou, Benin and Yaoundé, Cameroon). DESIGN: Cross-sectional study, using standardized methods, including a standardized questionnaire and standardized laboratory tests, in four cities in sub-Saharan Africa. METHODS: In each city, a random sample of about 2000 adults aged 15-49 years was taken. Consenting men and women were interviewed about their socio-demographic characteristics and their sexual behaviour, and were tested for HIV, syphilis, herpes simplex virus type 2 (HSV-2), gonorrhoea, chlamydial infection, and (women only) Trichomonas vaginalis infection. Risk factor analyses were carried out for chlamydial infection and syphilis seroreactivity. RESULTS: The prevalence of gonorrhoea ranged between 0% in men in Kisumu and 2.7% in women in Yaoundé. Men and women in Yaoundé had the highest prevalence of chlamydial infection (5.9 and 9.4%, respectively). In the other cities, the prevalence of chlamydial infection ranged between 1.3% in women in Cotonou and 4.5% in women in Kisumu. In Ndola, the prevalence of syphilis seroreactivity was over 10% in both men and women; it was around 6% in Yaoundé, 3-4% in Kisumu, and 1-2% in Cotonou. Chlamydial infection was associated with rate of partner change for both men and women, and with young age for women. At the population level, the prevalence of chlamydial infection correlated well with reported rates of partner change. Positive syphilis serology was associated with rate of partner change and with HSV-2 infection. The latter association could be due to biological interaction between syphilis and HSV-2 or to residual confounding by sexual behaviour. At the population level, there was no correlation between prevalence of syphilis seroreactivity and reported rates of partner change. CONCLUSION: Differences in prevalence of chlamydial infection could be explained by differences in reported sexual behaviour, but the variations in prevalence of syphilis seroreactivity remained unexplained. More research is needed to better understand the epidemiology of sexually transmitted infections in Africa.
Severe anaemia in pregnancy is an important preventable cause of maternal and perinatal morbidity and mortality. Different methods of screening for severe anaemia in pregnancy were evaluated in a 2-phased study conducted in Kilifi, Kenya. In phase 1 (in 1994/95), pallor testing was evaluated alone and in addition to raised respiratory/pulse rates: 1787 pregnant women were examined by one of 2 midwives. Sensitivities for detecting severe anaemia (haemoglobin
Lameness in herds during one year was commonest in the first month of lactation (15 per cent of all cases). Leg lesions were particularly common at this time (24 per cent of all cases of leg lesions) but white line abscess and sole ulcer were more common a month later. Foul-in-the-foot was one of the two most common lesions at all stages of pregnancy and lactation, and white line abscess the most common (20 per cent of all lesions) in late lactation. Both sole ulcer and underrun heel had lower incidence in the second half of the year than the first. White line abscess was particularly common in March and November although there were significant interactions between month and veterinary practice; foul-in-the-foot was most common in October. Susceptibility to lameness increased with age; 10-year-old cows were over four times more likely to develop lameness than three-year-old cows. This was due particularly to increased incidence with age of white line abscess and sole ulcer and, to a lesser extent, underrun heel. In contrast, foul-in-the-foot and leg lesions showed little change with age. Whereas these lesions accounted for 68 per cent of the total in cows up to two years old, they accounted for only 15 per cent of all lesions in cows over 10 years old. White line abscess was slightly commoner in cows with large heart girths.
Cell mediated immunity (CMI) to Fasciola hepatica antigens was detected by lymphocyte proliferation and interleukin-2 (IL-2) production tests in cattle during the first 4 weeks following liver fluke infection. From the fifth week of infection onwards peripheral blood lymphocytes were unresponsive to fluke antigens by these in vitro tests. Investigations into the cause of this unresponsiveness found no evidence to suggest a selective loss of the IL-2 producing lymphocyte sub-population or that macrophages were responsible for the suppression or that antigen responsive cells were being sequestered in the spleen and mesenteric lymph nodes. Tests carried out on culture supernatants demonstrated the production during this unresponsive period of factors capable of suppressing in vitro responses to PHA. Although further tests failed to show antigen specific suppressor factors the presence of MHC restricted suppressor factors could not be ruled out. The early and transient appearance of CMI during F. hepatica infection of cattle indicates that delayed type hypersensitivity is unlikely to be important in protective immunity in cattle.
