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Suicidal behaviour constitutes a serious public as well as mental health problem all over the world. Many developed countries have done away with the legal provision of punishing attempted suicides. However, in India this continues to be a punishable offence under the Indian Penal Code (1833). This review discusses the various issues related to criminalizing suicide and their implications.
In 1998 the Department of Health Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment issued a report to British general practitioners, which advised that pregnant mothers with a family history of atopy may wish to avoid peanuts during pregnancy/lactation. To explore the lived-in experience of mothers who avoided/did not avoid peanuts during pregnancy/lactation in the light of the information issued. A qualitative approach, using unstructured in-depth interviews to explore what it was like for mothers to have a particular experience. A purposive sample frame was designed to ensure a maximum variation of participants. Forty-two interviews were conducted: 25 participants avoided peanuts; 15 with a family history of atopy and 10 with no such history. Seventeen participants did not avoid peanuts; 10 with a family history of atopy and seven with no such history. Emergent themes included: variations in information provision, a lack of clarity in relation to information and advice about peanut avoidance, the risks entailed and the introduction of peanuts to the developing child's diet; the importance of atopy in influencing participants' decisions to avoid peanuts and the importance of individual's choice in the decision making process. There was a significant difference in family size with respect to avoidance behaviour with 'avoider' families being smaller (p = 0.007). Avoidance was more likely in single child families (71% vs. 53%) although this difference was not significant. Improvements to the experience of avoidance and/or non-avoidance were primarily focused around provision of information and advice. In particular, a need for clear, consistent factual information and advice about the real risks associated with peanut consumption during pregnancy/lactation, and to whom these risks apply.
BACKGROUND: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. METHOD: For these guidelines, the CPG Team for Deliberate Self-harm reviewed the treatment outcome literature (including meta-analyses) and consulted with practitioners and patients. TREATMENT RECOMMENDATIONS: (i) Organization of general hospital services to provide: emergency department admission; a safe environment; integrated medical and psychiatric management; risk assessment; identification of psychiatric morbidity, and adequate follow-up. (ii) Detection and treatment of any psychiatric disorder. (iii) Dialectical behaviour therapy, psychoanalytically orientated partial hospitalization or home-based interpersonal therapy (for certain patients) to reduce repetition of deliberate self-harm (DSH). CONCLUSION: Deliberate self-harm is common and is costly in terms of both individual distress and service provision. General hospitals are often the first point of clinical contact, but may not be appropriately organized to care for these patients. Evidence for the effectiveness of psychological treatments is based on single RCTs without replication. The three recommended psychological treatments are not widely available in Australia and New Zealand, and the interventions that are, such as cognitive behaviour therapy, problem solving and 'green cards' (an agreement guaranteeing access to services), do not reduce repetition of DSH. The effect of follow-up in psychiatric hospitals or in the community is poorly understood. We need to develop and evaluate interventions that will reduce repetition of both fatal and non-fatal deliberate self-harm and improve the person's functioning and quality of life.
The early development of self-injurious behaviour in three young boys (aged 17, 25, and 30 months at start of study) with Lesch-Nyhan syndrome was examined by means of parental interviews and by direct observations completed at 3 to 4 monthly intervals over an 18-month period. Results suggest that the self-injury began in a different way from that of other young children with autism and/or developmental disabilities in that, from the start, self-injurious responses were sudden and violent, rather than emerging gradually over time. Drastic measures, such as removal of the teeth or provision of tooth guards, were often taken to prevent further tissue damage. Direct observations showed that the boys' self-injury occurred at lower rates, but their carers were highly concerned about the behaviour. Sequential analysis of the observational data indicated that on some occasions the children were more likely to self-injure during periods of low social interaction, suggesting that their self-injury may have been influenced by environmental factors. The theoretical and practical implications of these findings are discussed.
