Folk names of plants are the roots of traditional plant biodiversity knowledge. This paper mainly records and analyses the wild plant folk names of the Mongolians in the Ejina desert area based on a field survey for collection and identification of voucher specimens. The results show that a total of 121 folk names of local plants have correspondence with 93 scientific species which belong to 26 families and 70 genera. The correspondence between plants' Mongol folk names and scientific species may be classified as one to one correspondence, multitude to one correspondence and one to multitude correspondence. The Ejina Mongolian plant folk names were formed on the basis of observations and an understanding of the wild plants growing in their desert environment. The high correspondence between folk names and scientific names shows the scientific meaning of folk botanical nomenclature and classification. It is very useful to take an inventory of biodiversity, especially among the rapid rural appraisal (RRA) in studying biodiversity at the community level. Indigenous knowledge is the systematic information that remains in diverse social structures. It is usually unwritten and preserved only through oral tradition, and it refers to the knowledge system of indigenous people and minority cultures. Traditional knowledge of biodiversity concerns the names, uses, and management of plants and animals as perceived by the local and or indigenous people of a given area. Folk names of plants and animals are the roots of traditional biodiversity knowledge. Berlin has indicated a strong need for linking the scientific and folk systems of classification . ExampleIn pace with social change and development, the Mongols are changing from nomadic people into settlement residents. The knowledge concerning grassland ecosystems is vanishing gradually because the related knowledge is no longer useful to the Mongols who are settled down or engaged in farming or other economic pursuits. The Mongolians in Inner Mongolia have been influenced by the Chinese culture, e.g. in some areas Han Chinese words, including plant names, are more or less mixed up with the Inner Mongolians' spoken language. This may be leading to the Mongols forgetting traditional botanical knowledge related to the language of plant folk names and classifications.Both artificial and natural factors lead to degradation of the grassland and desertification. As a result, plant diversity that Mongolians traditionally named and used has decreased. The reduction of plant diversity may also lead to the extinction of the related knowledge of biodiversity. Thus it will be impossible to hand down to future generations. For this reason, collection and analysis of plant folk names of the Mongolians is extremely important.Ethnobotanical studies in Inner Mongolia have been carried out since the 1980s, having studied useful plants of herdsmen , folk noMongolian traditional knowledge of biodiversity includes aspects of folk nomenclature, and traditional use and management of regional biodiversity. In this paper, in accordance with the ethnobotanical collections of the Mongolian folk names of wild plants in the Ejina desert area, the relationship between folk names and scientific names are studied, and the structure of Ejina Mongolian folk botanical nomenclature is also analyzed.2, the altitude ranges from 820 m to 1400 m. This area has a temperate zone continental climate, with an average annual temperature of 8.3°C, and a mean rainfall of only 38.2 mm. The frost-free period in the area is 145 days  or ebes [grass] which indicates the life form, such as chagan bot, chagan ebes, honht ebes, huji ebes, narin ebes, sogtuu ebes, wumhei ebes etc. In this type of folk classification, a word bot or ebes serves as a taxon such as family or genus in scientific taxonomy. These types of names belong to productive complex primary names. Other complex primary names don't include a word to express a folk taxon, belonging to the productive complex primary name, such as botgon tabag, dalan tobqi, hulnai wumdagan, wusun hor, wuyet wulan, zherin deleng etc.A primary name is considered to be 'semantically unitary' which means that it is a single expression, even if composed of more than one constituent. Many primary names have just a single constituent, and they belong to simple primary names, such as wulan suhai (Tamarix ramosissima) and imaan suhai (Tamarix leptostachys) are formed from the simple primary name suhai, and xihir boya  and horen boya  are formed from boya. A word suhai serves as a folk generic and equals to the scientific genus Tamarix (Tamaricaceae). But a folk generic boya usually is used to name the plants which have fleshy roots, and it isn't specially appointed to a scientific genus. Among the plant folk names in the Ejina desert area, there are 10 folk generic names collected. The relationship between folk specific, folk generic and scientific species and family names can be seen in table Secondary names are formed from simple primary names by simply adding a modifier which further describes the plant. Among these types of names, simple primary names serve as a folk generic. For example, secondary names burgas was recorded in advance and based on the descriptions of the plant's characteristics and habitats specimens were collected afterwards by local herdsmen. The result of the identification of specimens shows that the scientific name of burgas is Salix cheilophila Schneid. Thus a folk name led to finding this species in this area for the first time.The high correspondence between folk names and scientific names shows the scientific meaning of folk botanical nomenclature and classification. Ejina Mongolians' folk botanical nomenclature and classification is an important part of their natural culture. This type of knowledge and culture has a great effect on their adaptation to the desert environment, utilization of plant resources and traditional biodiversity management on the community level. The collection and analysis of plant and animal folk names is very useful to the inventory of biodiversity, especially among the rapid rural appraisal (RRA) in studying biodiversity at the community level. Sometimes the folk names lead to finding new species records in a given area. In this study the plant folk name The field work for data collection and analysis were conducted by all authors. Manuscript preparation was by Khasbagan. All authors read and approved the final manuscript.


Dealing with pregnancy, childbirth and the care of newborn babies is a challenge for female asylum seekers and their health care providers. The aim of our study was to identify reproductive health issues in a population of women seeking asylum in Switzerland, and to examine the care they received. The women were insured through a special Health Maintenance Organisation (HMO) and were attending the Women's Clinic of the University Hospital in Basel. We also investigated how the health professionals involved perceived the experience of providing health care for these patients.A mixed methods approach combined the analysis of quantitative descriptive data and qualitative data obtained from semi-structured interviews with health care providers and from patients' files. We analysed the records of 80 asylum-seeking patients attending the Women's Clinic insured through an HMO. We conducted semi-structured interviews with 10 care providers from different professional groups. Quantitative data were analysed descriptively. Qualitative data analysis was guided by Grounded Theory.The principal health problems among the asylum seekers were a high rate of induced abortions , due to inadequate contraception, and psychosocial stress due to the experience of forced migration and their current difficult life situation. The language barriers were identified as a major difficulty for health professionals in providing care. Health care providers also faced major emotional challenges when taking care of asylum seekers. Additional problems for physicians were that they were often required to act in an official capacity on behalf of the authorities in charge of the asylum process, and they also had to make decisions about controlling expenditure to fulfil the requirements of the HMO. They felt that these decisions sometimes conflicted with their duty towards the patient.Health policies for asylum seekers need to be designed to assure access to adequate contraception, and to provide psychological care for this vulnerable group of patients. Care for asylum seekers may be emotionally very challenging for health professionals. Approximately half of the world's international migrant population - 95 million - is female.Among these migrants, female refugees and asylum seekers are among the most vulnerable. In addition to the hardships of forced migration, they suffer from problems due to their gender . After fHealth risk factors for refugees in general include trauma and economic difficulties. In addition, for asylum seekers, there is their uncertain residency status -11. In SThe most frequently observed health problems among asylum seekers relate to depression and post-traumatic stress ,15. In gWomen asylum seekers are also confronted with particular problems related to reproductive health. Many studies have been conducted in order to examine the impact of migration on reproductive health. The outcomes have been varied. A meta-analysis published in 2009 could not show a consistent marker for risk of poor perinatal health outcomes for women with an immigrant background .Studies on perinatal outcomes specifically for asylum seekers show inconsistent results: while a US study of pregnant asylum-seeking women reported increased obstetric complications , a BritiHowever, general assessments of female asylum seekers' or refugees' health are limited, due to there being few instruments which are validated across languages and ethno cultural groups .In general, little information is available to physicians, nursing staff and midwives regarding the specific health needs of asylum-seeking women. Physicians in Switzerland report that their training - both basic and postgraduate - has not prepared them adequately for caring for such patients ,26. DespThe aim of the present study was to investigate the reproductive health care provided for women asylum seekers attending the Women's Clinic of the University Hospital in the city of Basel, Switzerland. Our aims were to identify the health needs of asylum seekers attending the Women's Clinic and to investigate the health care they received in a Health maintenance organisation (HMO) specifically established for asylum seekers. In addition, we explored the perceptions of the health care professionals involved, about providing health care for this group in this setting.This study on women's reproductive health was embedded in a larger project examining health and health care provision for all asylum seekers enrolled in the specific HMO model ,29 of thWe combined quantitative and qualitative methods for data collection and data analysis. The quantitative part was observational, based on records from patients' files and the hospital database and covered the frequencies of diagnoses and medical interventions. The qualitative part included a study of the relevant information from the records in patients' files, and semi-structured interviews with health care providers and textual documents in the patients' files. We analysed the qualitative data guided by the analytic procedures of Grounded Theory .The study took place in the University Women's Hospital, Basel, which is part of the Basel University Hospital. From 2000 through 2003, 979 asylum seekers in the Canton of Basel-Stadt (Basel City) -approximately half of all asylum seekers in the Canton- were assigned to the specific HMO established at the Basel University Hospital. 