Background: Depression is the commonest mental illness in developing countries and impoverished women are most at risk. Formal mental health services in these situations are rare. Depression commonly co-presents with physical symptoms or else is unspectacular, so the condition often goes unrecognised. To strengthen the prevention and management of depression, information is required on easily recognisable correlates of depression. This study explored associations between depression and reproductive health conditions in rural African women of reproductive age. Methods: A community-based reproductive health survey among rural women aged 15-54 years in The Gambia, West Africa, included screening with a modified Edinburgh Depression Scale (EDS), a reproductive health questionnaire and a gynaecological examination. Depression was then assessed clinically and data for 565 women were used to estimate the prevalence of depression and examine associations with reproductive health conditions and demographic factors. Results: The weighted prevalence of depression was 10.3% (95% CI 8.3-12.7). Being depressed was most significantly associated with widowhood or divorce (adjusted Odds Ratio (aOR) 8.42, 2.77-25.57), infertility (3.69, 1.42-9.65) and severe menstrual pain (3.94, 1.52-10.27). There were significant differences between ethnic groups. Being in the postpartum period was not associated with an increased likelihood of depression. Conclusion: This study points to the importance of reproductive potential and reproductive health in maintaining women's mental well-being across different strata of a rural and resource-poor society. It could provide an initial focus for the management of women with depression as well as directing future research in reproductive health and psychiatry. © Steinkopff Verlag Darmstadt 2006.
Weiss HA, Buve A, Robinson NJ, Van Dyck E, Kahindo M, Anagonou S, Musonda R, Zekeng L, Morison L, Carael M, Laga M, Hayes RJ (2001) The epidemiology of HSV-2 infection and its association with HIV infection in four urban African populations, AIDS 15 pp. S97-S108
LIPPINCOTT WILLIAMS & WILKINS
OBJECTIVES: To estimate age- and sex-specific herpes simplex virus type-2 (HSV-2) prevalence in urban African adult populations and to identify factors associated with infection. DESIGN AND METHODS: Cross-sectional, population-based samples of about 2000 adults interviewed in each of the following cities: Cotonou, Benin; Yaoundé, Cameroon; Kisumu, Kenya and Ndola, Zambia. Consenting study participants were tested for HIV, HSV-2 and other sexually transmitted infections. RESULTS: HSV-2 prevalence was over 50% among women and over 25% among men in Yaoundé, Kisumu and Ndola, with notably high rates of infection among young women in Kisumu and Ndola (39% and 23%, respectively, among women aged 15-19 years). The prevalence in Cotonou was lower (30% in women and 12% in men). Multivariate analysis showed that HSV-2 prevalence was significantly associated with older age, ever being married, and number of lifetime sexual partners, in almost all cities and both sexes. There was also a strong, consistent association with HIV infection. Among women, the adjusted odds ratios for the association between HSV-2 and HIV infections ranged from 4.0 [95% confidence interval (CI) = 2.0-8.0] in Kisumu to 5.5 (95% CI = 1.7-18) in Yaoundé, and those among men ranged from 4.6 (95% CI = 2.7-7.7) in Ndola to 7.9 (95% CI = 4.1-15) in Kisumu. CONCLUSIONS: HSV-2 infection is highly prevalent in these populations, even at young ages, and is strongly associated with HIV at an individual level. At a population level, HSV-2 prevalence was highest in Kisumu and Ndola, the cities with the highest HIV rates, although rates were also high among women in Yaoundé, where there are high rates of partner change but relatively little HIV infection. The high prevalence of both infections among young people underlines the need for education and counselling among adolescents.
