Using cognitive-behavioural techniques to improve exclusive breastfeeding in a low-literacy disadvantaged population

Despite being an important component of Pakistan's primary health care programme, the rates of exclusive breastfeeding at 6 months remain among the lowest in the world. Low levels of literacy in women and deeply held cultural beliefs and practices have been found to contribute to the ineffectiveness of routine counselling delivered universally by community health workers in Pakistan. We aimed to address this by incorporating techniques of cognitive-behavioural therapy (CBT) into the routine counselling process. We conducted qualitative studies of stakeholders' opinions (mothers, community health workers, their trainers and programme managers) and used this data to develop a psycho-educational approach that combined education with techniques of CBT that could be integrated into the health workers' routine work. The workers were trained to use this approach and feedback was obtained after implementation. The new intervention was successfully integrated into the community health worker programme and found to be culturally acceptable, feasible and useful. Incorporating techniques of CBT into routine counselling may be useful to promote health behaviours in traditional societies with low literacy rates.     

Is home delivery really preferred? a mixed-methods national study in Pakistan

Background

Pakistan has a high maternal mortality ratio and a low rate of skilled birth attendants (SBAs). To address these two important issues, the Pakistan Maternal Newborn and Child Health (MNCH) programme launched the community midwives (CMW) initiative in 2007. CMWs are supposed to conduct deliveries at community level outside health facilities. The purpose of the current study is to document perceptions about CMWs and preferences for birthing place.

Methods

A mixed-methods study was conducted covering four provinces. For the quantitative survey, households were selected through a multistage sampling technique from rural districts. In 1,450 rural households, preferences of respondents about CMW-conducted deliveries were recorded. Qualitative data were obtained through focus group discussions (FGDs) and in-depth interviews (IDIs) with women, community elders, CMWs, and MNCH programme personnel in the same areas where the quantitative study was carried out. In both studies, preferences and the reasons behind particular respondent preferences were recorded. Frequencies of responses were analysed for the quantitative study. Narration and quotes from various types of participants were used to present findings from FGDs and IDIs.

Results

In the quantitative study, 42% of respondents expressed a preference for birthing stations, i.e. a place where CMWs conduct deliveries; 22% preferred home deliveries. Birthing stations were favoured because of the availability of space and equipment and the proximity to women’s homes. These findings were largely supported by the qualitative component, although a range of views about where a CMW should conduct deliveries were expressed.

Conclusion

Insights into where CMWs might provide delivery services were obtained through this study. Birthing stations may be an option as a preferred location for delivery care and should be considered as part of Pakistan’s national CMW programme.

     

Developing cancer services strategy in primary care in England: primary care trust managers' views of the primary care cancer leads initiative

PURPOSE: Primary care cancer lead clinicians (PCCLs) act strategically in primary care trusts (PCTs) in England to improve communication and understanding of cancer across primary and secondary care and provide a link between Cancer Networks and primary care. The aim is to evaluate the first three years of the initiative. DESIGN/METHODOLOGY/APPROACH: A postal questionnaire was sent to all PCT chief executives in all PCTs in England and some were passed on to other PCT managers for completion. The response rate was 61 per cent. PCT directors of public health were the largest group of respondents (29 per cent). Most (74 per cent) PCCLs were GPs and 22 per cent were nurses. FINDINGS: PCCLs were most likely to focus on palliative care and preventive services. Key achievements were identified as raising awareness of cancer, developing relationships and promoting primary care. The personal skills of the PCCLs were important as was support of colleagues at all levels. Lack of time was a major barrier to achievement, as was a lack of understanding of the role from others. Links with the Cancer Networks were being developed. About 85 per cent of managers wanted the role to continue. ORIGINALITY/VALUE: The paper illustrates that PCCLs are at the forefront of improving cancer services in primary care. They are particularly important in view of the priority of reducing premature deaths and promotion of healthy lifestyles.     

Is home delivery really preferred? a mixed-methods national study in Pakistan

Background

Pakistan has a high maternal mortality ratio and a low rate of skilled birth attendants (SBAs). To address these two important issues, the Pakistan Maternal Newborn and Child Health (MNCH) programme launched the community midwives (CMW) initiative in 2007. CMWs are supposed to conduct deliveries at community level outside health facilities. The purpose of the current study is to document perceptions about CMWs and preferences for birthing place.