AIMS: To investigate the attitudes of community pharmacists towards HIV prevention services for drug misusers and the relationship between these and their involvement in service provision. DESIGN: Postal survey of a one in four random sample of community pharmacies (N = 2654) in England and Wales, stratified by Family Health Service Authority, in 1995, using up to four mailshots. SETTING: Community pharmacies in England and Wales. PARTICIPANTS: The community pharmacist in charge of the dispensary at the random sample of community pharmacies. MEASUREMENTS: Information on attitudes and behaviour were collected through self-completion and postal return of structured questionnaires using questions with both category responses and Likert scales. FINDINGS: A 74.8% response rate was achieved. Community pharmacists were positive about their role in HIV prevention and the provision of clean injecting equipment to injecting drug users--positive attitudes that were more evident among those pharmacists already providing these services. However, they had concerns over the effect drug misusers may have on business and indicated a need for more training and for more role support. Only a minority had taken part in training on drug misuse and HIV prevention (34.7% and 21.3%, respectively). Many community pharmacists supported the proposal that there should be extensions of their involvement, to include services such as supervising the consumption of methadone in the pharmacy (38.6%) and collecting used prescribed ampoules from patients (33.8%). Positive relationships were identified between training and attitude, and between attitude and service provision. Changes in attitude responses between this 1995 survey and the earlier 1988 survey are also presented. CONCLUSIONS: Recommendations are made for further training and greater communication between prescriber/carer and the community pharmacists, for involvement of community pharmacies in new possible forms of service provision, and for there to be greater attention to the value of role support.
OBJECTIVE: To determine the preponderance of ideas in adolescents about the relationship between maternal habits and the health of the fetus. DESIGN: Quantitative survey using a precoded questionnaire, the content of which was derived from the transcripts of interviews and the responses to open-form questionnaires. SETTING: North West Region Health Authority area, UK. PARTICIPANTS: 674 adolescents in British National Curriculum Year 10 (age 14/15) from 6 Community Comprehensive Schools. FINDINGS: Most of the adolescents were aware of the dangers to the fetus of alcohol and smoking, including passive smoking. However, they were less aware of the potential hazards during pregnancy of eggs (Salmonella), soft cheeses (Listeria), liver (Vitamin A excess) or handling cats (Toxoplasmosis). Most of the respondents thought that the optimum time to initiate actions for a healthy pregnancy was when pregnancy had been confirmed, suggesting that the benefits of preconceptual care are not well known. KEY CONCLUSIONS: Adolescents lack knowledge about some of the specific hazards to the fetus of maternal diet and behaviour during pregnancy and are unaware of the importance of the early stages of pregnancy in this context. IMPLICATIONS: There is a need for the provision of education about the importance of a healthy maternal lifestyle before conception and during early pregnancy for adolescents. Midwives may have a proactive role in such education, but should be aware that young people may have specific areas of ignorance and misconceptions which will need addressing.
BACKGROUND: The anticipated scale-up of antiretroviral therapy (ART) in high-prevalence, resource-constrained settings requires operational research to guide policy on the design of treatment programmes. Mathematical models can explore the potential impacts of various treatment strategies, including timing of treatment initiation and provision of laboratory monitoring facilities, to complement evidence from pilot programmes. METHODS AND FINDINGS: A deterministic model of HIV transmission incorporating ART and stratifying infection progression into stages was constructed. The impact of ART was evaluated for various scenarios and treatment strategies, with different levels of coverage, patient eligibility, and other parameter values. These strategies included the provision of laboratory facilities that perform CD4 counts and viral load testing, and the timing of the stage of infection at which treatment is initiated. In our analysis, unlimited ART provision initiated at late-stage infection (AIDS) increased prevalence of HIV infection. The effect of additionally treating pre-AIDS patients depended on the behaviour change of treated patients. Different coverage levels for ART do not affect benefits such as life-years gained per person-year of treatment and have minimal effect on infections averted when treating AIDS patients only. Scaling up treatment of pre-AIDS patients resulted in more infections being averted per person-year of treatment, but the absolute number of infections averted remained small. As coverage increased in the models, the emergence and risk of spread of drug resistance increased. Withdrawal of failing treatment (clinical resurgence of symptoms), immunologic (CD4 count decline), or virologic failure (viral rebound) increased the number of infected individuals who could benefit from ART, but effectiveness per person is compromised. Only withdrawal at a very early stage of treatment failure, soon after viral rebound, would have a substantial impact on emergence of drug resistance. CONCLUSIONS: Our analysis found that ART cannot be seen as a direct transmission prevention measure, regardless of the degree of coverage. Counselling of patients to promote safe sexual practices is essential and must aim to effect long-term change. The chief aims of an ART programme, such as maximised number of patients treated or optimised treatment per patient, will determine which treatment strategy is most effective.