38% of them were female (n = 375).This HMO was established specifically for the asylum seeking population. Health Insurance is mandatory for all residents in Switzerland, and people can choose between different insurance models ranging from a free choice in type of care to more restrictive  HMO models. Asylum seekers are insured through the Federal Office of Migration who allocates them to an insurance scheme. In response to a drastic increase in numbers of asylum seekers as a result of the war in former Yugoslavia in the 1990s, the Swiss government attempted to reduce health expenditure by limiting the asylum seekers' choice of where to seek care and assigning them to primary health care providers .The University Hospital in Basel, where the present study was carried out, therefore registered as a primary care provider, having established a HMO model specifically for the asylum-seeking population of its area . The UniA specialty of this hospital is its unit of Gynaecological Social Medicine and Psychosomatics . Physicians and psychologists working in this unit are trained in psychosomatics. The care offered to patients includes not only joint medical, psychosomatic and psychological care, but also assistance by social workers. The women's hospital also runs an interpreter service for migrant patients.The study group initially consisted of all the 88 asylum-seeking women who received treatment at the University Women's Hospital in- or outpatient clinics from 2000 through 2003. Eight patients had to be excluded from the analysis because their patient charts were missing, leaving a group of 80. Half (50%) originated from former Yugoslavia, the others came from Africa (19%), Asia (16%), Eastern Europe (9%), and other countries (6%). The mean age was 28 years (range: 19-60 years). Only two women were over 45 years, which means that most patients were of childbearing age. The majority of the women (64%) were married at the time of the study. 22% of all the women had never been married. Others were widowed or divorced, or had undocumented family status.Table Very little information specifically on the asylum-seeking history of the 80 women in our group was accessible to us. An analysis of the total population of asylum seekers enrolled in the hospital's HMO program at this time, concluded that on average, asylum seekers had to wait 1.7 years (maximum 11 years) from the day of filing a request for asylum until the day the decision was made by the authorities .Our sample of health care providers included members of the different professional groups involved in caring for the asylum seeking patients. There were 3 physicians, 3 members of the nursing/midwifery team, 1 psychologist and 3 interpreters. The people who were invited to participate were those who had been most involved with the asylum-seeking patients insured in the HMO model. They were informed about the study's purpose and signed a statement of informed consent. All the professionals invited agreed to participate.All the health care professionals were women. One physician and the psychologist were part of the team working at the unit of Gynaecological Social Medicine and Psychosomatics. They had the most intensive contact with the asylum-seeking patients, as these patients were often referred to this unit.For the quantitative part, we extracted data on asylum-seeking patients from the hospital's electronic database (socio-demographic and insurance data) and from the patients' files . All data were anonymised. For comparative analyses, we extracted data from the University Women's Hospital annual statistics (2000-2003) which documented services provided for the general patient population.For the qualitative part, we extracted textual data related to health situation and treatment, or to the asylum-seeking process, from patient files - for example, physicians' notes on consultations and referrals, and medical certificates issued for the asylum-seeking authorities. To ensure participants' anonymity specific details  were changed or omitted in the extracted text segments.Information from the health care professionals was obtained in semi-structured interviews, conducted in a quiet room at the hospital or at the university, as chosen by the participants. The interviews were based on an interview guide. Interviewees were encouraged to describe the experience of providing care for asylum-seeking women from both professional and personal points of view. They were asked about their own roles and duties in the HMO-model, about the health concerns of asylum-seeking women as opposed to other women seeking assistance at the University hospital, and about the possibilities and limitations, success and frustration they had experienced when caring for asylum-seeking women. In addition, the physicians were interviewed about their conflicting roles and responsibilities as clinicians, as manager of resources in the HMO, and as writer of certificates for the asylum process.  We used probes, like 'What possibilities did you have to help these patients? Which barriers did you experience? What did you consider to be your main duty in caring for the asylum-seeking women?' The interviews were 'audio'-recorded and transcribed verbatim.We used descriptive statistical analysis to evaluate quantitative data such as age, frequencies of diagnoses and interventions. Analyses were run using SPSS statistical software.For the qualitative analysis of transcribed interviews and textual extracts from the patient charts we followed the analytic steps suggested by Grounded Theory methodology. This qualitative approach offers tools to understand human interactions and social processes, taking into account the interdependences of macro-, meso- and micro-levels . To depiWe started the process by open coding, which means that we categorized text segments into broad categories or themes . We continued with axial coding which included examining relationships between categories and connecting them accordingly . Finally, selective coding included the organisation of the diverse categories into a framework to explain the phenomenon under study. This framework is depicted and explained in details in the result section.To strengthen the rigour of the analysis, we discussed the results with experts in women's health, ethics and research. Furthermore, we presented the findings to two participants from the health professionals' group and they judged that the findings mirrored their experiences.In part one of this section we review the main reproductive health issues identified among 80 asylum-seeking women and the care they received at the Basel University Women's Hospital. In part two, we detail the range of psychosocial problems encountered in the care of asylum-seeking women, looking at a) stress factors for patients, b) challenges in providing health care from the provider's perspective and c) support strategies for patients that were implemented.Information from the files of the 80 patients in the study showed that gynaecological diagnoses most frequently involved urogenital infections (41%), followed by lower-abdominal pain (25%), spontaneous abortions (8%), dysmenorrhoea (5%) and hypermenorrhoea/menorrhagia (5%). Eight files documented that patients had been raped. Of these sexual assaults, six had occurred in the countries of origin, and two in Switzerland.During the interviews, health professionals and interpreters often mentioned women who had been sexually assaulted in war situations. Any patient who reported such trauma was cared for by a female physician or psychologist from the University Women's Hospital's unit of gynaecological social medicine and psychosomatics.Of the 80 patient files, 55 (69%) documented contraceptive measures. The most commonly used contraceptive was the IUD , followed by oral ovulation inhibitors . Overall, 18 unwanted pregnancies were documented. Language barriers were also noted as a reason for women not using contraceptives. The cost of contraceptives, which are not covered by health insurance in Switzerland, was also identified as an obstacle to the use of adequate contraception among women whose resources were very limited, as illustrated in the following file entries:'The patient comes for fitting of an IUD. But the financing is unclear. Procedure: The financing is being clarified.' (File 16)'Has no money for the pill.' - [Entry 4 months later:] 'Surgical diagnosis: 24 years old, ninth week of pregnancy, does not want children. Operation: suction curettage, postoperative insertion of an Implanon [hormone releasing rod inserted in upper arm to provide continuous contraception] (File 25).spontaneous abortion (7 cases) and laparoscopy (4 cases). Other interventions were necessary only in isolated cases. Some types of situations in which asylum-seeking women decided on pregnancy termination are illustrated in the following file entries:The most frequent gynaecological intervention was induced abortion (18 cases), which occurred at a rate far higher than in the general University Women's Hospital population. Data from the 80 files screened yielded an abortion to live-birth ratio of 1:2.5, compared with the overall ratio of 1:7.5 in the University Women's Hospital . Induced'Patient wants termination of her pregnancy because of severe pain, 'cannot have a child', otherwise no exact reasons can be elucidated, she feels overburdened. History of a miscarriage in 2001, which occurred after a fall on a stairway [after interrogation by the police she was pushed into a dark room and fell down the stairs]. Two days later she miscarried and since then she has felt weak' (File 75).'No menstruation, unwanted pregnancy, the woman is returning [to the Balkans] to poor living conditions'. - [Three weeks later:] 'Surgical diagnosis: a 27-year-old patient who does not want children, with a psychiatric indication for termination of the pregnancy' (File 59).Past psychological trauma as well as worries about the future when sent back to the country of origin, were thus identified as some of the reasons for women asylum seekers to ask for induced abortion.The most frequently documented prenatal complications were premature labour (in 15% of pregnancies) and bleeding (11%), followed by gestational diabetes (9%) and retardation of intrauterine growth and anaemia (each 7%).Two-thirds of the 46 documented deliveries (67%) were spontaneous (see Table Table th and 37 th week of pregnancy). The general rate of premature babies for Switzerland is around 9%  as necessary'. No list was included of medical services to withhold from HMO patients. It was left to the judgement of each physician to interpret 'as much as necessary' with regard to everyday clinical practice.'From the way I see my task, it is in fact more a question of preventing duplications and redundancies, rather than just limiting them ....I would have been a bit concerned - and we have also discussed this - if I had in fact had the feeling that I now have to limit the care being provided. We of course always have to be careful that we do not somehow create a second-class medicine.' .Other interviewees also describe efforts to treat patients insured under the HMO model according to the same standards as patients with standard insurance coverage:'Not that one would have specially reduced any of the investigations. I can't remember that ever happening... In our clinic every woman gets what she needs.'  