First generation British Indo-Asian men: Cardiovascular disease mortality in relation to childhood and adulthood socio-economic markers.
T. Tillin
Imperial College, University of London
People of Indo-Asian origin across the world are at increased risk of cardiovascular disease (CVD). In the UK, mortality rates for CVD are 50% higher in Indo-Asians compared with the general population. The reasons for this are not understood.
We studied the effects of childhood and adulthood socio-economic position (SEP) and time since migration on rates of CVD mortality in British Indo-Asians. Our analyses are based on a cohort of 1,400 first generation Indo-Asian men aged 40-69 and living in West London, first studied between 1988 and 1990 and since followed for mortality. During the average 16 year follow-up, 126 men have died from CVD. Men with 11 years or more of schooling were 40% less at risk than those with less than 11 years, p=0.004. Men whose fathers had manual occupations and who themselves had manual occupations were three times more likely to die from CVD than those who were most advantaged during childhood and adulthood (p=0.027). Each year since migration was associated with a 2.4% increase in risk of CVD death (p=0.061). These associations remained after adjustment for each other and other markers of childhood and adulthood SEP, lifestyle and conventional CVD risk factors, including diabetes and smoking.
We conclude that childhood SEP has an enduring effect on risk of CVD death in first generation Indo-Asian migrants to the UK and that this effect is additive to that of adult SEP and time since migration. These effects were unexplained by conventional risk factors measured in middle age.
Email: t.tillin@imperial.ac.uk
From torture to torment: Unwilling migrants and the cost of mental health care.
Sallyann Goodall
Psychologist, Clinical Health, East London
Immigration to the UK is an issue whose political controversy has increased on an almost weekly basis. In the written mass media the perception has been created that most immigrants are illegally in the UK. The Home Office has been found to have 'allowed this to happen', its leadership changed twice. Yet the public remains largely uninformed about what really ails this department. Public perception is that 'the Home Office allows too many people to stay here'. It follows that there are too many people for current health and social service budgets. This argument locates health and social economic danger in immigrants, casting the Home Office in the role of 'illegal immigrant enabler'.
Using descriptive case studies, this paper uses clinical psychological material of three anonymous Ugandan refugees diagnosed with HIV while in the UK. It explores the course of their psychological condition in relation to the way their everyday life events increase or decrease their need for mental health services.
Seen through a qualitative phenomenological lens, the refugees' experience of and response to immigration services can be seen as directly contributing to their need for increased mental health care. This evidence contradicts the perception that the Home Office's allowing a large number of 'illegal immigrants' to remain in the UK is an economic danger to British citizens. It favours a hypothesis that there is at least one systemic factor funded by the public purse which increases and perpetuates their need for services.
Email: Contact via pic@lse.ac.uk
Socio-economic inequalities and demographic differentials in mental and physical health of the Greek elderly population.
Georgia Verropoulou1 and Cleon Tsimbos2
1University of Piraeus, Greece; Research Associate, Centre for Longitudinal Studies, Institute of Education, University of London
2University of Piraeus, Greece
This paper aims to explore factors affecting both the mental and physical health of persons aged over 50 in Greece. The analysis is based on data obtained from the SHARE project (Survey of Health, Ageing and Retirement in Europe) carried out in 2004. Mental health is measured using the EURO-D depression scale while physical health is represented by various indices pertaining to limitations with activities (GALI), activities of daily living (adl, iadl) and number of chronic diseases the respondent suffers from. Multivariate modeling techniques have been used to explore associations with demographic, socio-economic and other covariates. Among predictors of poor mental health are the respondent's age, sex (female), his past history of depression, his perception of his own physical well-being, his mobility and every day tasks he can perform on his own as well as other indices of physical health. The marital status of the respondent, his living arrangements and his educational qualifications seem to have only a modest relationship with mental health. As far as physical health is concerned, there is a strong negative association with age while being a woman seems related to poorer health in most cases. Socio-economic indicators such as educational attainment, income and current employment seem to have a strong effect on physical health as do behavioural risk factors, mainly body weight (obesity), levels of physical activity and, in some instances, cigarette smoking.