Education of patients and their partners about appropriate lifestyle changes following myocardial infarction (MI) is a key element in rehabilitation; developing relevant educational strategies requires a knowledge of patient beliefs and attitudes. This paper reports findings from a survey of diet and exercise in a group of 153 middle-aged men who had suffered a first uncomplicated MI. Just over half of those questioned expressed a desire to change their diet post-MI; those who perceived their pre-morbid diet to be 'less healthy' were more likely to want to change. Significant changes in food consumption (towards a more healthy diet) were observed at 3 months post-MI. Patients were less likely to change their behaviour with respect to exercise, and few attained recommended levels of physical activity either pre- or post-MI. Patients held a number of misconceptions regarding the role of diet and exercise in predisposing to coronary heart disease, and the need for change in behaviour. Beliefs and behaviour change were only weakly associated with receipt of information and advice. The findings have important messages for the more appropriate targeting of information-provision during the period of rehabilitation.
BACKGROUND: Computer-assisted diagnostic systems are not substantially more accurate than the clinician in the differential diagnosis of jaundice but may help in optimal selection and sequencing of tests. The present study aimed to assess with an electronic diagnostic tool the pattern of ordering tests and the diagnostic contribution and related financial cost of each test in jaundiced patients with pancreatobiliary carcinoma, in an effort to make the clinician's diagnostic behaviour more efficient and economical. METHODS: Clinical and diagnostic test data were prospectively gathered from 356 jaundiced patients with pancreatobiliary carcinoma and entered in a Bayesian diagnostic programme. The test results were added to the existing diagnostic evidence, and the programme calculated the diagnostic contribution of each test. RESULTS: A total of 1804 diagnostic tests were ordered. Quantitative assessment of the diagnostic contribution of each test showed that percutaneous transhepatic cholangiography and computed tomography were associated with the highest provision of information. The most cost-effective tests were ultrasonography and liver function tests. CONCLUSIONS: It is possible to determine objectively the diagnostic contribution of each test in establishing the diagnosis of pancreatobiliary carcinoma. The observed physician behaviour in ordering the various diagnostic tests might be improved with regard to its efficacy and its cost-effectiveness profile.
Procellariiform seabirds such as the Manx shearwater Puffinus puffinus, rear only one chick at a time but may breed many times in their lives; parents should thus limit food delivery to the chick in keeping with the balance between current and future reproductive output. Yet procellariiform chicks accumulate large quantities of lipid, which may provide a buffer against pronounced and unpredictable variation in food provisioning, resulting in part from an inability of parents to regulate food supply to the nest. We switched chicks between nests to examine the roles of parents and offspring in controlling food delivery. The serial autocorrelation in age-specific body masses for unmanipulated chicks decreased from 0.61 (P< 0.01) to 0.35 (NS) over a period of 15 days and remained nonsignificant thereafter. By contrast, the serial autocorrelation for switched chicks increased from 0.64 (P< 0.01) to 0.83 (P< 0.001) and the serial cross-correlation rose from 0.23 (NS) to 0.50 (P< 0.05). These results supported both chick determination and parental determination models of food provisioning, indicating that chicks conveyed information about their nutritional status, which parents acted upon by adjusting their rate of food delivery. We discuss these results in relation to the optimization of nestling lipid reserves and parental foraging effort. We suggest that information conveyed by the chick's begging intensity serves to reduce the provisioning rate to well-fed chicks, but parents cannot or do not increase food provisioning to poorly fed chicks. Such adjustment of food provisioning does not refute the hypothesis that nestling obesity provides a buffer against highly variable food delivery. Copyright 1999 The Association for the Study of Animal Behaviour.
AIM: To explore and investigate differences between the views of qualified nurses working in psychiatric intensive care units (PICUs) and acute care wards on which patients are appropriate for PICU care. BACKGROUND: Previous research on the area of psychiatric intensive care highlights the great differences that exist in all aspects of service provision, from unit size and staffing levels to treatment approaches and physical environment. One of the most common areas of controversy is the type of client behaviour that warrants admission to the PICU. METHOD: Structured interviews of 100 qualified nursing staff (in the London area, England) working on either acute or PICU wards were used to gather data on appropriate and inappropriate referral to PICUs. Comments made during the course of the interviews were also collected and subjected to content analysis. FINDINGS: There was evidence to support the hypothesis that acute ward staff considered patients suitable for PICU care at a lower level of risk than PICU staff thought appropriate. In comparison to acute ward nurses, those working in PICUs attended to a broader range of factors when considering suitability for admission to PICU. Appropriate reasons for transfer fell into five groups: risk to others; risk of intentional harm to self; risk of unintentional harm to self; therapeutic benefit from the PICU environment; and legitimate acute ward care problem. Inappropriate reasons for transfer fell into four groups: low risk to others and/or self; illegitimate acute admission care problems; patient belongs elsewhere; policy issues. CONCLUSION: The study opens up a range of issues not previously studied in relation to the use of PICUs and the intricate relationship of this use with the available acute care wards and other services. These findings and their implications for the care of acute and disturbed psychiatric patients are discussed.