However, the physicians were aware that treatment of HMO patients 'should cost as little as possible.' Combining the three roles was demanding for the physicians involved:'These requirements differed: on the one hand to be the care giver, to be the patient's advocate in fact, and on the other to act as advocate of the Federal Office for Refugees, and thirdly to be responsible for the organisation, to save costs for the health insurance. But that is simply not possible.'  And: 'A lot was expected of me. [I had to know] all the things that I could do for asylum seekers, with some kind of certificate or something else. And it takes a lot of strength for one to be aware - to make oneself aware - of what one can offer and what one cannot offer. Working under these conditions was difficult. The problem of conflicting roles meant that beyond their normal commitment to the care of their patients, physicians had to make additional efforts to fulfil the tasks assigned through the government and the HMO model.Other members of the team caring for asylum seekers did not have to write certificates, but they too had to cope with various problems, including their own response to the patients' often tragic histories. An interpreter said:Maybe in the beginning it was so difficult because I would always translate for the same patients, who had survived the war. The entire hour they just cried and cried and cried. I remember a woman who had lost her 12-year-old girl during the war. She would say: 'they killed her in front of my house door' and then she cried and cried. Honestly, I would have preferred not to translate for this woman any more. Not because I did not like her but because it was so extremely draining .A certain amount of general emotional support was given by members of the health care team. In addition, we identified three types of more specific support provided mainly through specific teams.The most frequent measure for providing psychological care was referral to the University Women's Hospital's unit of Gynaecological Social Medicine and Psychosomatics. Fifty-three percent of participants needed some form of psychological care, which was provided on an outpatient basis by health professionals trained in psychosomatics. Patients received continuous care, supportive counselling and support in overcoming specific difficulties.'Earlier dreams were discussed. Has lost her family in [...]; she has still not come to terms with this. She has always been afraid. Now she is very exhausted. She tries to dispel the present images and to concentrate on something else' (File 25).To alleviate the symptoms of mental illness, psychotropic drugs were sometimes prescribed. The health professionals interviewed cited the successful collaboration between the psychosomatics team and the interpreters, along with extended consultations for psychosomatic patients, as favourable factors to provide adequate care for asylum-seeking women.Emotional support was also provided by members of staff outside the psychosomatics team to asylum seekers:She was in serious pain. When she saw me, she grabbed my hand and wouldn't let go. She said: Please don't go away, please don't go away' and cried. Because she was so happy to see me, I waited with her until the examination was over. I stroked her hair and said: "be calm, it will be all right". They did not find anything serious. The pain was due to a missed abortion. Asylum-seeking patients had a wide variety of problems beyond those that had led them to come to the clinic. The care providers consulted the hospital's Social Services department or contacted various authorities or organisations themselves. This support included improving housing conditions, financing contraception and special diets, creating a support network, and bringing families together.'The partner lives in [another region] and at present he is not permitted to live with Ms. [...]. It would be extremely helpful for the patient if her partner could live with her and support her at least during the pregnancy and for the first two to three months after the birth' .As part of the asylum process, the Federal Office for Migration required treating physicians to provide medical certificates concerning the asylum seekers' health. The physician had to judge the patient's ability to travel, and possible prognoses with or without continued treatment in case of a deportation to the country of origin. As an illustration, here is an extract from a medical certificate provided for the asylum authorities:Diagnosis: Pregnancy at risk. . Prognosis without treatment: Danger of miscarriage. Prognosis with treatment: Reduction of the danger of miscarriage. Ability to travel from the medical point of view: No. With a pregnancy at risk, travelling would be dangerous because of the stress due to the change of location (File 73).The principal health problems of the group of asylum seekers attending the Women's Hospital during our study were the high rate of induced abortions, and psychosocial stress symptoms. The latter were due to the experience of forced migration, the women's precarious situation in the host country, and their fears of an uncertain future. Up to 53% of patients required special care from a team specializing in psychosomatics.Staff found caring for asylum seekers emotionally challenging, and for the physicians there was the additional problem that they had to take on additional roles - writing certificates required by the asylum authorities, and allocating limited resources under an HMO model. They often felt that these activities were in conflict with their desire to provide support and the best possible care for this extremely disadvantaged group of patients.Despite the high level of medical care available in Switzerland not all the women had full access to adequate contraception. We found that there were problems owing to difficulties of understanding, and also financial hurdles. It is likely that in some cases the negative attitude towards contraception which was identified in a Danish study  as a risAnalysis of our data showed an abortion rate per conception 2.5 times higher than that of the local population. A Dutch study  shows a More than half of the women in our study group required special care from the psychosomatic team of the women's clinic, which emphasises how much they needed help in coping with many aspects of their lives. The trauma many of them had suffered in their homelands, the experience of forced migration, the difficult present situation in the host country, and uncertainty about the future, were the main psychosocial stressors identified.High rates of sexual assault before and after arriving in the host country are likely to have increased the need for support.The analysis of files indicated that the high rate of induced abortions was also connected to the women's socio-economic situation, in which some asylum-seeking women felt ill-equipped to care for a newborn child. For mothers of newborns and small children, various stress factors, including the lack of a familiar social environment, left them prone to exhaustion. Our results are supported by the study carried out by Zahorka and Blöchliger  who, in In this study we also asked health care providers about their experience of caring for asylum-seeking women, and whether they encountered any special problems. As in earlier studies on health care for migrants, health professionals described language barriers and the legal/social difficulties faced by asylum-seeking patients as challenges they were only partly able to meet ,41. We aAnalysis of the interviews with physicians confirms that for them, meeting their obligations towards their patients, while fulfilling the official requirement of issuing neutral and objective health certificates, was a cause of conflict. The possibility that physicians might support patients to the extent that they write deceptive certificates to improve patients' chances in the asylum process has been discussed in the literature . There iAnother stress factor for physicians was that the HMO model that provided insurance for the asylum seekers required that they should limit health care measures for these patients to doing 'as much as necessary'. In complying with this demand, health professionals felt they ran the risk of compromising their professional/ethical obligation to treat all patients equally, irrespective of their status or country of origin . In factThe strength of this study, which combined quantitative and qualitative approaches, lies in the cross-validation and better interpretability of results . A further strength was that the study population of asylum-seeking women comprised all patients getting gynaecologic and obstetric care who were insured in an HMO model which covered half of the asylum-seeking population of Basel, which is one of the largest Swiss cities. This sample can therefore be considered quite representative of the population of women asylum seekers in Switzerland during the time period of the study. The HMO setting did not allow medical consultations outside the study setting, so this potential confounding factor was absent.However, the results of this study have to be interpreted in the light of certain limitations. Some of these apply to the data on the distribution of health conditions. Retrospective analysis of patients' documentation may result in incomplete information. Small numbers and a short period of investigation did not allow analysis of rare conditions or changes over time, nor an in-depth analysis of pregnancy outcomes. Comparing findings with a standard group was limited to comparing with basic general hospital statistics available.A further limitation was that the method of collecting data about patients also did not give any information on their perceptions of their health needs and the care they received.Concerning the perspectives of health professionals, given the small numbers which were interviewed in each professional group, the findings may not reflect the entire range of professionals' experiences when providing care for asylum seekers. In addition, this study was carried out in a hospital setting where highly developed services provided by interpreters, social workers and psychosomatic specialists support care provision for asylum-seeking patients. In other settings, where such services are less developed, providing care for this group may be an even greater challenge for health professionals.Providing adequate care for asylum-seeking women is a challenging task for health care providers. Language barriers can be largely overcome by having the services of well-trained professional interpreters who should be available when needed. This is crucial both for the patients' sake and to avoid frustration in health care providers.Additional training and ongoing support for health care providers may also be necessary, especially when no health professionals specialised in the care of asylum seekers, in psychosomatics or in intercultural issues are available in an institution. Training and support are needed not only because of the emotional challenges resulting from the situation, but because the patients do not only need medical care, but very often suffer from severe psychosocial problems arising from the stressful situation they are in. They may have a wide variety of problems, ranging from financial limitations and the problems of coping with life in a new culture, to the stress resulting form the asylum process, and the traumatic experiences they underwent before they arrived in the host country.There was some evidence in this study that financial difficulties could prevent women from practising adequate contraception in a