Background: Among mental health staff, burnout has been associated with undesirable outcomes, such as physical and mental ill-health, high levels of staff turnover and poorer patient care. Aims: To estimate the prevalence and predictors of burnout amongst Improving Access to Psychological Therapist (IAPT) practitioners. Methods: IAPT practitioners (N = 201) completed an on-line survey measuring time spent per week on different types of work related activity. These were investigated as predictors of burnout (measured using the Oldenburg Burnout Inventory). Results: The prevalence of burnout was 68.6% (95% confidence interval (CI) 58.8?77.3%) among psychological wellbeing practitioners (PWP) and 50.0% (95% CI 39.6?60.4%) among high intensity (HI) therapists. Among PWPs hours of overtime-predicted higher odds of burnout and hours of clinical supervision predicted lower odds of burnout. The odds of burnout increased with telephone hours of patient contact among PWPs who had worked in the service for two or more years. None of the job characteristics significantly predicted burnout among HI therapists. Conclusions: Our results suggest a high prevalence of burnout among IAPT practitioners. Strategies to reduce burnout among PWPs involving reductions in workload, particularly telephone contact and increases in clinical supervision need to be evaluated.
Background: Individuals with OCD tend to delay help seeking due to fear of stigma, particularly individuals who experience sexual intrusive thoughts. Few studies have examined sexual intrusive thoughts about children (sometimes called pedophile-OCD). The current study assessed the effectiveness of a brief education intervention in reducing stigma towards a person experiencing such thoughts.
Method: 120 participants took part in an online survey. Participants were shown a vignette describing a target individual who experienced sexual intrusive thoughts about a child. Participants completed stigma measures (perceived dangerousness, perceived unpredictability, and desired social distance), and assigned a diagnostic label before and after being shown educational information about OCD and Pedophilic Disorder. Participants also completed six open-ended questions about their decision making.
Results: Ninety participants (75%) assigned an initial diagnosis of pedophilia. Following the education, more than half of these changed their diagnosis from pedophilia. A McNemar?s test demonstrated that a significant number of individuals moved away from a pedophilia diagnosis post education. Paired comparison tests demonstrated that perceived dangerousness and desired social distance from the target decreased significantly following the intervention. Repeated measures ANOVA demonstrated that the group of participants who moved away from an initial pedophilia diagnosis showed a greater decrease in stigma ratings than those who did not.
Discussion: Based on the mere presence of a sexual thought about a child, most individuals assigned a label of pedophilia. However, initial judgments and level of stigma were amenable to significant change following a brief education intervention. Future research may benefit from examining the experiences of people with pedophile-OCD directly as well as ascertaining the most effective style of psycho-education materials to promote anti-stigma messages.
To explore the impact social class biases may have on the treatment of clients by psychological and psychotherapeutic professionals in Britain.
A cross-sectional on-line study among 156 psychological and psychotherapeutic professionals working in the NHS incorporating a comparison between two groups - video vignettes representing ?lower? and ?upper? class clients.
The video vignette depicted a psychological assessment session of a client who had been referred by his general practitioner after incidences involving deliberate self-harm. The accent and dress of the client were varied. Study participants completed measures of clinical reasoning relating to diagnosis, risk and treatment, measures of their awareness of the influence of social class on their work and a social class brief implicit association test.
Within the context of this study participants tended not to discriminate against clients in relation to their class. However, they believed that a ?lower-class? client was more likely to receive an ?alcohol or substance misuse? diagnosis (p= .002; d=0.40). They also scored the ?lower-class? client as more motivated to make changes (p=.032; d=.29). Seeing a ?lower-class? client resulted in significantly higher scores indicating participants reflection on personal conflicts relating to their own social class and the impact such biases may have on their work.
There was no general pattern of discrimination against clients in relation to their social class. This may be due to client class cues priming the psychologist to reflect on their position.
"Training and professional development for Psychological and Psychotherapeutic Professionals in ways to raise awareness of their personal beliefs about social class may help reduce class bias.
"Working with clients such professionals perceive to be a ?lower? class allows them to reflect on these personal beliefs.