AIMS: To examine the prevalence of five life-style behaviours among New South Wales police. DESIGN: A cross-sectional survey using a self-administered questionnaire. SETTING AND PARTICIPANTS: A total of 852 police were recruited from metropolitan Sydney. MEASUREMENTS: Prevalence related to age and sex of self-reported alcohol consumption, cigarette smoking, inadequate exercise, perception of overweight and stress symptoms. RESULTS: A high level (89%) of participation was achieved in the survey. Almost half (48%) of males and more than two-fifths (40%) of females consumed alcohol excessively including continuous hazardous or harmful consumption and binge drinking. Excessive drinking was more prevalent among younger police. There were 8% of male and 15% of female police who reported that they did not drink alcohol. Over one-quarter (27%) of male and one-third (32%) of female respondents reported smoking. Almost half (46%) of men and women (47%) believed that they were overweight. More than one-fifth (21%) of men and less than one-quarter (24%) of women reported that they did not exercise. Finally, 12% of men and 15% of women reported feeling moderate to severe symptoms of stress. CONCLUSIONS: The police work-force offers an opportunity to screen for a large number of healthy, young and high risk individuals (particularly men) who are hard to reach in other settings and who rarely visit their general practitioner. A sizeable majority (83%) of NSW police had at least one unhealthy life-style behaviour with 19% reporting 3-5 unhealthy factors. The high prevalence of excessive alcohol consumption among police is of particular concern. More active health promotion and provision of brief interventions among police may reduce morbidity and mortality associated with unhealthy life-styles.
1. A field experiment was conducted with commercial broiler breeder females to assess the hypothesis that the provision of bunches of string and bales of wood shavings would provide attractive environmental enrichment and improve welfare by decreasing aggression and feather damage. 2. The experiment was a randomised block factorial design conducted in a commercial flock of 21,600 female broiler breeders in 12 pens of 1800 chicks. Treatments were environmental enrichment (4 plastic coated bales of wood shavings and 50 bunches of string) from hatch (EE1) or 8 weeks of age (EE2) and a control treatment with no environmental enrichment. There were 4 replicates (rooms). 3. Bird activity was videotaped at 5, 10 and 16 weeks of age and subsequently scored for the number of birds using the perch or pecking at a bale, drinker, litter and section of the wall at 10-min intervals for 4 h throughout the photoperiod (24 times/d). Aggression was assessed by determining the number of aggressive acts in 2-min intervals during 8 periods of the day. The skin and feather condition of 25 birds in each pen were scored at 6, 12 and 18 weeks and the condition of the string bunches was scored at the end of the experiment. 4. The proportion of birds pecking the bales, wall and litter declined and the proportion pecking at the drinker and using the perch increased with age. The number of birds pecking at the bale was similar in EE1 and EE2 at 10 and 16 weeks of age. 5. The string bunches were not extensively used. The condition of the bunches of string in EE2 was worse than in EE1 at the end of the experiment. 6. The number of aggressive acts increased with age and there was no consistent difference between treatments. 7. There was an increase with age in the damage score for feathers over the back and wings and around the tail and vent but no differences between treatments.8. Provision of litter in the form of unopened bales of wood shavings was a commercially acceptable form of environmental enrichment, but there was no evidence that behavioural changes associated with feed restriction, including the prevalence of aggression, were improved.
Evolutionary explanations of cooperative breeding based on kin selection have predicted that the individual contributions made by different helpers to rearing young should be correlated with their degree of kinship to the litter or brood they are raising. In the cooperative mongoose or meerkat, Suricata suricatta, helpers babysit pups at the natal burrow for the first month of pup life and frequent babysitters suffer substantial weight losses over the period of babysitting. Large differences in contributions exist between helpers, which are correlated with their age, sex and weight but not with their kinship to the young they are raising. Provision of food to some group members raises the contributions of individuals to babysitting. We discuss the implications of these results for evolutionary explanations of cooperative behaviour.