setting like Switzerland, where contraceptives have to be paid for and are not included in insurance schemes. This can potentially result in unwanted pregnancies followed by induced abortion. There is a good case for making contraception free of charge.Further studies of reproductive health in asylum-seeking women with a larger cohort would bring further insights into their needs, and help to optimise care and preventive measures such as contraception.An additional problem is that if the State system also charges health professionals treating asylum seekers with tasks unrelated to therapy, this may compromise the relationship between them and their patients. A solution would be the separation of therapeutic and non-therapeutic roles.Attention should also be paid to stressors that could potentially affect health professionals and their work: the need for support and training of health care providers caring for vulnerable populations should be investigated further. Special attention should be given to the needs of interpreters who may - through potentially sharing the same backgrounds and similar experiences as the patients - be emotionally particularly challenged. The effect on health care providers of working in a restrictive HMO setting, where they do not only have to carry out their traditional clinical tasks but must also cope with increasing managerial responsibilities and financial restrictions, may also warrant further study.Even in a country like Switzerland, with a high level of resources, policy makers' and professionals' ongoing efforts are required to ensure appropriate health care provision for asylum-seeking women and to meet their particular needs, especially concerning adequate contraception and psychosocial care. It is necessary to ensure that there is sufficient support for the health professionals involved, since care for asylum seekers may be emotionally very challenging for them.The authors declare that they have no competing interests.Study conception and design: EK, AB, EZ, ST. Coordination and implementation of the study: EK, AB, ST. Data collection: EK. Data management and analysis: EK, AB. Drafting of manuscript: EK. In-depth revision of manuscript, literature research and reevaluation of findings: FNJ. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/659/prepub


School-based breakfast provision is increasingly being seen as a means of improving educational performance and dietary behaviour amongst children. Furthermore, recognition is growing that breakfast provision offers potential as a means of addressing social inequalities in these outcomes. At present however, the evidence base on the effectiveness of breakfast provision in bringing about these improvements is limited.This paper describes the research design of a large scale evaluation of the effectiveness of the Welsh Assembly Government's Primary School Free Breakfast Initiative. A cluster randomised trial, with school as the unit of randomisation was used for the outcome evaluation, with a nested qualitative process evaluation. Quantitative outcome measures included dietary habits, attitudes, cognitive function, classroom behaviour, and school attendance. The study recruited 111 primary schools in Wales, of which 56 were randomly assigned to control condition and 55 to intervention. Participants were Year 5 and 6 students (aged 9–11 years) in these schools. Data were collected for all 111 schools at each of three time points: baseline, 4 month and 12 month follow-up. This was achieved through a repeated cross-sectional survey of approximately 4350 students on each of these occasions. Of those students in Year 5 at baseline, 1975 provided data at one or both of the follow-ups, forming a nested cohort. The evaluation also included a nested process evaluation, using questionnaires, semi-structured interviews and case studies with students, school staff, and local authority scheme coordinators as key informants.An overview of the methods used for the evaluation is presented, providing an example of the feasibility of conducting robust evaluations of policy initiatives using a randomised trial design with nested process evaluation. Details are provided of response rates and the flow of participants. Reflection is offered on methodological issues encountered at various stages through the course of the study, focusing upon issues associated with conducting a randomised trial of a government policy initiative, and with conducting research in school settings.Current Controlled Trials ISRCTN18336527 Many school children do not eat breakfast everyday: in a survey of year 6 children aged 10–11) conducted in the United Kingdom, 5% of children reported having not had anything for breakfast that day, 3% had only consumed a drink and approximately a further 10% reported eating crisps or chocolate for breakfast 0–11 cond-4 poorerA recent study amongst schoolchildren in Wales focusing upon associations between physical activity, dietary behaviours and obesity indicated that breakfast was the most commonly missed meal amongst all children, with obese children skipping breakfast on average twice a week, double the frequency of normal weight children . FurtherIn recent years, many efforts to facilitate change in dietary behaviours have been directed towards schoolchildren due to the capacity of such approaches to reach large numbers of children simultaneously ,15. HabiAppropriate manipulation of the school environment may offer an efficient and effective long-term means of improving the health of the population. Furthermore, if such intervention brings about sufficient dietary improvement to impact upon cognitive functioning and behaviour , this maRecognition of these potential benefits has led to a number of government funded school breakfast initiatives . These Nevertheless, there is evidence to suggest that school breakfast programmes can help improve nutrition and may also be associated with improvements in attendance, academic performance and behaviour e.g., ,25-28). -28. 25-2The Welsh Assembly Government's Primary School Free Breakfast Initiative arose from a Labour Party manifesto commitment to make free healthy breakfasts available to all maintained primary schools in Wales. This paper reports upon the design of a comprehensive national evaluation of this initiative, using a cluster randomised controlled trial design with a nested process evaluation, and discusses issues in the implementation of the evaluation design.The evaluation study comprised of two key components. In order to evaluate the overall effectiveness of the intervention, a randomised controlled design was employed. Randomised controlled trials (RCTs) are generally considered the most reliable means of assessing intervention efficacy . Since As the intervention was implemented at the school-level, randomisation of individual students to control or intervention groups was not practicable. As such the evaluation adopted a cluster randomised design with school as the unit of randomisation. A summary of this study design is presented in Figure The intervention provided a school-based breakfast before the commencement of classes, without any cost being borne by parents. The aim of the intervention was not only to encourage breakfast consumption per se, but to improve the nutritional quality of children's breakfasts. Hence a particular focus was placed upon limiting available food choices to breakfast items considered to be healthful. Provision was therefore offered from four food types: non-sugar coated cereals, bread, milk products and fruits, in addition to drinks. Schools were provided with guidelines regarding how the scheme should be run, in terms of staff to student ratios and the food to be provided, but were given a reasonable degree of autonomy in the operation of the scheme.The scheme was rolled out in two distinct phases by the Welsh Assembly Government, with initial priority given to schools in more deprived areas of Wales. As such, schools classified as 'Communities First' schools were eligible to receive the intervention initially before the scheme was made available to all schools the following year. At the time of writing, information about the scheme can be found on the Welsh Assembly Government's website .In autumn 2004, head teachers of infant, junior and primary schools located in 'Communities First' (i.e. deprived) areas in nine local education authorities (LEAs) in north, south and west Wales were invited to participate in the evaluation. Schools were offered £250 to compensate for additional teacher time and disruption to school activities. One hundred and fifty-two schools were approached and 58 schools agreed to participate. Reasons for non-participation were generally related to the running of the breakfast scheme itself (worries about implementing the new initiative and bringing forward the start date) rather than any concerns over data collection burden. Those that agreed to participate were randomised to the intervention or control condition using strata defined by LEA, school size, free school meal entitlement and Welsh language medium.Head teachers of infant, junior and primary schools located in 'Non-Communities First' (i.e. more affluent) areas, in the same nine LEAs were invited to participate in the evaluation. As before, schools were offered £250 to compensate for additional teacher time and disruption to school activities. This time, 456 schools were approached and 53 schools agreed to participate. Again, reasons for non-participation were generally related to fears about relinquishing control over the start date of the scheme, although a number of differences in reasons for non-participation unique to this phase of the study were identified (see response biases section of Discussion). Those who agreed to participate were randomised to intervention or control following the same methods of stratification as described above.For both phases, schools in the intervention group were asked to set up a breakfast scheme, following the guidance issued by the Welsh Assembly Government, after baseline measures had been collected. Schools in the control condition were asked to refrain from setting up a breakfast scheme until after the 12 month measures had been collected.In each of these 111 schools, following the timetables set out in Figure The quantitative measures employed in the evaluation aim to provide an accurate assessment of the impact of the scheme on children's dietary habits, cognitive performance, attitudes and classroom behaviour. As previously discussed, since the intervention is implemented at the school-level, randomisation has to take place at this level. As a consequence, relatively large numbers of participants are needed in order to detect any intervention effect. For such a trial to be feasible it is therefore important that the outcome measures employed are relatively quick, cost-effective and easy to implement. In an attempt to address the inevitable tension between measurement precision and sample size/response bias  our evaluation incorporated two levels of assessment. For dietary measurement, the study first used a less sensitive dietary recall questionnaire administered simultaneously to the whole class. Secondly, a subsample of children also participated in a validated, and much more time consuming, one-to-one dietary interview procedure.The following standardised, previously validated measures were used:Classroom administered cognitive tests were used to assess episodic memory, working memory, sustained attention and psychomotor speed -36. IndiThe Strengths and Difficulties Questionnaire  was compIndividually administered dietary