Christina Pagel

Managing the health effects of climate change

Climate change is the biggest global health threat of the 21st century. Effects of climate change on health will affect most populations in the next decades and put the lives and wellbeing of billions of people at increased risk. During this century, earthﾒs average surface temperature rises are likely to exceed the safe threshold of 2ﾰC above preindustrial average temperature. Rises will be greater at higher latitudes, with medium-risk scenarios predicting 2ﾖ3ﾰC rises by 2090 and 4ﾖ5ﾰC rises in northern Canada, Greenland, and Siberia. In this report, we have outlined the major threatsﾗboth direct and indirectﾗto global health from climate change through changing patterns of disease, water and food insecurity, vulnerable shelter and human settlements, extreme climatic events, and population growth and migration. Although vector-borne diseases will expand their reach and death tolls, especially among elderly people, will increase because of heatwaves, the indirect effects of climate change on water, food security, and extreme climatic events are likely to have the biggest effect on global health.

Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial.

BACKGROUND Community mobilisation through participatory womens groups might improve birth outcomes in poor rural communities. We therefore assessed this approach in a largely tribal and rural population in three districts in eastern India. METHODS From 36 clusters in Jharkhand and Orissa, with an estimated population of 228 186, we assigned 18 clusters to intervention or control using stratified randomisation. Women were eligible to participate if they were aged 15-49 years, residing in the project area, and had given birth during the study. In intervention clusters, a facilitator convened 13 groups every month to support participatory action and learning for women, and facilitated the development and implementation of strategies to address maternal and newborn health problems. The primary outcomes were reductions in neonatal mortality rate (NMR) and maternal depression scores. Analysis was by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN21817853. FINDINGS After baseline surveillance of 4692 births, we monitored outcomes for 19 030 births during 3 years (2005-08). NMRs per 1000 were 55.6, 37.1, and 36.3 during the first, second, and third years, respectively, in intervention clusters, and 53.4, 59.6, and 64.3, respectively, in control clusters. NMR was 32% lower in intervention clusters adjusted for clustering, stratification, and baseline differences (odds ratio 0.68, 95% CI 0.59-0.78) during the 3 years, and 45% lower in years 2 and 3 (0.55, 0.46-0.66). Although we did not note a significant effect on maternal depression overall, reduction in moderate depression was 57% in year 3 (0.43, 0.23-0.80). INTERPRETATION This intervention could be used with or as a potential alternative to health-worker-led interventions, and presents new opportunities for policy makers to improve maternal and newborn health outcomes in poor populations. FUNDING Health Foundation, UK Department for International Development, Wellcome Trust, and the Big Lottery Fund (UK).

Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis

BACKGROUND Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of womens groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. METHODS We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of womens groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the womens group intervention and estimated its potential effect at scale in Countdown countries. FINDINGS Seven trials (119,428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to womens groups was associated with a 37% reduction in maternal mortality (odds ratio 0.63, 95% CI 0.32-0.94), a 23% reduction in neonatal mortality (0.77, 0.65-0.90), and a 9% non-significant reduction in stillbirths (0.91, 0.79-1.03), with high heterogeneity for maternal (I(2)=58.8%, p=0.024) and neonatal results (I(2)=64.7%, p=0.009). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0.026 and p=0.011, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 55% reduction in maternal mortality (0.45, 0.17-0.73) and a 33% reduction in neonatal mortality (0.67, 0.59-0.74). The intervention was cost effective by WHO standards and could save an estimated 283,000 newborn infants and 41,100 mothers per year if implemented in rural areas of 74 Countdown countries. INTERPRETATION With the participation of at least a third of pregnant women and adequate population coverage, womens groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. FUNDING Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.