BACKGROUND: The aim was to assess the clinical usefulness and economic viability of an aftercare worker for psychotic patients discharged from half-way houses in Hong Kong. METHOD: A sample of 32 chronic psychotic patients was provided with a full-time aftercare worker. A matched control group received no such service. RESULTS: The experimental group was found to have greater and better employment prospects, better mental status with less hospitalisation and less law-breaking behaviour than the control group. Some of these benefits were converted into economic terms and the tangible costs incurred in the project were calculated. CONCLUSIONS: The provision of an aftercare service is clinically useful and economically viable.
The study of territorial polygyny in birds has been influential in the development of the theory of social mating systems. Alternative female mating options have been studied within the framework of the polygyny-threshold model and later as the outcome of conflicts of interest between individuals. However, little attention has been given to variations between individual females, and how this affects their mating behaviour. Here, we test the hypothesis that some females are better adapted to raise nestlings without male assistance, and thus to mate polygynously. Specifically, we investigate whether intraspecific variation in female bill morphology is related to mating behaviour. This hypothesis is derived from earlier studies showing that, in both intra- and interspecific comparisons, uniparental care by females is correlated with the catching of larger prey items than when both parents provision the young. Using the polygynous dusky warbler (Phylloscopus fuscatus) as a model species, we found that, in accordance with our prediction, females with deep bills were more likely to mate as a secondary female. Moreover, regardless of mating status, females with deep bills settled in territories with more food and they received less male assistance in feeding their offspring. We argue that females with stronger bills are better adapted to exploit the abundance of large food items in rich territories and thus to raise young on their own. Our results demonstrate the importance of studying variations between individual females, and provide evidence for an extended version of the 'constrained-female hypothesis'. As bill depth is a highly heritable trait, our study strongly suggests that variation in female mating behaviour is not only related to ecological factors and female condition (as shown elsewhere) but also to heritable morphological traits.
The focus of this paper is the extent to which the purchaser-provider split and the creation of a market in the provision of health care can be expected to bring about greater efficiency within the new NHS. The starting point is a theoretical discussion of markets and competition. In particular, emphasis is placed upon the economic model of perfect competition. It is argued that because of the existence of externalities, uncertainty and a lack of perfect information, an unregulated market in health care will almost certainly fail. In view of this, the imperfect provider markets of monopoly and contestable markets, which are of particular relevance to health care, are discussed. A description of the new health care market and the principal actors within it is followed by an evaluation of the new health care market. It is argued that in view of the restrictions to competition that exist between providers, some form of price regulation will be necessary to prevent monopolistic behaviour in the hospital sector. Regulation of purchasers is also suggested as a means of improving efficiency. It is concluded that competition may be a necessary condition for increased efficiency in health care provision, but is not sufficient in itself. Other incentives in the hospital sector are necessary to assist the market process and to enhance its impact on efficiency.
BACKGROUND: Most AD patients are cared for at home by informal caregivers. The effect of different kind of stressors on caregivers has been referred to as caregiver burden. OBJECTIVE: To determine (1) the level of burden of informal caregivers of Alzheimer's patients in a French national sample; (2) the factors associated with a high level of burden. METHODS: Cross-sectional study of informal caregivers of the demented elderly referred to a psychogeriatric, geriatric or neurological service. The principal caregivers of 531 patients with mild to moderate dementia attending an outpatient cognitive assessment clinic were interviewed via a structured questionnaire that focused upon caregiver-related characteristics such as whether they were living with the patients, their feelings of burden assessed by the Zarit Burden Interview and patients were examined at baseline to evaluate their cognitive, behavioral and functional limitation. RESULTS: Logistic regression analysis showed that patients' characteristics (MMSE, behavioral problems, nutritional problems), caregiver's characteristics (female gender, number of tasks involved in caregiving, cohabitation) and the provision of medical services were independently associated with a high level of burden. In this study increased caregiver burden was related independently to increased levels of patient behaviour disturbance and cognitive impairment. However, neither the illness duration nor the functional disabilities in activities of daily living affected the level of burden. This may have relevance to appropriate interventions for informal caregivers.