Previous research suggests that individuals have revealed moderate to serious personal issues to bar tenders, hairdressers, divorce lawyers and industrial supervisors and that training for these groups may provide a ?cost-effective? method of allowing people to access ?primary care?. Such training already exists for the police, the military and in education settings and has been shown to be effective at imparting knowledge, building skills, and moulding the attitudes of these groups. Current training offered to personal trainers (PTs) relates specifically to clients referred with diagnosed mental health problems, rather than those sharing personal issues for the first time. This study investigates PTs? experiences of clients sharing personal issues during a PT session. Eleven PTs aged 21 to 34 years (M = 26.3) participated in 26-58 minute semi-structured interviews. Interviews appeared to have reached saturation, and were analysed using Inductive Thematic Analysis. Four main themes were identified, with PTs expressing that ?I didn?t think that supporting clients with personal or emotional problems was part of being a PT?. Because PTs felt that ?it?s difficult to balance boundaries with building a good rapport?, this meant that they found themselves in situations where ?I?m having to deal with clients opening up about a whole range of things on a regular basis? and were consequently left ?managing the fallout?. PTs regularly experience clients sharing of personal issues during PT sessions and many wish to receive further education, training and guidance regarding this issue.
Key words: Personal trainer, boundaries, experiences, education, training
Nigeria has the sixth highest number of students from non-EU countries coming to the UK. Not only are professional mental health services underutilised by black men, but the acculturative stressors that typically accompany international students can heighten the risk of experiencing mental distress. The help-seeking experiences of male Nigerian international students in the UK are a significantly under-researched area. Interviews were conducted with eight male Nigerian international students from a UK university, an Interpretive Phenomenological analysis was used to explore how this population makes sense of their help-seeking experiences. The results identified four themes (1) Coping strategies (2) barriers to accessing support, (3) African identity and (4) Masculinity. Findings suggest a preference for using a combination of independent coping strategies, with most participants considering formal psychological support as inappropriate. Clinical implications and the limitations of the study are discussed.
We report the results of a randomized trial (N/=/337) examining the effectiveness of a daily audio-guided MBI in raising academic achievement in 16 volunteer classrooms across two socio-demographically diverse United States primary schools. The study's findings were that, over the intervention period, improvements in Math scores, Social Studies scores and Grade Point Averages (GPA) were generally higher for students in intervention classrooms. However, confidence intervals were wide and there was pre-existing variability between schools and grades, resulting in few significant differences as a result of the intervention and generally low effect sizes. Through a careful discussion of the study's results, the paper contributes to theory by generating a comprehensive agenda for follow-up research. The study also contributes to practice by reporting on the effectiveness of technology-enabled mindfulness training because participating teachers seemed able to implement the intervention with almost no further training or need for hiring external mindfulness experts.
Although males constitute a substantial proportion of carers until recently there has been little focus on the impact of caring on their mental well-being. This study aimed to examine the extent to which a variety of contextual, caring related and protective factors predicted the mental well-being of middle-aged male carers informed by Pearlin?s Stress Process Model.
The study used secondary data from the Understanding Society study. Cross-sectional analysis of how factors relating to the role of caring, interferences of caring on employment and social participation and leisure predict mental well-being measured by the GHQ-12 was undertaken. Longitudinal analysis following those that became carers and potential changes in social participation, satisfaction with leisure and mental well-being was also undertaken. Data from 8,063 middle-aged men (1,612 carers and 6,451 non-carers) was used for the cross-sectional element and data from 4,665 (614 carers and 4,051 non-carers) was used for the longitudinal element.
An estimated 20% of middle-aged men were carers. Carers had significantly poorer mental well-being (p = 0.014), measured by their scores on the GHQ-12, compared to non-carers but the difference was very small (·² = 0.001). At the cross-sectional level, three predictors were identified to most strongly impact mental well-being: subjective financial status; satisfaction with leisure time; and employment status (partial eta squared = 0.053; 0.046; 0.051 respectively). Longitudinal analysis suggested that carers? mental well-being was poorest prior to undertaking caring. However, there was no evidence that mental well-being became worse for those that became carers relative to those who remained non-carers.