recall interviews were used to provide a more accurate estimate of the impact of the initiative on children's diets. These interviews were conducted using a standardised protocol based on that employed by Lytle et al. .Due to a shortage of previously validated measures the following measures were developed and validated for use in the present study ,43:Children were asked to list all foods and drinks consumed at chronologically ordered time points throughout the day . Details of breakfast on the day of reporting  were collected first, followed by details of the previous day's intake . PrimaryAttitudes were assessed using a questionnaire containing thirteen statements referring to a variety of domains, such as concentration and behaviour, energy, and the general importance placed on breakfast. Children were asked to indicate the extent to which they agreed or disagreed with each statement by placing a tick in one of 5 boxes (agree a lot/agree a bit/don't agree or disagree/disagree a bit/disagree a lot) .The parental questionnaire contained 10 questions designed to assess children's breakfast eating habits. Five of these asked parents how many times on school days their child usually engaged in a particular behaviour . These were answered by placing a tick in one of 7 boxes (number of days ranging from 0 to 5 or 'Don't know'). Four questions asked parents how many times at the weekend their child usually engaged in a particular behaviour . These were answered by placing a tick in one of 4 boxes (number of days ranging from 0 to 2 or 'Don't know'). An additional question asked parents to rate the frequency with which they thought their child ate a healthy breakfast. This was answered by placing a tick in one of 5 boxes ranging from 'My child always eats a healthy breakfast' to 'My child rarely eats a healthy breakfast'.Since there are a range of outcome measures, sample size requirements were calculated using effect sizes. Sample size calculations assume an intra-cluster correlation of 0.02, 80% power, and a two-tailed alpha of 0.05. With 111 schools in the trial, for pupil outcomes from the self-complete questionnaire, assuming an average of 50 responses per school, there will be power to detect an effect size of 0.11. For parent reports of breakfasting behaviour, assuming 20 responses per school, there will be power to detect an effect size of 0.15. For pupil outcomes from the dietary recall interviews, there will be power to detect an effect size of 0.2.Parents were informed of the research in advance by means of a letter and information sheet either posted to them or sent home with children, and were asked to complete a return slip and/or contact the school if they did not wish their child to participate in the study. At each data collection, children were also informed that they were under no obligation to participate. The study received ethical approval from the Cardiff University Social Science Ethics Committee.Cognitive tests, the attitudes questionnaire and the dietary recall questionnaire were completed between 9 am and 12 pm as supervised classroom exercises with a maximum class size of 40 children. For the attitudes questionnaire, to minimise conferring and ensure that children worked at the same pace and did not distract one another, the researcher read out the statements one by one and children marked their response for each statement after it was read out. For the dietary recall measure, the researcher read out the instructions and asked children to complete the questionnaire independently from one another. Children were asked to put their hands up when they had finished or if they needed help with spelling, or further clarification of questions. Three members of the research team were present to assist children.As described above, at baseline and 12-month follow-up only, 3–5 children from each year group (e.g. year 5 and 6) were selected to complete individual tests between 12:30 and 3:30 pm . These were conducted on a one-to-one basis with one researcher guiding each child through the computerised cognitive tests and the dietary recall interview.Schools were divided between key members of the research team, and each key researcher was responsible for all liaison with their assigned schools, and held principal responsibility for data collections. Two trained temporary research assistants were also brought to each school at baseline and 12-month follow-up, to provide general assistance with group testing and to conduct individual testing in the afternoon. For the first follow up, only one assistant was required as only the morning's group testing was carried out. All temporary research assistants were fully trained and monitored by the key researchers in order to maximise standardisation across the trial sites and data collection sweeps.a priori defined as tertiary outcomes, including cognitive measures other than episodic memory, the total difficulties score on the strengths and difficulties questionnaire, parental reports of morning routines and child care arrangements before school and variables collected from the individually administered in-depth dietary recall and cognitive measure interviews.There was no one primary outcome, but a pre-specified analysis plan was agreed in which the following were identified as primary outcomes: the proportion of students consuming two breakfasts over two days; episodic memory; number of healthy food items consumed at breakfast and number of unhealthy food items consumed at breakfast according to the dietary recall questionnaire. Secondary outcomes were identified as attitudes towards eating breakfast; rest of day healthy food items; rest of day unhealthy food items; scores on the hyperactivity/inattention scale of the strength and difficulties questionnaire, and parental reports of frequency of eating breakfast at home and at school. A number of other outcome measures were For each outcome variable, the primary analysis is a school-level weighted regression analysis  adjustinSub-group analyses are planned for study phase, socio-economic status and groups defined by consumption of breakfast, healthy and unhealthy food items at baseline. Socio-economic status will initially be defined in terms of a school level variable indicating the proportion of students entitled to free school meals, but through further data linkage it is planned that student level socio-economic measures based on postcode of residence will be available. If this additional data linkage is undertaken, it will also allow the performance of students in Statutory Assessment Tests and public examinations to be included as additional (secondary) outcome variables, although this is not included in the current protocol as it is dependent on ethical approval and funding. Other sub-group analyses may be conducted according to variables identified in the process evaluation, which may include measures on the implementation of the scheme or relating to the school and community context.Whilst recognising the need to adopt appropriate research designs and to draw on theoretically informed outcome measures to evaluate complex interventions, it is of equal importance to understand processes . The evaAn initial preliminary process evaluation was also completed with schools who began provision of free breakfasts during the first wave roll out in September 2004. This consisted of telephone interviews with the Welsh Assembly Government breakfast team, LEA co-ordinators and questionnaires with school based co-ordinators. In addition, a number of case study schools were selected for an in-depth observational and interview study with teachers, caterers and students. This preliminary study allowed process measures and an appropriate design to be developed and piloted before the main process evaluation was undertaken. Results also formed the basis of a report to the Welsh Assembly Government on the initial implementation with recommendations for policy and practice .The main process evaluation consisted of telephone interviews with LEA co-ordinators, a postal questionnaire for school co-ordinators of the scheme and interviews and observation in case study schools. Following lessons learnt from the preliminary study, the process evaluation drew on the framework proposed by Steckler and Linnan  to exami1. Context. Existing dietary health promotion activity to determine the relationship between school climate, implementation and outcomes .2. Fidelity and dose. Details of initiative content and a comparison of daily record keeping for the Assembly Government and for guidance documentation.3. Integration. Details of existing, and any changes to, school policies and the level of integration with curriculum and extra-curricular activities.4. Recruitment, participation and reach. Approaches to promotion and recruitment, any use of targeted recruitment, level of, and explanation for, participation and non participation.5. Implementation and sustainability. Barriers and facilitators to implementation, level and type of staff involvement, level and type of parental involvement, in and out of school time involved, direct and indirect financial costs, benefits and costs to school, staff, students and parents.The case study schools consisted of eight participating schools from each phase of the evaluation that were purposefully selected to explore these issues in greater depth. Schools were chosen so that differences in size of school, local education authority, setting  and percentage of free school meal entitlement were reflected. School selection was determined by information gathered from the teachers, uptake records and school characteristics. In this way a range of approaches to, and experiences of, implementation were examined. In these schools, semi-structured interviews were conducted with head teachers, teachers, breakfast scheme staff and students attending the scheme. The interviews asked for accounts of any changes to the school, dietary behaviour, school behaviour, attitudes and norms as well as views on, and experiences of, the initiative and its implementation. Breakfast schemes were observed in each of the case study schools with observational records taken of the delivery of the intervention.Finally a questionnaire was sent to head teachers in all participating schools asking about policies, initiatives and contextual issues that had occurred over the course of collecting the quantitative data. In this way, events that may have affected the outcome data could also be taken account of.Of the schools where baseline data were collected, no schools withdrew from the study prior to final data collection. There were however five schools randomised to the control group who nevertheless set up a free breakfast scheme prior to the 12-month follow up, while ten schools randomised to the intervention group had not set up the scheme within the follow-up period. Thus the per protocol analyses have 61 schools coded as control schools and 50 as intervention.Response rates for students participating in classroom data collections are presented in Table For both control and intervention schools, and across all 3 data sweeps, data were collected from more than 85% of those eligible to take part, with the majority of non-participation due to the child's absence from the school on the day of testing. Only very small numbers of children were excluded either by parents prior to data collections or by their decision not to give consent on the day of testing. The variation between the numbers of children sampled at each sweep reflects the clustered nature of the sampling strategy, with repeated cross sections sampled from within each