Email: gverrop@otenet.gr & cleon@unipi.gr
Urban South African adolescents are consuming "western" diets.
Chiedza Zingoni1, Paula Griffiths1,Shane Norris2, Noel Cameron1
1Loughborough University, Loughborough, UK.
2 Birth To Twenty, Wits Medical School, South Africa
Background : Nutrition transition is recognised as a change in dietary pattern from a traditional low fat, high fibre diet to a high fat, low fibre diet. This change has been accompanied by an increase in nutrition related non communicable diseases (NCDs). The impact on health is a rising concern because the transition is not confined to adults but is also being increasingly observed in children and adolescents. The evidence on which this is based comes mostly from national aggregate data on adult samples and there is a dearth of information about the aetiology and characteristics of nutritional transition at a group or individual level in adolescents in developing countries.
Aim : To investigate the characteristics of the urban South African adolescent diet.
Method: A quantitative food frequency questionnaire was administered to a sample (n=154) of 15-year-old adolescents who have been followed from their birth in 1990 within the Birth to Twenty birth cohort study in urban Johannesburg-Soweto. Anthropometry, socio-economic status, physical activity and pubertal stage of development were also assessed.
Results: The macronutrient composition as a proportion of total energy intake was consistent with a western diet incorporating 11% protein, 34% fat and 52% carbohydrate. Bivariate and multivariate analyses are underway to determine the association of socioeconomic status with dietary intake and body composition within this transitioning environment.
Conclusion: A typical 'western 'diet is being consumed indicating that this generation of adolescents have a similar dietary risk for NCDs to their counterparts in more economically developed regions of the world.
Email: c.zingoni@lboro.ac.uk
Neighbourhood, community and family wellbeing.
A. Cullis
Institute of Education
A number of studies have highlighted the impact of ecological or area effects upon individuals and their health. Following in this tradition, the author is investigating whether the social and economic characteristics of the neighbourhood in which people live are associated with the wellbeing of the individuals living in them. The UK Millennium Cohort Study (MCS) is a nationally representative longitudinal survey of over 17,000 children born at the beginning of this century. The analysis focuses on the MCS children when they were aged approximately 3 years. The paper provides a review of the literature concerning neighbourhood effects and wellbeing in the context of young children in the U.K together and some preliminary results from the study.
Email: acullis@ioe.ac.uk
Household versus community socio-economic status and their relationships to adolescent health in urban Johannesburg and Soweto: What can community members tell us?
Zoë A. Sheppard1, Paula L. Griffiths1, Shane A. Norris2, John M. Pettifor2, and Noël Cameron1
1Loughborough University
2University of Witwatersrand
UNICEF's (1989) Convention on the Rights of the Child states that all children have the right to the highest possible health and living standards. In order to identify those at greatest risk of ill-health and target public health resources accordingly, it is important to understand the role of community versus household socio-economic effects on health. Because of the magnitude of income inequalities, South Africa is an ideal setting to study health inequalities.
Participants from the Birth to Twenty birth cohort study (Bt20) were born in Johannesburg-Soweto in 1990. Bt20's longitudinal design brings an opportunity to analyse the changing role of socio-economic status (SES) on health. Until recently Bt20 has focussed on measuring SES at the household level, meaning little is known about community SES. Additionally, few tools exist to measure community SES within urban developing country environments.
As a result, this paper outlines a qualitative study which further contextualises SES within this dynamic urban environment. It uses focus groups with adolescents aged 15 years and their caregivers, and key informant in-depth interviews, to establish lay knowledge and perceptions of the importance of community/school SES for health. This enables community members to contribute to developing an understanding of the local SES environment. The findings will be used to develop questionnaires to collect community SES data from the cohort from age 16 years. Findings suggest that both economic and social support factors are equally important in understanding the role of community SES for adolescent health in this context.