Effect of scaling up women's groups on birth outcomes in three rural districts in Bangladesh: a cluster-randomised controlled trial

BACKGROUND Two recent trials have shown that womens groups can reduce neonatal mortality in poor communities. We assessed the effectiveness of a scaled-up development programme with womens groups to address maternal and neonatal care in three rural districts of Bangladesh. METHODS 18 clusters (with a mean population of 27 953 [SD 5953]) in three districts were randomly assigned to either intervention or control (nine clusters each) by use of stratified randomisation. For each district, cluster names were written on pieces of paper, which were folded and placed in a bottle. The first three cluster names drawn from the bottle were allocated to the intervention group and the remaining three to control. All clusters received health services strengthening and basic training of traditional birth attendants. In intervention clusters, a facilitator convened 18 groups every month to support participatory action and learning for women, and to develop and implement strategies to address maternal and neonatal health problems. Women were eligible to participate if they were aged 15-49 years, residing in the project area, and had given birth during the study period (Feb 1, 2005, to Dec 31, 2007). Neither study investigators nor participants were masked to treatment assignment. In a population of 229 195 people (intervention clusters only), 162 womens groups provided coverage of one group per 1414 population. The primary outcome was neonatal mortality rate (NMR). Analysis was by intention to treat. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN54792066. FINDINGS We monitored outcomes for 36 113 births (intervention clusters, n=17 514; control clusters, n=18 599) in a population of 503 163 over 3 years. From 2005 to 2007, there were 570 neonatal deaths in the intervention clusters and 656 in the control clusters. Cluster-level mean NMR (adjusted for stratification and clustering) was 33.9 deaths per 1000 livebirths in the intervention clusters compared with 36.5 per 1000 in the control clusters (risk ratio 0.93, 95% CI 0.80-1.09). INTERPRETATION For participatory womens groups to have a significant effect on neonatal mortality in rural Bangladesh, detailed attention to programme design and contextual factors, enhanced population coverage, and increased enrolment of newly pregnant women might be needed. FUNDING Women and Children First, the UK Big Lottery Fund, Saving Newborn Lives, and the UK Department for International Development.

The Papworth Bleeding Risk Score: a stratification scheme for identifying cardiac surgery patients at risk of excessive early postoperative bleeding

OBJECTIVE We have developed a risk stratification score to identify cardiac surgical patients at higher risk of severe postoperative bleeding to aid a decision of whether to use a specific intervention preoperatively. METHODS We prospectively created a database of 11592 consecutive patients, who underwent cardiac surgery with cardiopulmonary bypass. An adverse outcome was formally defined as a mean blood loss exceeding 2 ml kg(-1)h(-1) measured between arrival in the intensive care unit (ICU) and the earliest of the elapse of 3h; the start of transfusion of any one of fresh-frozen plasma, platelets or cryoprecipitate; return to theatre or death. Univariate and multivariate associations of severe postoperative bleeding with patient characteristics, clinical features and procedure details were analysed on a development set. The final risk stratification scheme was then evaluated on a test set. RESULTS Severe postoperative bleeding was associated with urgent or emergency surgery, surgery that was not coronary artery bypass grafting or single valve surgery, presence of aortic valve disease, low body mass index and older age. A risk stratification score was constructed from the above variables to define preoperative categories that demonstrated high, medium and low risk of severe postoperative bleeding. Patients deemed to be at high, medium and low risk by our preoperative scoring had a 21% (95% confidence interval: 18-24%), 8% (7-10%) and 3% (2-4%) rate of severe postoperative bleeding, respectively, within the test set. CONCLUSION We have developed a simple risk stratification score that can separate, preoperatively, patients into risk groups with markedly different rates of severe postoperative bleeding.

Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model

BACKGROUND Maternal mortality in Africa has changed little since 1990. We developed a mathematical model with the aim to assess whether improved community-based access to life-saving drugs, to augment a core programme of health-facility strengthening, could reduce maternal mortality due to post-partum haemorrhage or sepsis. METHODS We developed a mathematical model by considering the key events leading to maternal death from post-partum haemorrhage or sepsis after delivery. With parameter estimates from published work of occurrence of post-partum haemorrhage and sepsis, case fatality, and the effectiveness of drugs, we used this model to estimate the effect of three potential packages of interventions: 1) health-facility strengthening; 2) health-facility strengthening combined with improved drug provision via antenatal-care appointments and community health workers; and 3) all interventions in package two combined with improved community-based drug provision via female volunteers in villages. The model was applied to Malawi and sub-Saharan Africa. FINDINGS In the implementation of the model, the lowest risk deliveries were those in health facilities. With the model we estimated that of 2860 maternal deaths from post-partum haemorrhage or sepsis per year in Malawi, intervention package one could prevent 210 (7%) deaths, package two 720 (25%) deaths, and package three 1020 (36%) deaths. In sub-Saharan Africa, we estimated that of 182 000 of such maternal deaths per year, these three packages could prevent 21 300 (12%), 43 800 (24%), and 59 000 (32%) deaths, respectively. The estimated effect of community-based drug provision was greatest for the poorest women. INTERPRETATION Community provision of misoprostol and antibiotics to reduce maternal deaths from post-partum haemorrhage and sepsis could be a highly effective addition to health-facility strengthening in Africa. Investigation of such interventions is urgently needed to establish the risks, benefits, and challenges of widespread implementation. FUNDING Institute of Child Health and Faculty of Mathematical and Physical Sciences, University College London, and a donation from John and Ann-Margaret Walton.

How many births in sub-Saharan Africa and South Asia will not be attended by a skilled birth attendant between 2011 and 2015?

BackgroundThe fifth Millennium Development Goal target for 90% of births in low and middle income countries to have a skilled birth attendant (SBA) by 2015 will not be met. In response to this, policy has focused on increasing SBA access. However, reducing maternal mortality also requires policies to prevent deaths among women giving birth unattended. We aimed to generate estimates of the absolute number of non-SBA births between 2011 and 2015 in South Asia and sub-Saharan Africa, given optimistic assumptions of future trends in SBA attendance. These estimates could be used by decision makers to inform the extent to which reductions in maternal mortality will depend on policies aimed specifically at those women giving birth unattended.MethodsFor each country within South Asia and sub-Saharan Africa we estimated recent trends in SBA attendance and used these as the basis for three increasingly optimistic projections for future changes in SBA attendance. For each country we obtained estimates for the current SBA attendance in rural and urban settings and forecasts for the number of births and changes in rural/urban population over 2011-2015. Based on these, we calculated estimates for the number of non-SBA births for 2011-2015 under a variety of scenarios.ResultsConservative estimates are that there will be between 130 and 180 million non-SBA births in South Asia and sub-Saharan Africa from 2011 to 2015 (90% of these in rural areas). Currently, there are more non-SBA births per year in South Asia than sub-Saharan Africa, but our projections suggest that the regions will have approximately the same number of non-SBA births by 2015. We also present results for each of the six countries currently accounting for more than 50% of global maternal deaths.ConclusionsOver the next five years, many millions of women within South Asia and sub-Saharan Africa will give birth without an SBA. Efforts to improve access to skilled attendance should be accompanied by interventions to improve the safety of non-attended deliveries.

Real time monitoring of risk-adjusted paediatric cardiac surgery outcomes using variable life-adjusted display: implementation in three UK centres

Objective To implement routine in-house monitoring of risk-adjusted 30-day mortality following paediatric cardiac surgery. Design Collaborative monitoring software development and implementation in three specialist centres. Patients and methods Analyses incorporated 2 years of data routinely audited by the National Institute of Cardiac Outcomes Research (NICOR). Exclusion criteria were patients over 16 or undergoing non-cardiac or only catheter procedures. We applied the partial risk adjustment in surgery (PRAiS) risk model for death within 30 days following surgery and generated variable life-adjusted display (VLAD) charts for each centre. These were shared with each clinical team and feedback was sought. Results Participating centres were Great Ormond Street Hospital, Evelina Childrens Hospital and The Royal Hospital for Sick Children in Glasgow. Data captured all procedures performed between 1 January 2010 and 31 December 2011. This incorporated 2490 30-day episodes of care, 66 of which were associated with a death within 30 days.The VLAD charts generated for each centre displayed trends in outcomes benchmarked to recent national outcomes. All centres ended the 2-year period within four deaths from what would be expected. The VLAD charts were shared in multidisciplinary meetings and clinical teams reported that they were a useful addition to existing quality assurance initiatives. Each centre is continuing to use the prototype software to monitor their in-house surgical outcomes. Conclusions Timely and routine monitoring of risk-adjusted mortality following paediatric cardiac surgery is feasible. Close liaison with hospital data managers as well as clinicians was crucial to the success of the project.