school, varying marginally from one time point to the next due to changing class compositions.The flow of participants through the study is presented in Figure A number of key issues arising from this, and similar, evaluations are likely to be of interest to those attempting to undertake similar work. Developing and maintaining an effective working relationship with schools is crucial to a project involving such long-term commitment and intrusion into their operation. Related to this, efforts to minimise attrition rates are crucial. Further potential difficulties arising from attempting to align a research timetable with an externally defined policy timetable include response biases and contamination. A number of ethical and operational issues surround gaining consent from students and parents and the undertaking of data collections in primary schools settings.It is important to remember that schools' involvement in a large-scale trial such as this requires significant voluntary co-operation and commitment from a group of professionals with many conflicting demands and priorities. The trial of the Primary School Free Breakfast Initiative required both a considerable relinquishment by schools of control over when to set up the initiative, and a commitment to participate for a period of over one year. Given these concerns, the importance of maintaining a positive working relationship with schools is paramount. Principles for maintaining such relationships are laid out by Peterson et al , includiThese principles were followed throughout this trial from recruitment onwards. Once the schools expressed an interest in taking part, a research team member visited the school and discussed any concerns that they may have, before the head teacher either agreed to set up the scheme or withdrew interest. This meeting was intended to ensure that schools were fully informed and aware of their commitments as participants, as well as providing an opportunity to address any concerns. Some considerable work on the part of the schools was required, in terms of for example completing questionnaires and twice labelling 35 parental questionnaires with addresses (as we could not ask for these addresses ourselves due to data protection restrictions). Hence, it was important to make clear from the outset exactly what was expected, and that the payment for taking part was our way of expressing gratitude for this dedication.This visit, from the research team member who would be leading data collections in that school, helped to humanise the project, providing the school with a contact person for any concerns regarding the study. Where possible, this contact remained constant throughout, though in many cases this was not possible due to staff turnover. For schools wishing to participate, contact details were provided for an LEA representative to speak to about operational issues surrounding the scheme. Over the course of the following year, the research team maintained regular contact with schools, sending newsletters to keep schools up to date with the trial's progress and thanking them for their involvement.Whilst issues surrounding attrition may arise from the relationship developed between schools and the research team, in the context of evaluating an initiative such as this one, where schools are asked to relinquish control of start dates for an otherwise available initiative, external pressures and difficulties may arise for schools at a later date which influence their ability to fulfil these obligations. These need to be dealt with sensitively on a one-to-one basis.Whilst no schools refused to allow researchers into the school to collect all three rounds of data, a number of intervention schools experienced significant difficulties in setting up the scheme and ten were unable to set-up prior to follow-up data collections. All LEAs were informed which schools were in the control condition and were advised that these schools had agreed not to set up until after 12 month follow up. However, a number of control schools experienced external pressures from parents and other sources to set up the scheme earlier than agreed, which they felt unable to resist. In these instances, the research team attempted to either negotiate with schools to wait until the agreed date, or if such an agreement could not be reached, data collections were brought forward to a slightly earlier date to allow set up to take place earlier. In five cases, schools set up the scheme before these measures could be put in place. Data were still collected from all schools thus allowing intention to treat and per protocol analyses to be undertaken.Response biases, whilst likely to be minimal at the individual level due to the high rates of participation amongst children, may occur at the school level. Schools choosing not to set up the breakfast scheme may differ systematically from those recruited to the trial. Furthermore, as the intervention was to become available to all schools regardless of their participation within the trial, those wishing to set up the scheme but choosing not to participate in the evaluation may also differ from evaluation study participants. Data were routinely collected on school characteristics such as size, deprivation levels  and language of teaching. These were used as criteria for stratified randomisation and will be used to establish representativeness.Factors relating to the timing of intervention implementation may have impacted upon responses, and there were a number of contrasts between the first and second phases of the evaluation in terms of these issues. As discussed, the manifesto commitment underpinning the initiative's rollout ensured that it would become available to all schools in due course. However, in the first phase (Communities First Schools), participation in the trial provided the prospect of starting the intervention earlier than general roll-out. By contrast, in the second phase (Non-Communities First schools), the initiative began to be rolled out to non-participating schools as the evaluation began, and hence schools who strongly wished to set up the scheme in their school were perhaps likely not to take part in case they were assigned to the control condition and were required to wait a further year. Furthermore during the second phase of the study, some head teachers appeared anxious to set up the initiative as soon as possible, with many nearby schools having already established the scheme. Breakfast provision was seen by some as a factor which influenced parental choice of school, hence impacting upon school numbers. Conversely, some heads, having observed the experiences of others, had made the decision not to set up the scheme in their school. Reasons for non-participation have been collected wherever possible, and these will be used to explore such issues in greater depth.Issues surrounding the provision of information and awareness of the scheme amongst control schools cannot be overcome in the context of such a large-scale evaluation of a high profile government initiative. However, to minimise contamination, schools in the control arm of the intervention were asked not to partake in any form of marketing for the scheme until after final follow up data were collected. In a number of instances, the Welsh Assembly Government distributed promotional information to all Welsh primary schools regarding the initiative. Efforts were made to ensure that this information was not distributed to schools within the control arm.Consent for participation in the trial was sought at three levels. Firstly, consent for the schools participation was sought in the form of a signed agreement between headteachers and the research team. Secondly, consent was sought from parents. Rather than written, opt-in consent which is the established practice in clinical trials, a standardised information sheet was sent to all parents accompanied by a letter requesting that the parent contact the research team or school prior to data collection, should they wish to exclude their child from the study. Passive, opt-out consent is favoured over opt-in consent in order to ensure high response rates and minimise response biases, and has been described as an ethical and appropriate way of informing parents of 'low-risk' research .The third and final level of consent was sought from children themselves on the day of data collection. Prior to any data being collected, procedures were described to children and children were all asked whether they were happy to take part, and it was made explicitly clear that they were under no obligation to if they did not wish to do so. This combining of parental and child consent has been used effectively in similar school-based cluster-randomised controlled trials .A number of important issues arise in collecting data in a school setting. As with any form of work with children, child protection issues are paramount, and as such, all data collections were conducted by lead researchers who had been cleared by the Criminal Records Bureau, accompanied by one or two assistants. This small team of researchers would remain together throughout the day, with no single person ever left alone with individual children or groups of children.Secondly, issues of confidentiality must be dealt with effectively, which is inherently difficult in the context of a trial where it is desirable to match children's responses at baseline and follow-up, and as such names are required. All eligible children's names were provided by schools prior to data collections, and entered into a secure password-protected database alongside their individual participant number. This number appeared at the top of all questionnaires distributed to children, and in all data files where the child's responses were entered. At no point was any child's data ever entered alongside their name, and the database of names and participant numbers was used to ensure that the child was given the same identification number at baseline and follow-up.Thirdly, in order to maximise participation and engagement, methods had to be as child-friendly as possible. As recommended by Petersen et al. , data weResults of this study will be disseminated in a report to the Welsh Assembly Government once all data has been coded, entered, accuracy checked and analysed, and will also appear in a number of academic journal publications. In the meantime, it is hoped that the description offered in this paper is of use to those concerned with the development of further evaluations of similar school-based initiatives.The author(s) declare that they have no competing interests.Principal responsibility for study design was assumed by LM, SM and KT. KT and SM project managed. GM was primarily responsible for day-to-day running of the quantitative side of the evaluation and RL was primarily responsible for day-to-day running of the qualitative process evaluation. GM drafted the manuscript, integrating substantial written contributions from KT. LM conducted sample size calculations. LM and CD designed the analysis plan. JH and CR were responsible for developing the initial research specification and for input into the study design. All authors read and commented on drafts and approved the final manuscript.The pre-publication history for this paper can be accessed here:


One reason for monitoring social inequalities in health is to evaluate whether the health effects of social or public health policies may differ by social position. The paper in this issue by Much more could be said about the positive aspects of this study (and the authors larger body of work on cancer surveillance) than its limitations, but a few methodological points are of interest. First is the issue of inequality measurement. Rachet and colleagues present only information on the survival trends of the most- and least-deprived quintiles of the population, which ignores the 60% of the population in the middle deprivation categories. One could argue that estimating the gap between the upper and lower quintile provides a legitimate summary of the extent of socioeconomic inequality, but knowing what's happening to the rest of the population also matters, as different patterns may be hidden by the same high-low gap, and may suggest different strategies for reducing inequalities. It is important to know, for example, whether the deprivation gap primarily results from a graded association between deprivation and survival, from an advantaged group that is doing considerably better than the rest of the population, or from a disadvantaged group that is doing considerably worse that the other 80% of the population. One could argue that the latter case may suggest a more troubling situation, if this indicates inadequate or lack of timely treatment , but it could potentially lead to underestimation of socioeconomic inequalities in survival. In the United States, for example, most cancer mortality gradients are considerably steeper when measured using individual rather than area-based socioeconomic indicators , it may Third, it's worth emphasising that the estimates presented by Rachet and colleagues are model based, and thus subject to modelling assumptions. For good reason they attempted to estimate period-specific linear trends to isolate pre-Cancer plan, post-initialisation, and post-implementation differences. However, it's not clear whether this particular periodization provides a good fit to the data . Commendably, they also experimented with a more flexible modelling strategy, but I disagree slightly with the authors that the trends and conclusions are identical using the two strategies. For example, using linear models Figure 2B supports their conclusion that the deprivation gap widened between 1996 and 2000 and then declined post-cancer plan, but the supplementary graph using a more flexible methods shows that the trends were constant over the entire period of study, and no change in inequality by period is evident. In the supplementary web table, the estimate of the change in the rectal cancer survival gap among women from 1996 to 2006 is a 0.7 percentage point increase in the gap when using a linear model, but a 0.8 percentage point decrease in the gap when measured using non-linear regression . Similar differences in both the magnitude and the direction of change of the deprivation gap using linear versus non-linear models are evident for a number of other cancers . In short, although the modelling scheme may lead to generally similar conclusions for all cancers combined, for several specific cancers the results seem quite sensitive to model specification.These methodological issues notwithstanding, I am inclined to agree with Rachet and colleagues that there is little evidence that the NHS Cancer Plan has yet to reduce inequalities in cancer survival. Very few of the estimates of the annual change in the deprivation gap for specific cancers for any one of the authors’ phases of the NHS plan statistically exclude zero , and it seems unlikely that tests of whether the annual change differs between pre- and post-phases (arguably a better test of whether the plan is working) would show any effect. However, my view of the overall secular trend is somewhat more positive than that of the authors. If one ignores the potentially artificial designation between initialisation and implementation and looks at the entire period from 1996–2000 to 2004–2006, the results in Table 2 suggest that 21 of the 35 cancer-gender combinations are at least going in the right direction , though they are imprecisely estimated and may also reflect ceiling effects. Furthermore, inequalities in 1-year survival have improved for cancers with good prognosis for both men and women, and 3-year survival inequalities for both good and poor-prognosis cancers have improved for women. Rachet and colleagues are correct that this is no cause for celebration, as the magnitude of survival inequalities remains far too high to the disadvantage of poor areas, but one could nevertheless read these results as showing at least some progress toward success. This progress, however, seems largely the result of continued improvements in cancer survival for all social groups that have been occurring since at least the mid-1980s rather than the direct result of the NHS Cancer Plan. It may still be too early to tell whether the plan will ultimately succeed in reducing inequalities, but finding out will require the continuation of high-quality monitoring studies like that of Rachet and colleagues.


Cutaneous leishmaniasis can be caused by several Leishmania species and is transmitted to human beings and animals by sand flies, Down syndrome is known to cause immunodeficiency that might lead to increase the susceptibility to infection with Leishmania.Up to our knowledge this is the first case of isolated facial cutaneous leshmaniasis in association with Down syndrome.A 2 month old Saudi Arabian male infant was admitted in the pediatric ward of maternity and children's hospital, Buraidah, Kingdom of Saudi Arabia for the management of multiple ulcers on his face, two ulcers were big and were surrounded by edema, causing severe disfigurement. This disfigurement caused difficulty in recognizing the facial feature of Down syndrome. The presence of hypotonia, microcephaly, low set ears, bilateral simian creases and wide separation between big toe and other toes directed us to request karyotyping. The result of karyotyping confirmed the diagnosis of Down syndrome.Children with Down syndrome are immunodeficient, they have been reported to have a complex of immunological alterations which might lead to increased susceptibility to infection. Leishmaniasis consists of a group of diverse diseases that affect viscera, skin, and/or mucous membranes with a wide spectrum of clinical activity caused by vector-borne, obligate, intracellular hemoflagellates of the genus leishmania. Three major clinical syndromes are recognized: visceral, cutaneous, and mucocutaneous leishmaniasis. The clinical manifestations of leishmaniasis appear to depend on a complex set of factors, including tropism and virulence of the parasite strain and the susceptibility of the host that may be genetically determined .The true incidence of leishmaniasis is not known. However, the World Health Organization (WHO) has estimated that 350 million individuals are at risk and that the disease is endemic in more than 80 countries. The estimated incidence of visceral leishmaniasis is 500,000 cases per year, and for cutaneous leishmaniasis and mucocutaneous leishmaniasis, it is 1.5 million cases per year. Although the parasite most commonly is transmitted via the bite of the sand fly vector, it may be transmitted also as a result of a laboratory accident, direct person-to-person transmission, and blood transfusion. In addition, there is evidence that it may be transmitted either in utero or during the peripartum period.Cutaneous leishmaniasis can be caused by several Leishmania species and is transmitted to human beings and animals by sand flies. In endemic countries, diagnosis is often made clinically and, if possible, by microscopic examination of lesion biopsy smears to visually confirm leishmania parasites as the cause. The use of more sophisticated diagnostic techniques that allow for species identification is usually restricted to research or clinical settings in non-endemic countries. The mainstays of cutaneous leishmaniasis treatment are pentavalent antimonials, with new oral and topical treatment alternatives only becoming available within the past few years; a vaccine currently does not exist. Disease prevention and control are difficult because of the complexity of cutaneous leishmaniasis epizoology, and the few options available .A two months old Saudi Arabian male infant was admitted to the pediatric ward of maternity and children's hospital, Buraidah, Kingdom of Saudi Arabia for the management of multiple ulcers on his face. The ulcers was observed by the parents at the age of one month and progressively increased in size with no history of fever. He was the third child of healthy unrelated boduin Saudi Arabian parents, the mother's age was 35 and the father's age was 40. There was no history of perinatal or postnatal complication. The child was delivered in a tent in the desert where his parents live.On physical examination, there was severe disfigurement of the face with 3 crusty ulcers Surrounded by a notable erythematous reaction, the biggest one presents on the right cheek and measures 2 × 2 cm. The second ulcer presents on the right lower eye lid and measures 1 × 1.5 cm. The third ulcer presents on the forehead and measures 0.5 × .5 cm  were within normal limits. Histopathologic examination of the ulcers' sections stained with hematoxylin and eosin showed a superficial reticular dermis occupied by large pale histiocytes with leishmania. With the Giemsa stain technique multiple leishmania were seen confirming the diagnosis of cutaneous leishmaniasis. After the diagnosis of leishmaniasis, sodium antimony gluconat was administered intravenously along with other antibiotics, the condition started to improve but unfortunately after two weeks of treatment the child was discharged from the hospital under the request and insistence of his parents. The parents were seeking cautery treatment for the ulcers which is a common practice in the Kingdom of Saudi Arabia; the parents refused all medical advices to continue the treatment in the hospital. The child was discharged and was never seen again.Up to our knowledge this is the first case of isolated facial Cutanenous leshmaniasis affecting the face of a Down syndrome infant. The age of our case is the youngest age affected with cutaneous leishmaniasis in literature.Ferreli et al reported an atypical leishmaniasis involving the inferior lip of a 57-year-old female with Down's syndrome at the Dermatology Department of Cagliari  .Children with Down syndrome are immunodeficient , they haCell-mediated immunity appears to be a major factor modulating leishmania infection . LymphopAlthough cutaneous leishmaniasis does not cause mortality, the cosmetic disfiguration, prolonged period of lesions, great expense of treatment, and side effects of available drugs, it has created many problems . In our Previous descriptions of the disease indicated that extremities were more often involved in cutaneous leishmaniasis than the face ,17. ThisThe presence of multiple skin lesions on the face of our case may be attributed to the fact that a sand fly, because of its physiologic characteristics, bites the host more than one time, and from every area of the bite, parasites enter the blood .Children with Down syndrome are immunodeficient, they have been reported to have a complex of immunological alterations which might lead to increased susceptibility to infection.Written informed consent was obtained from the parents of our patient for publication of this case report and the accompanying images.The authors declare that they have no competing interests.KA & HS carried out the patient diagnosis, investigation, follow up and management. AAA-E carried out general coordination, drafting of the manuscript, writing the final manuscript and provided important suggestions. All authors read and approved the final manuscript.