References:
UNICEF. (1989). Convention on the Rights of the Child. Available at: www.ohchr.org/english/law/pdf/crc.pdf [Accessed 11 January 2006].
Email: z.a.sheppard@lboro.ac.uk
Mapping children's health inequalities in Nigeria: Contextual influence of child's place of residence.
Kandala Bakwin1, J. Micklewright2
1University of Warwick, 2University of Southampton
The links between health, geographic location, environment and economic development need to be better understood if the problems associated with these issues that face developing countries are to be overcome. With a population of about 120 million people, Nigeria is the most populous country in Africa. Its under-five child mortality rate of 183 per 1000 is among the highest in the world. The large area covered by the country together with geographic, socio-economic and ethnic differences lead one to expect substantial spatial variation in disease. One contributory cause can be expected to be the country's oil industry and which has led to substantial environmental damage.
The first aim of this paper is to use household survey data (The 2003 Nigeria Demographic and Health Surveys) to map the state-level variation of diarrhoea, fever, and cough prevalence among young children in Nigeria. The second aim is to use appropriate statistical techniques to explain differences across the states in the prevalence of childhood diseases using the household socio-economic characteristics that are observed in our data. This will draw on Bayesian geo-additive methods of spatial statistics, taking advantage of advances in Geographic Information Systems. The modelling of the structured and unstructured components is done jointly in one estimation procedure that thereby simultaneously identifies socioeconomic determinants, and the spatial effects that are not explained by these socioeconomic determinants. In this way, we will be able to identify regional or state patterns of morbidity that are either related to omitted socioeconomic variables that have a clear spatial pattern or point to spatial (possibly epidemiological or environmental) processes.
Email: n-b.kandala@warwcik.ac.uk
Attitudes to life style risk factors of coronary heart disease among the various South Asian groups and sub-groups.
Giju George
De Montfort University
Aim of the investigation
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To establish key issues relating to knowledge and attitudes to life style risk factors among South Asian males, 35 years and above and living in the United Kingdom.
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To contribute to delivery of effective Health Promotion to these groups.
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To find out of there is a variation in the level of understanding of risk factors in Coronary Heart Disease (CHD) among the South Asian community.
Heart disease and stroke kill some 17 million people a year, which is almost one-third of all deaths globally (WHO, 2003). South Asians SA have been shown to be at significantly higher risk from CHD than the general population with the overall increased risk of mortality up to around 40% (Macleod et al, 2002)
Combining risk factors in data is misleading (Bhopal et al, 2000). Lifestyle change and the effects of racism may be the root cause of high morbidity and mortality (Reddy et al, 2002)
Among the Hindu community, several castes can be identified, while the Sikhs, who formally have no caste structure, still form several status groups:
Methodology
Grounded Theory, Qualitative Methodology, using Focus Group methodology, recruitment participants from Leeds and Leicester, men only group between the ages of 35-65 . Four groups have already been studied at the present moment. Hoping to conduct min of 10 focus groups 8-10
Email: ggeorge@dmu.ac.uk
Lidia Panico, Yvonne Kelly, and on behalf of the ETHINC team
University College London
Unmarried parenthood, including cohabiting and lone parents, increased from 6% in 1960 to 40% in 2001 in the UK. There is evidence linking family living arrangements to child development and emotional outcomes, mediated through economic and social factors. Less is known about the impact on child health. There are variations in family living arrangements across ethnicities in the UK; as well as differences in child health measures and behaviours.
Using birthweight, this paper addresses three questions: do family living arrangements affect child health? Does this vary by ethnicity? What are the pathways and do vary by ethnicity? The UK Millennium Cohort Study allows for a detailed breakdown of ethnicity. Parents of 18,553 babies born in the 2000-2001 academic year were interviewed when the cohort member was aged approximately 9 months.