Moving improvement research closer to practice: the Researcher-in-Residence model

The traditional separation of the producers of research evidence in academia from the users of that evidence in healthcare organisations has not succeeded in closing the gap between what is known about the organisation and delivery of health services and what is actually done in practice. As a consequence, there is growing interest in alternative models of knowledge creation and mobilisation, ones which emphasise collaboration, active participation of all stakeholders, and a commitment to shared learning. Such models have robust historical, philosophical and methodological foundations but have not yet been embraced by many of the people working in the health sector. This paper presents an emerging model of participation, the Researcher-in-Residence. The model positions the researcher as a core member of a delivery team, actively negotiating a body of expertise which is different from, but complementary to, the expertise of managers and clinicians. Three examples of in-residence models are presented: an anthropologist working as a member of an executive team, operational researchers working in a front-line delivery team, and a Health Services Researcher working across an integrated care organisation. Each of these examples illustrates the contribution that an embedded researcher can make to a service-based team. They also highlight a number of unanswered questions about the model, including the required level of experience of the researcher and their areas of expertise, the institutional facilitators and barriers to embedding the model, and the risk that the independence of an embedded researcher might be compromised. The Researcher-in-Residence model has the potential to engage both academics and practitioners in the promotion of evidence-informed service improvement, but further evaluation is required before the model should be routinely used in practice.

Intracluster correlation coefficients and coefficients of variation for perinatal outcomes from five cluster-randomised controlled trials in low and middle-income countries: results and methodological implications

BackgroundPublic health interventions are increasingly evaluated using cluster-randomised trials in which groups rather than individuals are allocated randomly to treatment and control arms. Outcomes for individuals within the same cluster are often more correlated than outcomes for individuals in different clusters. This needs to be taken into account in sample size estimations for planned trials, but most estimates of intracluster correlation for perinatal health outcomes come from hospital-based studies and may therefore not reflect outcomes in the community. In this study we report estimates for perinatal health outcomes from community-based trials to help researchers plan future evaluations.MethodsWe estimated the intracluster correlation and the coefficient of variation for a range of outcomes using data from five community-based cluster randomised controlled trials in three low-income countries: India, Bangladesh and Malawi. We also performed a simulation exercise to investigate the impact of cluster size and number of clusters on the reliability of estimates of the coefficient of variation for rare outcomes.ResultsEstimates of intracluster correlation for mortality outcomes were lower than those for process outcomes, with narrower confidence intervals throughout for trials with larger numbers of clusters. Estimates of intracluster correlation for maternal mortality were particularly variable with large confidence intervals. Stratified randomisation had the effect of reducing estimates of intracluster correlation. The simulation exercise showed that estimates of intracluster correlation are much less reliable for rare outcomes such as maternal mortality. The size of the cluster had a greater impact than the number of clusters on the reliability of estimates for rare outcomes.ConclusionsThe breadth of intracluster correlation estimates reported here in terms of outcomes and contexts will help researchers plan future community-based public health interventions around maternal and newborn health. Our study confirms previous work finding that estimates of intracluster correlation are associated with the prevalence of the outcome of interest, the nature of the outcome of interest (mortality or behavioural) and the size and number of clusters. Estimates of intracluster correlation for maternal mortality need to be treated with caution and a range of estimates should be used in planning future trials.