Middle-aged male carers who were under financial stress, unable to pursue leisure activities and unemployed or long term sick were found to be particularly vulnerable to poorer mental well-being. Providing support to this group of middle-aged men both in practical and therapeutic terms would help meet their mental well-being needs.
Gender Role Conflict (GRC) correlated with different measures of psychological distress. However, there has been little research investigating the mechanism underpinning these relationships. Shame may be an important mechanism due to conceptual relevance to GRC, and previous research had shown that shame correlated with GRC and different measures of psychological distress. This study aimed to investigate whether shame mediates the relationship between GRC and psychological distress. A quantitative cross-sectional design was used to gather questionnaires relating to the study variables from 204 male participants with a mean age of 29.22 (SD=7.68). Using the causal step approach (Baron & Kenny, 1986) and bootstrapping, the analysis found that shame mediates the relationship between GRC and psychological distress. This finding has treatment implications for treating men?s psychological distress, including targeting shame and deconstructing dominant masculine norms. However, further research would help to establish support for the causal inferences of the study?s findings.
Background: Research has found that carers have limited leisure engagement compared with non-carers and they have reduced mental wellbeing. Middle aged women who are intensive carers (>20 hours a week) are at particular risk and were therefore the focus for this study.
Objectives: The cross-sectional part of this study aimed to explore whether there was an association between leisure time satisfaction, variety, sporting engagement and frequency of leisure with carer wellbeing. The longitudinal part of this study aimed to explore whether becoming an intensive carer was associated with reduced leisure engagement and reduced wellbeing. Further, whether leisure engagement predicts wellbeing.
Method: This study used data from a national UK study (UKLHS) that stratified sampling across the country. Data was collected annually and waves two and five were used for this study as they included a module about leisure and culture. Wellbeing was assessed through the GHQ-12. Secondary analysis of this data included general linear modelling and chi square.
Results: Generally, cross sectional hypotheses were supported although frequency of leisure engagement was less relevant for wellbeing than variety and satisfaction (the latter of which explained 12% of the variance). Individuals who did sport had better wellbeing than those who did not. Individuals who became carers did not reduce their leisure engagement more than non-carers. Change in satisfaction and variety predicted change in wellbeing but change in frequency did not. Unexpectedly, individuals who were not carers at wave two, but were at wave five had poorer wellbeing at both time points compared to the non-carers.
Conclusions: Leisure is a key contributor to emotional wellbeing, in particular, carer?s satisfaction with the amount of leisure time they have and whether they engage in physical activities. This has important implications for services that work with carers at a local level, and at a policy level.
Hargreaves J, Hatcher A, Busza J, Strange V, Phetla G, Kim J, Watt C, Morison Linda, Porter J, Pronyk P, Bonel (2011) What happens after a trial? Replicating a cross-sectoral intervention addressing the social determinants of health: the case of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in South Africa, In: Blas E, Sommerfeld J, Kurup S (eds.), Social determinants approaches to public health : from concept to practice.
World Health Organisation
This research portfolio contains three pieces of work conducted during my training as a Counselling Psychologist at the University of Surrey. Initially there is a review of literature on men and their close relationships. This is followed by two qualitative studies, with each based on a group of white British, professional mid-life men. The first of these explores experiences of relational closeness and the second focuses on developing new theory regarding how closeness is conceptualised.
Background: Parent programmes are a NICE (2017) recommended intervention for parents of children who have a conduct disorder and evidence suggests a number of benefits to paternal involvement in such interventions. However, on the whole fathers are often unrepresented at parenting groups. The present study aimed to understand the issues to which facilitators attributed paternal absence from parenting groups.
Method: Thematic analysis was chosen to highlight salient ideas in facilitators? explanations. The participants were a volunteer sample of nine parenting group facilitators, from various child services in South East England. Semi-structured interviews were conducted in person and over the phone, and were up to 60 minutes long. Interviews were transcribed and analysed using an inductive approach.