Overall, babies from cohabiting parents households were 75 grams lighter at birth, and those from one-parent households were 150 grams lighter, compared to households with two married parents. In the White group one-parent household babies were 177 grams and cohabiting parents households babies were 106 grams lighter at birth than babies from married parent households. Differences were not statistically significant across the South Asian groups, possibly due to small sample sizes. Differences of about 100 grams between Black Africans babies from married and non-married parents households were not significant. Black Caribbean babies from non-married parents households were 180 grams than those from married parents households. In Whites, behavioural and socio-economic factors had similar importance in explaining differences between married and non-married parents households, although about half of these differences remained unexplained. For Black Caribbeans, most of the differences between married and one-parent households were explained by socio-economic factors, while differences between cohabiting and married parents households remained unexplained.
Email: l.panico@ucl.ac.uk
Health seeking behaviour for 10 childhood illnesses in urban South Africa.
N. Spark du Preez, Paula L. Griffiths, Noël Cameron
Loughborough University
In urban South Africa there has been increasing child morbidity and mortality as a result of HIV/AIDS, a paucity of data on health-seeking behaviour for childhood illnesses, high reported use of traditional medicine and general patient dissatisfaction with free public health services. This paper investigates health-seeking behaviour amongst Black caregivers of children under the age of 6 in Johannesburg and Soweto for 10 different childhood health problems using both qualitative and quantitative methods. In-depth interviews with caregivers (n=5), providers of traditional (n=6) and Western health care (n=6), as well as focus groups with caregivers (n=5) provide insight into different health care beliefs and practices. An utilisation-based survey was conducted with 206 Black caregivers of children under the age of 6 from 1 public clinic in Soweto (n = 50), 2 private clinics (n = 50) in Johannesburg, 2 public hospitals (n = 53) from Johannesburg and Soweto and 2 traditional healers (n = 53) from Johannesburg and Orange Farm, an informal settlement on the outskirts of Johannesburg. The facilities where interviews took place in this study were purposively selected.
When a child was unwell, caregivers usually gave home treatments first, particularly for diarrhoea, vomiting, fever, constipation and crying. Although the use of over-the-counter (OTC) medicines in this study varied according to the illness being treated, overall the higher socio-economic status (SES) respondents were more likely to use OTC medicines and less likely than other groups to use home treatments. Home treatments as well as OTC medicines were not always used appropriately. Nearly three quarters of caregivers had given or would give traditional medicine to their child if the need arose, although this varied by education levels and SES. The most well-known African childhood illnesses were inyoni and ibala, which in the South African world-view Western medicine is not able to treat.
Results from this study highlight the need for community and household integrated management of childhood illnesses (IMCI) which has remained underdeveloped in South Africa. In particular, this should involve understanding the symptoms that mothers themselves recognise as significant and incorporating these into health education messages as well as educating caregivers (mothers, grandmothers and relatives) about the safe, timely and appropriate use of enemas, home treatments, over-the-counter medicines and traditional medicines. Furthermore, these results underline the need to include traditional healers in the community component of IMCI, as well as training Western health care providers about health-seeking behaviour in the context of the local belief system.
Email: n.l.spark-dupreez@lboro.ac.uk
The importance of considering puberty when investigating the association between socio-economic status and BMI in a cohort of 9/10 year old children in urban South African children.
Griffiths, PL1, Sheppard, ZA1, Norris, SA2, Pettifor, JM2, and Cameron, N1
1 Loughborough University
2 University of the Witwatersrand
Globally the prevalence of overweight and obesity in children and adolescents is increasing. Adolescence is a complicated stage in human development to study body composition, because of the role that pubertal development plays in defining it. A number of recent studies have linked household socio-economic status (SES) to prevalence of overweight and obesity in different regions of the world either in late childhood or adolescence (e.g. Wang 2001). However, many of these studies (including Wang (2001)) cite as a limitation of their work a lack of information on pubertal status when assessing the association between SES and obesity. Other studies, mostly published outside of the social science literature, that do measure pubertal status have more commonly investigated the association between pubertal status and obesity after controlling for SES (e.g. Adair et al. (2001)). These studies report the effect of pubertal status on overweight and obesity not to be modified by SES. There are few studies which critically assess the confounding effects of puberty on the association between SES and body composition outcomes, especially in developing country contexts.