Selection potential based on differential fertility and mortality has been computed for seven population groups inhabiting different geographical locations of Northeast India.Crow’s as well as Johnston and Kensinger’s index have been used for the present purpose.Irrespective of the methodology, the total index of selection was found to be highest among the Deoris followed by the Kaibartas. The lowest selection index was found among the Oraon population. If the relative contribution of fertility and mortality components to the total index is considered to be multiplicative, it is observed that in all these communities the fertility component exceeds that of mortality component, which may indicate initiation of demographic transitional phase in the selected populations with the betterment of healthcare and socioeconomic condition within the last few decades. Natural selection is one of the major evolutionary forces that bring about changes in the gene frequencies in a population through the action of differential fertility and mortality over generations. Differential fertility and mortality are the basic events of natural selection, which operate singly or jointly to determine the fitness of a particular population in a given environment. Crow2]  2] devis6In the present study, the total index of natural selection is worked out to focus on the opportunity of natural selection among seven endogamous population groupsof Northeast India. The population groups thus studied have different ethnocultural histories and have different socioeconomic backgrounds.The materials for this study consisted of 196 women belonging to seven different ethnic communities of Northeast India. Seven villages, where the studied population groups live homogenously, were visited. A detailed demographic account of the investigated villages was collected. A total of 72 Deori, 27 Manipuri Meities, 24 Garo, 19 Oraon, 15 Kaibarta, 16 Assamese Muslim, 23 Tai-Khamyang evermarried women who had completed their fertility period were interviewed to get the relevant information for this study. An interview schedule was designed and was used to get the detailed reproductive history of these women. The information was later checked with their husbands and elderly members of the family. Crow’s indices Crow’s index can be computed by using his formula  and the modified one that includes the prenatal losses . The computed procedures are given below.Crow’s index:I is the index of total selection intensity, Im the index of selection due to mortality, Pd the probability of deaths up to prereproductive age, Ps the probability of survival upto reproductive age, If the index of selection due to fertility, V the variance due to fertility, and X is the mean number of live births.where Johnston and Kensinger’s index:I is the index of total selection intensity, Ime the index of total selection due to prenatal mortality, Ped the probability to die before birth, Pb the probability to survive till birth, Imc the index of total selection due to postnatal mortality, Pd the probability to die before reaching reproductive years, Ps the probability to survive till reproductive age, If the index of selection due to fertility, V the variance due to fertility, and X is the mean number of live births. Pd and Ps are calculated based on prereproductive deaths.where A brief descriptive account of the studied population groups has been provided below.Khels among the Deoris, viz., Tengapania, Borgonya, Dibongia, and Patorgonya. Each one derived its name either from a particular place or river. The last group has reportedly become extinct. Each of these divisions is again divided into a number of exogamous clans Bansha or Phoidya. Each group has certain distinctive features which help it to maintain its own identity. Nowadays, the Deoris are found in North Lakhimpur, Dhemaji, Tinsukia, Sibsagar, Jorhat, and Sonitpur districts in Assam, while in Arunachal Pradesh they are found in places like Mahadevpur, Tezu, Namsai, Sumpoi, Mohong, Dharampur, etc. The Deoris are Hindus by religion and the followers of Balia Baba, an incarnation of Lord Shiva. This study had been conducted in Mahadevpur Deori village situated in the eastern side of Namsai, the head quarter of Lohit subdivision, Arunachal Pradesh. The villagers belong to the Tengapania group of Deoris.The Deoris constitute one of the distinct tribes of Assam. Linguistically, they belong to the Tibeto-Burman linguistic family of Mongoloid stock. There are four great territorial groups or The Meities are predominantly settled in the central valley of Manipur, a small state of India situated in the northeastern corner of the country. Their settlements have also been reported from other states of India like Assam, Tripura, and Uttar Pradesh. The MeitThe Garo is a major matrilineal tribal population of Northeast India inhabiting mostly the Garo hills district of Meghalaya. A small section of them is also found to be scattered in different places of Assam. They call themselves as ‘Achik-mande’ which literally means ‘Hill man’. Ethnically, the Garos belong to the Bodo group of Tibeto Burman linguistic family. They call their dialect ‘achik kusik’ which literally means ‘voice of the hills’. Data for the present investigation were drawn from Poschim Bosti, a village homogenously inhabited by Garo people. They were generally brought into the present village by the British for various reasons, one of which was for cutting the forests for tea gardening. The people of the village are Christians by religion and cultivation is their main source of livelihood.The Oraon is a Dravidian speaking tribe. According to some authorities, the tribe is broadly divided into five subtribes and they are known as Berga Oraon, Dhanka Oraon, Kharia Oraon, Khendro Oraon, and Munda Oraon. Besides, there are a number of exogamous clans in each group. At present, their principal settlement is Ranchi district of Jharkhand. They are also found in Bihar, Madhya Pradesh, Orissa, West Bengal, and Assam. In Assam, the Oraons were brought by the British as a labor group for the tea gardens. Now they constitute one of the major tea garden labor populations in Assam. In Assam, they used to call themselves as ‘Urang’. Most of them are attached to the tea industry but with the passage of time they are also found to be attached to various other livelihoods. The data for the present work were collected from Tingkhong Tea Estate of Dibrugarh District, Assam. The work was confined to an area inhabited by Oraon community only.The Kaibarta is a scheduled caste population of Assam. They prefer to live on the river banks or near the sources of water where fishes are available. Their main traditional occupation is fishing. Though cultivation of paddy is also a subsidiary source of livelihood, they prefer their traditional occupation. Most of them earn their livelihood by selling fish. Womenfolk take active part in their traditional occupation. In the Assamese Hindu society, the Kaibarta occupies the lowest position in the caste hierarchy. This study was conducted in the Uppor Nazira Kaibarta village under Sibsagar district of Assam, which is 12 km away from Sibsagar town.th century Muslim saint who came from Baghdad. All the three sets form endogamous groups among themselves and prefer to marry among themselves. The people for this present study belonged to the Garia sect and were concentrated homogeneously in the Uppor Nazira Muslim village under Sibsagar district. The village is 12 km away from Sibsagar town.In Assam, Muslims constitutes the second largest of the mass. As per the historic records, the present day Assamese Muslims are the descendents of three different Muslim groups. One of t13th century. Mung means ‘a country’ and Kong means ‘a special king of drum’ called Dhakdhol. Linguistically, they belong to the Tai-speaking group and they are Buddhists of the Teravada school of religion. Earlier, they used to interact among themselves through Tai or Pali dialect. But later, when they came into contact with the local autochthons after migrating from their original abode, they gradually adopted Assamese as their language for conversation. Though they reside with the neighboring people, they still preserve their traditional cultural peculiarities like dress pattern, food and drink, fairs and festivals, clan organization, etc. This study was conducted in the Cholapathar village in Sibsagar district. Agriculture is their main source of livelihood; however, they are also found to engage themselves in other public as well as private jobs.Tai group is one of the significant elements that entered Assam in the historic past. The Khamyangs or Khamjangs who are popularly known as ‘Shyams’ is a section of the great Thai or Tai-stock. They had their independent principality in Mungkong till the end of the 18The mean number of live births along with its variance and other relevant parameters to detect the selection intensity among the seven population groups is shown in Z score values for intergroup variability with regard to postnatal mortality reveal that the Deori population varies significantly with all the populations except Kaibartas while the differences are not significant between the other population groups.The intergroup comparisons for embryonic and postnatal mortality estimates based on standardized normal deviate have beeI) in the Indian population ranges between 0.258 and 2.250. Thus, the present findings are inclined more toward the lower limit of Indian range. This finding goes in conformity with several other studies done recently in different parts of India.[The computed mortality and fertility components and the index of the total selection intensity as per Crow (1958) indicate a relatively low index of total selection among the studied populations of Northeast India. Recently, Reddy and Chopra have repof India.–22 As faof India. among thof India. however,of India. the inciThe study reveals a low intensity of natural selection among these seven population groups. Thus, the value of selection intensity is also relatively low in the studied populations in relation to the Indian ranges. Low values of selection intensity indicate a low pressure of natural selection in these populations. This may be because of the operation of different factors like sociocultural, better economic and education system, health awareness, and medical facilities among different population groups in the recent years. The low intensities of selection along with lower mortality indices may suggest that all these population groups are at the initial stage of demographic transition because it is suggested that at the initial stage of transitional phase selection index decline initially followed by a rapid decline of mortality component with stable fertility component (Sikdar). However