Methods

A mixed-methods study was conducted covering four provinces. For the quantitative survey, households were selected through a multistage sampling technique from rural districts. In 1,450 rural households, preferences of respondents about CMW-conducted deliveries were recorded. Qualitative data were obtained through focus group discussions (FGDs) and in-depth interviews (IDIs) with women, community elders, CMWs, and MNCH programme personnel in the same areas where the quantitative study was carried out. In both studies, preferences and the reasons behind particular respondent preferences were recorded. Frequencies of responses were analysed for the quantitative study. Narration and quotes from various types of participants were used to present findings from FGDs and IDIs.

Results

In the quantitative study, 42% of respondents expressed a preference for birthing stations, i.e. a place where CMWs conduct deliveries; 22% preferred home deliveries. Birthing stations were favoured because of the availability of space and equipment and the proximity to women’s homes. These findings were largely supported by the qualitative component, although a range of views about where a CMW should conduct deliveries were expressed.

Conclusion

Insights into where CMWs might provide delivery services were obtained through this study. Birthing stations may be an option as a preferred location for delivery care and should be considered as part of Pakistan’s national CMW programme.

     

A new role for nurses as Primary Care Cancer Lead Clinicians in Primary Care Trusts in England

AIM: The aim of this study was to evaluate the Primary Care Cancer Lead Clinician initiative in England. One of the objectives was to examine the impact of the Primary Care Cancer Lead Clinicians' clinical background on how they perform their role. This study compares nurses and General Practitioners in the Primary Care Cancer Lead Clinician role. BACKGROUND: The Primary Care Cancer Lead Clinician initiative developed from the National Health Service Cancer Plan. Primary Care Cancer Lead Clinicians are expected to work strategically to raise the standards of cancer care within primary care. METHODS: A postal questionnaire survey was sent to Primary Care Cancer Lead Clinicians and one manager in each Primary Care Trust in England. Telephonic interviews were also undertaken with a range of stakeholders in six case study areas. RESULTS: There were striking similarities between nurses and General Practitioners in the Primary Care Cancer Lead Clinician role. Differences related to the wider roles of the two groups. Nurses placed greater emphasis on fitting in whereas General Practitioners were more likely to expect to take charge and look for administrative support. CONCLUSIONS: There is evidence to show that whether the Primary Care Cancer Lead Clinician was a nurse or a General Practitioner was less important than having local credibility and the support of their Primary Care Trust.     

Expression,Purification and Characterization of GMZ2’.10C,a Complex Disulphide-Bonded Fusion Protein Vaccine Candidate against the Asexual and Sexual Life-Stages of the Malaria-Causing <Emphasis Type="BoldItalic">Plasmodium falciparum</Emphasis> Parasite

Purpose

Production and characterization of a chimeric fusion protein (GMZ2’.10C) which combines epitopes of key malaria parasite antigens: glutamate-rich protein (GLURP), merozoite surface protein 3 (MSP3), and the highly disulphide bonded Pfs48/45 (10C). GMZ2’.10C is a potential candidate for a multi-stage malaria vaccine that targets both transmission and asexual life-cycle stages of the parasite.

Methods

GMZ2’.10C was produced in Lactococcus lactis and purified using either an immunoaffinity purification (IP) or a conventional purification (CP) method. Protein purity and stability was analysed by RP-HPLC, SEC-HPLC, 2-site ELISA, gel-electrophoresis and Western blotting. Structural characterization (mass analysis, peptide mapping and cysteine connectivity mapping) was performed by LC-MS/MS.

Results

CP-GMZ2’.10C resulted in similar purity, yield, structure and stability as compared to IP-GMZ2’.10C. CP-GMZ2’.10C and IP-GMZ2’.10C both elicited a high titer of transmission blocking (TB) antibodies in rodents. The intricate disulphide-bond connectivity of C-terminus Pfs48/45 was analysed by tandem mass spectrometry and was established for GMZ2’.10C and two reference fusion proteins encompassing similar parts of Pfs48/45.

Conclusion

GMZ2’.10C, combining GMZ2’ and correctly-folded Pfs48/45 can be produced by the Lactoccus lactis P170 based expression system in purity and quality for pharmaceutical development and elicit high level of TB antibodies. The cysteine connectivity for the 10C region of Pfs48/45 was revealed experimentally, providing an important guideline for employing the Pfs48/45 antigen in vaccine design.