This paper uses data from a sub-sample (n = 212) of African black children aged 9 to 10 years from the Birth to Twenty (Bt20) birth-cohort initiated in 1990 in urban Johannesburg-Soweto. The aim is to assess the association between SES at birth and ages 9/10 years, Tanner measures of pubertal development, and body mass index (BMI) whilst controlling for sex and age. Results show Tanner ratings of breast and genitalia development are stronger predictors of BMI than Tanner ratings of pubic hair development in this sample. There is a significant positive association (P< 0.05) between SES measured at birth, as well as ages 9/10 years and BMI controlling for both age and sex. However, after controlling for stage of pubertal development the relationship between SES at birth and ages 9/10 years and BMI is less strong, resulting in some cases in a change of significance of the association between the SES predictor and BMI. This shows that the relationship between birth and 9/10 year measures of SES and BMI in this cohort are confounded by a child's stage of pubertal development, because children who are in puberty have higher BMI values. However, there is a weak independent influence of SES measured at ages 9/10 years on BMI after controlling for the stage of pubertal development and birth SES measures. These findings highlight the importance of social and biological scientists working together to understand how pubertal development and SES interact to influence inequalities in BMI in adolescents, especially given the globally increasing prevalence of obesity at these critical ages.
References
Adair, L. S. and Gordon-Larsen, P (2001). Maturational timing and overweight prevalence in US adolescent girls. American Journal of Public Health, 91, 4, 642-645.
Wang, Y (2001). Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socio-economic status. International Journal of Epidemiology, 30, 1129-1136.
Email: p.griffiths@lboro.ac.uk
Estimating the impact of household fuel pollution on the health status of young children.
P. Näsänen-Gilmore and Emily Rousham
Loughborough University
Household air pollution from low-quality biomass fuels (e.g. wood, crop-residues, dung) is a significant health risk for women and children in developing countries. Chronic exposure to biomass fuel smoke leads to inhalation of high doses of pulmonary toxins (e.g. carbon monoxide, particulate matter and carcinogens) which may impair pulmonary and immune functions. This is particularly damaging to the health of young children whose immunity is still under-developed.
625 households in northern Bangladesh were randomly recruited for a longitudinal health intervention. Children's health status (N=425) was assessed using anthropometry (height, weight), haemoglobin, reported illnesses and medical diagnosis of respiratory disease. Household air quality was assessed via carbon monoxide and particulate matter (size<2.5µm) levels.
Preliminary data reveals a rich ethnic diversity of the participant households, 55.7% were Bangla-speakers and 44.3% Urdu-speaking Bihari. The biomass fuels were used in 98.3% of households. The cooking-fuel quality varied across socio-economic status (SES) (Χ2=49.789, p<0.001). Daily particulate matter concentrations greatly exceeded the safety levels recommended by the World Health Organisation (<65µg/m3 over 24-hours). Height-for-age z-scores were positively correlated with SES (r=0.138, p<0.04). Respiratory infections were diagnosed in 60.1% of children (N=263), more commonly from lower SES households. This indicates that fuel-pollution exposure is a considerable health burden throughout this population.
This study population is ethnically diverse. A high dependency on polluting biomass fuels was observed in the population. Moderate/severe respiratory infections were prevalent among young children. Further analysis will be carried out to study the relationship between indoor air pollution exposure and respiratory infections.
Email: s.p.nasanen@lboro.ac.uk
Socio-economic determinants of pubertal development in an urban South African cohort.
Laura L. Jones1, Paula L. Griffiths1, Shane Norris2, John Pettifor2, Noël Cameron1
1Loughborough University, 2University of the Witwatersrand
Whilst the timing and duration of pubertal development is a function of gender, heredity and perhaps ethnicity, it is also known to be significantly affected by socio-economic status (SES) via previous and current health, nutrition and physical activity. To truly understand these associations a longitudinal study is fundamental. However, the requirements for a longitudinal study design are seldom met and therefore, there is limited research into the determinants of the timing and magnitude of pubertal development. This is particularly true in developing countries undergoing rapid social and economic transition such as South Africa.