Results: The data revealed five main themes: ?An uncomfortable topic?, ?Responsibility?, ?Our hands are tied?, ?Fathers are peripheral parents? and ?What makes fathers more comfortable??. Facilitators appeared uncomfortable discussing this topic and tried to avoid generalisations or the appearance of sexism. They had differing ideas of who was responsible for paternal attendance and many felt they had done all they could. An important aspect of facilitators explanations of paternal absence was of parents adherence to traditional gender roles in relation to childcare. They also considered that greater familiarity with services and the presence of other men in groups might make fathers more comfortable attending parenting groups.
Conclusion: Facilitators found this an uncomfortable topic but mainly explained absence in terms of parents adopting traditional gender roles and service constraints. Clinical implications and research recommendations based on this are discussed.
The overall aim of this research is to identify the impact of a brief, low-cost mindfulness meditation training program for employees in a workplace setting, specifically in the UK higher education sector. Although there has been extensive research on the efficacy of mindfulness training for perceived stress of employees, to date, there has been limited research exploring the following: (a) impact of mindfulness-based training interventions on work-related outcomes (b) long-term impact of those interventions, and (c) use of self-help training interventions (low-cost) without supplementary guidance.
This thesis aimed to address the research gaps through three empirical studies. Firstly, Study 1 used a randomised waitlist control trial design (N = 125) to assess the impact of offering a mindfulness-based intervention to employees. Intention-to-treat analysis showed improvements in mindfulness and perceived stress after the offer of the Headspace® app. With higher levels of participation, results showed progressively greater improvements in mindfulness, perceived stress and two work-related outcomes, work-life-balance and emotional job engagement. Study 2 then used a longitudinal (12 months) repeated-measures design (N = 60) to investigate the extent to which the amount of Headspace app usage predicted mindfulness, perceived stress and work-related outcomes. Simple regression analysis showed that higher Headspace usage led to greater improvements in work-life-balance and emotional job engagement, however other outcomes were not significant. Study 3 used a qualitative design (N = 13) to explore participants? 12-months experiences of practicing mindfulness, and the perceived impact on their workplace issues. From a thematic analysis of phone interview transcripts, three themes evolved: challenges (workplace related), selective focus (experience of mindfulness), and work impact (from more mindful approach to workplace).
Overall, the findings from this thesis provide support for the effectiveness of brief mindfulness-based training in improving mindfulness and perceived stress. The findings demonstrate that those who use a mindfulness training app can improve their work-life balance and emotional job engagement within two months and both work-related outcomes can be improved with increased usage over one year, although improvements do not increase in mindfulness and perceived stress, and other work-related outcomes. Finally, this thesis contributes to research on the use of digital smart-phone apps as an effective delivery method of mindfulness-based training.
Much of the burden associated with poor mental health is associated with symptom experience in the general population. We conducted a systematic review and meta-analysis of studies conducted in non-clinical samples, evaluating Mindfulness-Based Programs (MBPs) for outcomes related to psychological health and well-being. We focussed on Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) because they have the strongest evidence base. We searched MEDLINE, PsycINFO, EMBASE and CINAHL (2006 ? February, 2019) for published peer-reviewed journals articles of intervention studies evaluating MBCT or MBSR for psychological health and well-being in non-clinical samples. Data were pooled using a random-effects model and effect estimates were reported as Hedges? g. We included 49 studies conducted in non-clinical samples (n=4733). When compared to a passive control, MBPs significantly reduced symptoms of rumination/worry (g=-1.13, [-2.17, -0.08]), stress/psychological distress (g=-0.52 [-0.68, -0.36]), depression [g=-0.45 [-0.64, -0.26]), and anxiety (g=-0.44 [-0.65, -0.23]); and significantly improved quality of life/well-being (g=0.32 [0.10, 0.54]). In general, MBCT generated larger effect sizes than MBSR for all outcomes. This study provides evidence that in non-clinical samples, MBPs are associated with benefits to health and well-being. These findings add to the growing evidence-base suggesting that MBSR and MBCT may be effective approaches for sub-clinical levels of mental ill-health and could form part of the public mental health agenda.