The current investigation seeks to determine the relationship between SES and the initiation of puberty in a sample of peri-pubertal adolescents (n = 300) from the Birth to Twenty (Bt20) Cohort Study. The Bt20 study, established in 1990, is a large multiethnic birth cohort of children born in Soweto-Johannesburg, South Africa. The database is rich in growth, pubertal development, demographic and household SES data from birth through to adolescence. This investigation will use mixed longitudinal data from birth to early puberty to undertake a multivariate statistical analysis of the determinants of pubertal development. In particular, determinants of household SES (e.g. commodity ownership and parental education etc.) will be related to factors influencing the initiation of puberty.
Email: l.l.jones@lboro.ac.uk
Determinants of neonatal mortality in Bangladesh
Sarah Hall
University of Southampton
While there is a wide body of literature describing the determinants of infant and child mortality, less work has been carried out to analyse how these differentially affect children at different age groups, and specifically the neonatal period.
This study, uses data from Demographic and Household Surveys in Bangladesh. It first develops a conceptual framework for the factors affecting neonatal mortality. This framework is broadly based on Mosley and Chen's model where "distal" socio-economic variables exert an influence on child health outcomes through more direct "proximal determinants". The study then draws on this model to develop an empirical model using multivariate analysis which includes a much wider range of variables than is found in the vast majority of other studies. Factors included are socio-economic, maternal health and nutrition, biodemographic, environmental, behavioural, health service usage and biological. By including a wide range of variables it is possible to identify those most strongly associated with survival once confounding factors have been adjusted for. The work compares regression results with those for post-neonatal infant mortality. Increased knowledge in this area could provide valuable insights into why progress in reducing deaths in the first month of life has generally been much slower than in the post-neonatal or early childhood periods.
Email: nealse@tiscali.co.uk
Are health care providers biased towards boys? Evidence from public health facilities in Egypt.
Ray Langsten1, Emily Dixon1, Mahmoud el-Mougi2
1American University in Cairo, 2Al-Azhar University, Cairo
In many parts of the world, including Egypt, young girls continue to experience higher mortality than boys. Numerous studies attribute girls' excess mortality to parental bias in the allocation of food and healthcare. Recent work has suggested that health care providers may also deliver better treatment to boys. This work, however, is based on parental reports of the care given to boys and girls. We use observations of the clinical care provided by 115 physicians in 80 public health facilities in two governorates of Egypt (Minya and Qaliubia). We evaluate the assessment, diagnosis, and treatment of 579 children under 5 years of age, suffering from either diarrhea or acute respiratory infection. Well-trained physician-observers watched as the public facility physicians carried out their work. The observers recorded what assessment tasks were conducted and the physician's diagnosis and treatment. We find no gender bias on the part of these physicians. Physicians assess relatively few signs and symptoms of illness, but the overall quality of care is no worse for girls than for boys. Serious illness is under-diagnosed, but boys are as likely to be mis-diagnosed as girls. Antibiotics are over-prescribed, but girls are as likely as boys to be prescribed unneeded antibiotics. This behavior is consistent in both governorates, even though gender bias is believed to be particularly strong in Minya, in upper Egypt. We conclude that gender bias is the responsibility of parents, not influenced by the behavior of the physicians who treat their children.
Email: Langsten@auceegypt.edu
Dying alone: The distribution of Section 46 funerals in England, 2000-2004.
J. F. Mohan
University of Southampton
Section 46 funerals are provided by local authorities in circumstances where no relative comes forward to claim the body of the deceased (section 46 refers to the Act of Parliament which requires local authorities to do this). There were an estimated 11,000 such funerals in England the period under investigation, representing c. 0.5% of total deaths. Approximately half of local authorities in England supplied relevant data, in some cases providing a breakdown by age and sex and year. This allows analysis of: the contribution of such deaths to total mortality by local authority; age and sex differences; geographical variations, for example in average age at death; the relationship between the pattern of such deaths and controls such as deprivation, the presence of hostel or
short-term accommodation for single people, and the proportion of the population living alone; and some limited analysis of trends for a consistent set of authorities.
Email: j.f.mohan@soton.ac.uk
Health inequalities in the U.K.
J. Scanlan
Washington
Health inequalities in the United Kingdom have been a subject of considerable interest over the last quarter century and the consensus view has been that inequalities in mortality among different socioeconomic classes have been consistently increasing. However, the analysis of such issues has failed to take into account the statistical tendency whereby when two groups differ in their susceptibility to an outcome, the rarer the outcome the greater the disparity in experiencing it and the smaller the disparity in avoiding it. Thus, the perception that health inequalities have been increasing has reached without recognition that declining mortality will almost be invariably attended by increasing relative differences in mortality (though decreasing disparities in survival rates). Further, the measures aimed at reducing inequalities, the more successful of which tend to serially restrict avoidable mortality to the point where only the most susceptible segments of the population continue to experience it, tend to increase socioeconomic inequalities in such mortality (while reducing such inequalities in survival rates).
Email: jps@jpscanlan.com
The effect of birthweight on mortality in the first year of life: can we improve the estimates in developing countries?
Amos Channon
University of Southampton
Using the DHS surveys from Cambodia, Malawi and Kazakhstan I will look at the link between birth weight and mortality in the first year - infant, neonatal and postneonatal (and possibly early and late neonatal mortality too). Many infants do not have a recorded birth weight in the DHS, and thus models studying the link between birth weight and mortality are usually complete case analyses. Infants with birth weights are usually more wealthy, live in urban areas and are born in institutions than those without a recorded weight, and thus only using these infants in models may bias the results. This paper will compare the effect of birth weight on mortality using different ways to mitigate for this missing data. Complete case analyses will be compared with inverse probability weighted estimates and estimates from multilevel multiple imputation (using mothers perception of size as the main variable to impute birth weight) to see if the effect of birth weight, and other variables such as wealth on mortality changes.
Email: arc102@soton.ac.uk
National abortion guidelines and barriers to accessing safe abortion services in Nepal
Mahesh Puri
Centre for Research on Environment Health and Population Activities (CREHPA), Kathmandu, Nepal
In 2003, the World Health Organization (WHO) issued Safe abortion: Technical and policy guidance for health systems. Several countries are now issuing clinical guidelines to implement new or existing abortion laws. Despite this increased information for health systems and health professionals, women are not receiving enough information about different options in abortion technologies and experiencing different obstacles in accessing safe abortion services. Nepal has legalised abortion in 2002 and started services at the end of the year 2003. No previous analysis has been conducted so far on whether Nepal's safe abortion guideline follows the WHO recommendations and on the barriers in implementing new abortion law in the country. This paper compares Nepal safe abortion guidelines with the WHO and examines barriers to safe abortion services and ways to overcoming these barriers. Analysis shows that Nepal adopted the WHO safe abortion service guidelines in large extent, however, gaps exists in practice. Inadequacies in the health system (such as lack of client's choice on abortion technologies, limited access to services, abortion fees, unnecessary medical procedure and use of less safe procedure, registration process), administrative issues (limited number and types of health personnel authorised to provide abortion, GAG rule), lack of knowledge on new abortion law on the part women, communities, and health care providers and societal, cultural and religious attitudes including stigma are the major barriers to safe abortion services. Many groups and individuals have role in overcoming these barriers to make policies and practice more responsive to women's need. In conclusion, Nepal has made a good progress in expanding abortion services but need to do more. Considering high demand for medical abortion, this service should be available to reduce unsafe abortion practice and advocacy to policy makers and programme managers should be continued to introduce medical abortion and promote emergency contraception.
Email: