There is a broad consensus that climate change will increase the costs arising from diseases such as malaria and diarrhea and, furthermore, that the largest increases will be in developing countries. One of the problems is the lack of studies measuring these costs systematically and in detail. This paper critically reviews a number of studies about the costs of planned adaptation in the health context, and compares current health expenditures with MDGs which are felt to be inadequate when considering climate change impacts. The analysis serves also as a critical investigation of the methodologies used and aims at identifying research weaknesses and gaps. The most important include increased vector-, water- and food-borne diseases; injuries and deaths caused by extreme hydro-geological events; heat-related diseases and deaths caused by heat waves ; and negative impacts on malnutrition ,2. TheseIn order to reduce these negative health impacts, various programs or measures, known in the climate literature as adaptation measures, are being put in place or are being planned. Adaptation is defined by IPCC  as the “adjustment in natural or human systems in response to actual or expected climatic stimuli or their effects, which moderates harm or exploits beneficial opportunities” . The issFor informed decision-making, national governments need therefore to know what financial resources are needed for adaptation, what is the financial gap in funding, what damages could be avoided through adaptation, and what is the cost-effectiveness of the proposed programs. This would allow them to set priorities and to choose the most appropriate combination of measures to reduce the negative health impacts.This paper critically reviews a number of studies on the costs of health interventions. It analyses the methodological approaches used and identifies critical gaps and research priorities in this area. The goals are three-fold. First, we wish to explore the economic impact of climate change in developing countries in terms of planned adaptation costs, based on the empirical evidence from the existing literature. Quantification of the health costs of adaptation requires an extensive analysis of long-term data including the increase in the number of cases and deaths caused by climate change, as well as economic variables such as unit costs of specific health measures. Such an analysis is more complex in developing countries, due to the lack of consistent long-term datasets. Given these difficulties and the limited number of studies in the context of health adaptation, the analysis is completed by selecting a number of relevant studies coming from the public health literature for climate-related disease control programs. Second, we use the estimated total costs resulting from the literature to perform a simple cost-effectiveness analysis of different health interventions for different diseases, in order to identify the alternatives with the lowest cost to achieve the desired result. Preventive and reactive measures for different health endpoints are compared, the first aiming at avoiding deaths or episodes of illness, while the second are intended to treat the disease when already occurred and minimize the damage. Third, this analysis serves also as a critical investigation of the methodologies used for cost assessment with the purpose of identifying the research gaps and the conditions that need to be satisfied to assure reliable estimates.Section 2 presents a brief overview of the main health impacts caused by climate change with a specific focus on developing countries. Section 3 presents a classification of adaptation measures, identifies the main cost categories and reports on the methodological approach used for cost assessment. The methodological issues that arise in judging whether a measure is justified from an economic point of view are discussed in Section 4, reporting on two main approaches, cost effectiveness analysis and cost-benefit analysis. Section 5 details the existing studies on the costs of health interventions to reduce climate-related diseases, comparing results among macro-geographical regions. In Section 6 different health interventions are discussed in term of their cost-effectiveness. Finally Section 7 discusses the existing research gaps, the main methodological issues in the cost assessment and how to improve knowledge.2.Salmonella) and vector-borne diseases .Climate change will have a wide range of implications to human health. These include thermal-related morbidity and mortality due to extreme temperatures, effects associated with air pollution, impacts of extreme weather events, malnutrition, water-borne , food-borne , while indirect effects are related to the impact of heat extremes on urban air pollution and humidity (which can aggravate pre-existing morbidity).The risk of heat-related morbidity and mortality would increase mainly in the elderly, children, those with pre-existing cardio-vascular and respiratory diseases, and among the urban poor. The greatest impact is expected for mid- to high-latitude cities, especially in poor countries, characterized by poorly adapted buildings and without air conditioning. Lack of datasets and long-term statistics in developing countries makes it difficult to provide quantitative estimates of health effects in these countries. Nevertheless some studies exist which project large impacts in the temperate and tropical regions in Asiaand India –4.The negative impact of heat waves might be partially compensated by a decrease in cold-related deaths during the winter season. According to some studies, the decrease in winter mortality in temperate regions might be greater than the increase in heat-related mortality expected in summer ,6. TheseExtreme temperatures may also increase the exposure to urban air pollution, with the potential to aggravate pre-existing respiratory and cardio-vascular diseases. In the recent years, extreme weather events, such as floods and landslides, storms, cyclones and droughts, have caused considerable damage and loss of life in China, Venezuela, Bangladesh and Mozambique. Direct impacts of extreme weather events include increased incidence of deaths, physical injuries and psychological stresses, while indirect impacts are related to increased risk of exposure to water-borne diseases due to water contamination, and impacts on malnutrition due to loss in agricultural production. Unsafe water and sanitation conditions and decrease water accessibility would further increase the transmission of infectious diseases. It is estimated that by 2050, one billion people in Asia could have limited access to drinking water .Other indirect impacts of changes in weather patterns include variation in the geographical and seasonal distribution of vector-borne diseases , in some cases by expanding transmission to higher altitudes and latitudes. There is, however, considerable uncertainty as to the magnitude of the impacts. Some mathematical models project a net increase in the amount of population exposed to malaria and dengue transmission as a result of climate change , while oFinally, higher temperatures can lead to increased exposure to food-borne diseases due to contamination of food, which can cause various gastrointestinal diseases. Notwithstanding the existing scientific uncertainties, most researchers project that in the next decades these health impacts are likely to increase considerably in developing countries, which are more vulnerable to climate change impacts and less capable to adapt to such changes, having poor health care systems, poor health status, and few financial, social and technological resources to adapt. Hence climate change is threatening the capacity of these countries to attain the United Nations Millennium Development Goals by 2015 (UN 2015). It is therefore crucial to understand how climate change is likely to impact development priorities in poor countries, and to respond with appropriate and cost-effective measures for adaptation.3.3.1.In order to cope with the adverse health effects of climate change, adaptation measures, plans and programs are put in place. Adaptation is defined in terms of “policies, practices, and projects with the effect of moderating damages and/or realizing opportunities associated with climate change” . Adaptatbefore the damage occurs in order to avoid it by reducing exposure . When the health interventions are implemented after the impact has occurred but before the occurrence of the disease, it is termed as secondary prevention. These include measures such as monitoring and surveillance programs allowing an early detection of the disease , or strengthening the public health care. Finally tertiary measures do not attempt to prevent, but to minimize the health impacts already occurred, e.g. through curative treatments.Another important classification distinguishes between anticipatory (or proactive) or reactive adaptation. The first implies preventive actions which take place before the impact occurs in order to avoid of reduce the risk of disease and death. This type of adaptation involves long-term decision making and reduces long-term impacts, risk and vulnerability caused by climate change. For this reason, anticipatory adaptation is more effective and involves generally planned interventions. On the other side, reactive adaptation provides an immediate response to climate change. The actions take place after the impact with detection and subsequent treatment of the disease. In the public health sector, adaption actions are usually classified into three categories according to the timing: primary, secondary and tertiary ,13. PrimOther criteria distinguish between short term and long term adaptation, localized and widespread adaptation . FinallyLegislative measures consist of laws, guidelines and regulations put in place by the parliament and government to prevent negative impacts of climate change. Technical measures can be anticipatory or reactive, they can be implemented by various government departments depending on the type of measure , by the municipality (e.g. green islands in the city centre) or by the industrial sector . Education measures can be implemented by the central government with the cooperation of various departments . Finally, the behavioral measures are put in place by individuals and they are defined as autonomous adaptation.Examples of possible health adaptation actions are reported in etc. We can distinguish different categories of costs, according to the type of adaptation [etc.). The second category involves institutional costs incurred to improve the adaptive capacity of a system. These include actions for strengthening the health care system, infrastructure costs, training activities, communication, monitoring, surveillance and evaluation services, health information systems and population surveys. Finally, the last category includes the transition costs associated with the reallocation of the resources in the society during the adaptation process . Transition costs are often excluded from the analysis, due to the difficult estimation process.The cost of health adaptation programs includes the cost of building, operating and maintaining health provision service structures, setting up and running emergency response systems, aptation . The firFrom an economic point of view, we should estimate the social costs of adaptation programs. These include external costs incurred by the society (opportunity costs), besides the private costs of production. The studies analyzed in this paper focus on the first two categories of costs mentioned above, namely direct and institutional costs, excluding transition and opportunity costs.The costs of health adaptation are estimated using market-based data and information in order to perform a cost assessment based on unit values multiplied by the target population living in the vulnerable areas and by the incidence of diseases. Health adaptation costs include treatment costs of additional cases (reactive adaptation) and costs for preventive measures to reduce the incidence of disease (proactive adaptation). The cost of health adaptation will depend on the health outcome, the intervention type (e.g. treatment or prevention), the expected reduction in the incidence of mortality and morbidity and finally on the geographical region where the impact is expected.4.As important as estimating the costs of adaptation programs for health protection, is to have some way of judging whether these costs are reasonable and whether the program is justified. For this purpose economists use two tools: Cost-Benefit Analysis (CBA) and Cost-Effectiveness Analysis (CEA). The main difference between CBA and CEA is that in CBA both the costs and benefits of a proposed program are estimated in monetary terms, and then compared with the costs and benefits of alternative programs, in order to identify the program with the highest net benefits. By contrast, CEA estimates only the costs of attaining certain health goals, which are measured in physical units .4.1.Cost-effectiveness analysis (CEA) is a technique used to identify the least cost intervention to reach a desired result. It enables us to define priorities among different alternative interventions by identifying the least cost option able to reach the underlying objectives. CEA is sometimes used as a second-best option when a full-blown CBA would be desirable, but many benefits cannot easily be monetized .The cost-effectiveness ratio of a program is computed by dividing the annualized costs of the program by the physical benefits, measured in terms of lives saved (or life years saved), and cases of illness avoided. Results are expressed as unit costs, in terms of costs to be supported to save one life (or one year life) and to avoid one episode of illness. If all else is the same, the program deemed more cost-effective would be the one with the lowest cost per life saved or avoided case. For example a government might decide that any project where the cost per life year saved is in excess of €1,000 cannot be funded. It could arrive at this conclusion, given information on the range of possible interventions, the cost per life year associated with them and the budgetary resources available. Each project then would have to report a cost per life year saved and a necessary condition for adopting it would be that this cost is less than €1,000. This approach is attractive because: (a) it is generally feasible  to calculate the cost per life year saved or case avoided from health related interventions and (b) the criteria are simple and transparent. Traditionally, CEA has been used widely in medical decision-making and in public health although in practice the selection of health interventions does not rely exclusively on this criterion .Estimation of the costs of a program within a CEA is similar to that in a CBA. The advantage of the first is that the benefits are computed in physical terms and not in monetary terms as in a CBA, which results in a less complex calculation. Analysts engaging in a CEA, however, still have to deal with complex issues such as the choice of the discount rate when the costs of the program are incurred over several periods. Further problems arise when a program impacts on more than one indicator (e.g. it results in savings in life years as well as a reduction in the experience of unpleasant symptoms). In such cases other criteria have to be used or one has to be chosen at the expense of the other This is particularly relevant as a program could reduce both mortality and morbidity impacts, and in this case the use of one indicator (cost per case avoided) instead of the other (cost per life saved) could have misleading results if the two measures differ widely. In these cases another physical indicator known as the Quality Adjusted Life Year (QALY) is routinely used in medical decision-making and public health. This measure is based on the individual preferences over quality of life and longevity, which are assumed to depend on the health consequences . This indicator has the advantage of incorporating both mortality and morbidity effects, instead of favoring one of the two. The main problem with this approach is that older individuals would have fewer QALYs than younger individuals, which would lead to higher cost per case avoided or per life saved for the elderly. Furthermore this approach does not account for individual risk perception. For these reasons, in our computations we use the indicator cost per case and/or death avoided.In the context of climate change CEA is a useful tool to provide a measure of the costs of a program in terms that are comparable across programs. Studies on the costs of adaptation programs are indeed difficult to compare in a way that provides some guidance on whether they are justifiable or not. Although imperfect, measures such as the cost per case avoided or cost per life year saved are at least feasible and the numbers obtained useful for policy purposes.4.2.This technique has been used to analyze many public policies, including transportation, urban regeneration, agriculture, public health, education, and the environment. It is also used for valuing for adaptation to climate change impacts. By monetizing the benefits of a program, CBA makes it possible to evaluate many different types of government programs and to compare them with the costs of the programs. When different programs are examined, economists suggest choosing the one with the largest net benefits . Note that, unlike CEA, cost-benefit analysis also allows one to determine the socially optimal size of the program, i.e., the one that maximizes net benefits.In order to determine the net effect of a proposed program, we must first identify who will gain (beneficiaries) and who will lose from its implementation, and then estimate the gains or losses for each of the partners. In spite of that equity considerations are not sufficiently reflected in CBAs . CBA is complicated further by the fact that, while it is quite easy to identify the costs, it is more difficult to estimate the benefits, as these are generally non-market goods, for which no market prices exist.Another problem with CBA is that it must compare costs and benefits that are experienced at different times in a single measure. The choice of the rate at which future costs and benefits should be discounted is particularly relevant for climate projects because costs of adaptation measures will be incurred in the near future while the benefits will be spread over a much longer time period. The debate on discounting for climate change is not resolved but many economists argue that very long term impacts of the kind associated with climate change require very low discount rates – of the order of one percent or less. In practice normal public sector projects involve discount rates of around 5–6 percent .nd IPCC Report when a recommendation to take a lower value of life in developing countries compared to industrialized was strongly objected by representatives from developing countries). Studies in the climate change field have wrestled with this problem and resolved it with broadly two uneasy compromises. Some have taken different values for different countries, more or less in proportion to real per capita GDP [One other feature of the use of CBA to evaluate health adaptation programs is worth mentioning. This is the problem of valuing benefits that take the form of reductions in mortality – implying savings in life years, which in turn requires a value to be attached to a life year or a life saved. In the past this has produced serious debate and disagreement. Methods have been developed for making such estimates, but the studies are mainly from developed countries. In the context of climate change the use of different values for a life year according to the country in which the person lives has raised serious problems  to reduce the disease incidence and related mortality, with a specific focus on developing countries, expected to face most of the health impacts of climate change. The studies selected focus on similar targets in terms of health impacts reduction, which allows comparison among interventions types and countries. The health outcomes considered in the analysis are vector-borne and water-borne diseases, malnutrition, pneumonia and newborn causes of death in children. It must be recognized that quantification of costs is much more difficult in developing countries, due to the lack of data and long-term analysis, high variation of data among countries, inefficiencies in disease detection and reporting. Nevertheless we have selected some relevant studies in order to analyze the methodology and to draw some quantitative estimates of the cost of health adaptation.There are two main groups of studies considered in this analysis. The first relate to health care costs associated with the additional health impacts arising as a result of climate change. These costs include disease treatment measures (reactive adaptation) as well as preventive measures to reduce the incidence of climate related diseases (anticipatory adaptation). Despite the important role of adaptation in reducing the health costs of climate change (known as the ‘costs of inaction’), there is very little information available from the literature on the costs of health adaptation in different climate change scenarios. For this reason we have reported on a second group of studies focusing on the costs of health interventions programmed to achieve a reduction in the burden of climate-related diseases, in accordance with internationally agreed objectives and targets, like the MDGs. These costs are estimated outside the climate change context, but they focus on climate-related diseases . As the types of measures used for disease treatment and prevention are, in principle, the same in both contexts, the second group of studies can be reasonably used to provide some indications of how much adaptation measures would cost.The above mentioned studies focus on planned interventions only as they aim at identifying the financial resources needed by the government to address the increased impact of climate-sensitive diseases. Autonomous adaptation, which includes costs supported by households, is not taken into account. The figures discussed in this paper represent therefore a lower-bound estimate of the total costs of health adaptation supported by the society as a whole. Household costs include direct expenditures for health for both prevention and treatment  and indirect costs such as loss of earnings due to absence from work, inability to perform usual activities, need to care for children, time spent travelling and, in case of premature death, the discounted future lifetime earnings or the value of a statistical life. These studies are not included in the present review as the methodological approaches used for estimating these impacts rely on different theoretical backgrounds, raising specific research issues. Methods used in this context include cost of illness, compensating wage studies and contingent valuation.5.1.The methodological approach for estimating health adaptation costs requires to estimate the disease incidence due to climate change, to project future population under different scenarios, and to estimate the number of people at risk in the future (multiplying future population with the incidence ratio). The costs of adaptation are assessed by multiplying the number of people at risk in the future with the cost per capita of health interventions.2 equivalent by 2210 and stabilization at 550 ppm CO2 equivalent by 2170. Estimates are provided separately for Africa, North and South America, South-East Asia, Europe, Eastern Mediterranean countries and Western Pacific countries. The estimated figures do not include the full range of costs [Perhaps the most important study in this category is that of Ebi  who estiof costs ; for exaTotal costs under various categories for the year 2030 are summarized in For the sake of comparison among different countries, additional annual costs have been calculated for major geographical macro-regions in developing and developed countries. Detailed estimates for these macro-regions are reported in As regards diarrhoeal diseases, South East Asia and Africa are expected to face the highest costs in all scenarios, accounting for respectively 42% and 27% of total annual costs for health interventions in developing world, followed by Western Pacific with 16%. As for malaria, the majority of the costs are expected in Africa (82%), followed Eastern Mediterranean countries (14%).In terms of gains from reducing GHGs in developing countries, The second study in this context is from Van Rensburg and Blignaut  who haveThe above mentioned figures can be compared with the total expected costs of malaria if no intervention was implemented , which w5.2.In this section we analyse and discuss the results of some studies estimating the costs of health interventions outside the climate change context but focusing on climate-related diseases and therefore relevant to the climate change health discussion. The diseases looked at are malaria, diarrhoea, malnutrition, pneumonia and other newborn diseases. The studies included in the analysis report estimates for macro-geographical regions and for a combined set of intervention programs.et al. [The first study analysed is Kiszewski et al.  who estiThe study integrates cost valuation methodologies with epidemiological estimates about the proportion of people exposed to malaria  and projections of population growth rates .Results show that the total financial resources needed from 2006 to 2015 to implement the recommended measures  amount to US$ 38 to US$ 46 billion (on average US$ 3.8 to 4.6 billion per year). Among the different cost categories, the vector control costs are estimated to be the highest. The average annual costs (2006–2015) are expected to be around US$ 1.7–2.2 billion for Africa, around US$ 1.9–4.6 billion for South East Asia, Western Pacific and Eastern Mediterranean, and finally US$ 212–235 million for Central and South America .These figures are similar to the costs for health adaptation estimated by Ebi  . Treatment measures include distribution of several drugs, and combination treatments, while hospital admissions are not considered. Interventions have been evaluated at 50%, 80% and 95% coverage. Population at risk is calculated taking into account the proportion of person living in malaria endemic areas. Results show that, for 95% population coverage, annual costs are equal to US$ 468 million for Western Africa and US$ 442 million for Southern and Eastern Africa (based on year 2000 estimation), for a combination of measures including indoor residual spraying, impregnated bed nets, case management based combination therapy and intermittent presumptive treatment in pregnancy. These figures are 45 to 70 percent lower than those provided by Epstein and Mills  and Kiszet al. [per-capita health expenditure of US$ 0.47 in 2006 and of US$ 1.46 in 2015. The average incremental cost per child less than five years old who is treated is estimated to be US$ 12.31 in 2015. The suggested interventions would require an increase in total health expenditure in the 75 countries of around 8 percent on average and in government health expenditure of 26 percent over 2002 levels. Low and middle-income countries with weak health care systems would experience substantial difficulties to collect sufficient domestic funding to cope with MDG goals.A more extensive study estimating health care programs costs is Stenberg et al.  who estiet al. ). This iHutton and Haller  estimateTotal annual costs of these interventions (in developing and developed countries) range from US$ 1,782 million in the first scenario to a huge US$ 136,514 million in the fifth scenario. The first scenario involves improvement in water accessibility only, while the second scenario involves both water and sanitation accessibility improvement, requiring therefore much larger financial resources . Investments on sanitation are indeed considerably more expensive. In scenario three it is expected that the entire population has access to water and sanitation services, which doubles the costs of implementation . Scenario four requires only a low increase in financial resources as it includes the availability of disinfected water at the point of use .The high costs for the fifth scenario  is explained by the substantial investments and corresponding maintenance costs necessary to guarantee access for all, in order to regulated piped water supply and sewage connection in the houses. These figures are much higher than the corresponding annual costs for non-structural interventions for disease control and prevention in public health but the water and sanitation programs do attain a number of other objectives as well. In terms of health they attain a 60–70 percent reduction in the incidence of disease.etc.), followed by Western Pacific regions  with 32 percent and Africa regions with 18 percent of total costs. The number of cases avoided by water and sanitation programs range from 3 percent decrease in the first scenario to 70% decrease in the last scenario.et al. [The last study analyzed in this group is the one of Meddings et al.  in the c6.In this section we use the cost estimates from the above-mentioned studies to compute a simple index of cost-effectiveness for different intervention programs and health endpoints. We use two indicators, the cost per death or per case avoided, depending on the available data and the intervention targets and objectives. Only health benefits are incorporated in the index, while potential non-health benefits are excluded from the analysis.et al. [Results are reported in the fourth column of et al.  has beenet al. [The cost per case avoided in water and sanitation programs has been based on the data of Hutton and Haler . More deet al. , suggestet al. [et al. [Finally, we include the cost per death avoided estimated by Meddings et al.  which iset al. . This ca [et al. , while tThe analysis is completed with a critical review of the existing studies about the cost-effectiveness of single health interventions in developing countries   per death avoided, while breastfeeding promotion ranges from US$ 115 to 919 per death avoided. These results confirm that non structural health interventions are less cost-effective compared to structural environmental health interventions like water and sanitation programs .As regards prevention of malaria, cost per death avoided is around US$ 305 (US$ 1999) for vaccination, it ranges from US$ 227 to 858 for bed net impregnation measures, from US$ 73 to 414 for vitamin A supplementation and from US$ 81 to 950 for prevention in pregnancy. Treatment measures of malaria show a cost per death avoided of US$ 271–1,355 for early diagnosis and prompt treatment.These results are comparable with the cost per death avoided we estimated using data from Kiszewsky  and Sten7.In this paper we have looked at the costs of adapting to climate change from a health perspective and we have computed a simple cost-effectiveness index for alternative programs based on the estimated total costs resulting from the literature. The analysis is completed with a critical review of the existing studies about the cost-effectiveness of different health interventions.There is a broad consensus that climate change will increase the costs arising from diseases such as malaria and diarrhea and, furthermore, that the increases will be largest in the developing world. Estimates of the costs of adaptation measure the additional cases and the costs of treating those additional cases. They may also include some estimates of more preventive actions. One of the problems in this area is a lack of any studies that measure these costs systematically and report the data in detail. The detailed study of Ebi  concludeet al. [Although these estimates refer to 2025 and 2030, which may seem a long time away, the additional cases are already evident and climate change is increasing the relative risk of these and other diseases right now. The implications are quite serious in terms of the goals of reducing deaths from malaria and other causes of infant and child mortality . Estimates of expenditures made in respect of attaining these goals indicate expenditures for malaria alone of 2 billion US$ per annum in Africa  is comparable to the costs of health adaptation under climate change but the latter have a much wider range. Hence more work is needed to narrow the estimates of the costs of adaptation.The studies make it difficult to identify which interventions are the most cost effective in targeting diseases related to climate change. A more consistent approach to further work in reporting cost effectiveness indicators would help us make more informed judgments. One problem is the use of different metrics (cost per case or per death avoided). Another is how to consider programs with multiple benefits. As regards malaria, for example, the measures relate to disease prevention and treatment and they provide mainly health benefits. For diarrhoea, instead, structural intervention can be implemented which provide also considerable non-health benefits. These should be also taken into account when computing the cost-effectiveness ratio.In spite of this we note that the costs per life saved in the case of diarrhoea are considerably lower than those in the case of malaria. That would suggest at least starting out targeting diarrhoea cases. Furthermore, within that group the costs of improved water and sanitation, while requiring huge investments to meet the MDGs, result in costs per case avoided that are fairly low. Given that these same interventions have multiple benefits, not all of which have been accounted for would suggests that non-health structural interventions may be more cost effective but further research is needed to confirm this.


In 2001, the World Health Organisation (WHO) recommended exclusive breastfeeding for the first six months of life. The objectives of this study are to assess awareness of the WHO recommendation among first-time mothers (women at 24 to 34 weeks of pregnancy) and to explore the relationship between this awareness and mothers' intention to exclusively breastfeed for six months.This study was part of the Healthy Beginnings Trial (HBT) conducted in southwest Sydney, Australia. We analysed cross-sectional baseline data of the trial conducted in 2008, including 409 first-time mothers at 24 to 34 weeks of pregnancy. The mothers' awareness of the recommended duration of exclusive breastfeeding and their intention to meet the recommendation were assessed through face-to-face interviews. Socio-demographic data were also collected. Factors associated with awareness of the recommendation, or the intention to meet the recommendation, were determined by logistic regression modeling. Log-binomial regression was used to calculate adjusted risk ratios (ARR).Sixty-one per cent of mothers knew the WHO recommendation of exclusive breastfeeding for six months. Only 42% of all mothers intended to meet the recommendation (breastfeed exclusively for six months). Among the mothers who knew the recommendation, 61% intended to meet the recommendation, compared to only 11% among those mothers who were not aware of the recommendation.The only factor associated with awareness of the recommendation was mother's level of education. Mothers who had a tertiary education were 1.5 times more likely to be aware of the recommendation than those who had school certificate or less . Mothers who were aware of the recommendation were 5.6 times more likely to intend to breastfeed exclusively to six months .Awareness of the recommendation to breastfeed exclusively for six months is independently associated with the intention to meet this recommendation. A substantial number of mothers were not aware of the recommendation, particularly among those with low levels of education, which is of concern in relation to promoting breastfeeding. Improving mothers' awareness of the recommendation could lead to increased maternal intention to exclusively breastfeed for six months. However, whether this intention could be transferred into practice remains to be tested.HBT is registered with the Australian Clinical Trial Registry (ACTRNO12607000168459) Breastfeeding has a wide range of health benefits for mothers and children and is a key protective factor against childhood overweight and obesity -4. The cIn Australia, a national survey found that in 2004-5, breastfeeding initiation was 88% , and simBreastfeeding decisions and practices are influenced by multiple factors including knowledge, attitudes and beliefs, as well as socio-cultural and physiological factors -13. HoweThere is increasing recognition of the need to promote exclusive breastfeeding since the WHO recommendation on exclusive breastfeeding for six months was made in 2001. However, the impact of such promotion on rates of exclusive breastfeeding is less clear . This miResearch has repeatedly found that women's pre-birth breastfeeding intentions are a good predictor of the actual duration of breastfeeding ,17. In aTo enhance breastfeeding promotion strategies in the context of relatively recently changed recommendations, it is important to have a good understanding of mothers' knowledge of the current recommendation on breastfeeding and their intention to meet the breastfeeding recommendation. In 2008, we commenced the Healthy Beginnings Trial (HBT) to test the effectiveness of an early childhood obesity intervention in the first two years of life . The intThis paper reports on those aspects of the data collected for the HBT that were collected at the baseline interview, prior to randomisation. We aimed, firstly, to assess first-time mothers' awareness of the recommended duration of exclusive breastfeeding and their intention to meet this recommendation, and, secondly, to explore the factors that are associated with the intention to exclusively breastfeed so that appropriate breastfeeding intervention strategies could be developed.The design of the main study is a Randomised Controlled Trial (RCT), however for the purpose of this analysis we have used the data collected at the study baseline, which could be considered a cross-sectional survey. The RCT was conducted in southwest Sydney, Australia in 2008 and approved by the Ethics Review Committee of Sydney South West Area Health Service (RPAH Zone). The details of the HBT research protocol have been reported elsewhere .All pregnant women who attended antenatal clinics of Liverpool and Campbelltown Hospitals located in south-western Sydney were approached by research nurses with a letter of invitation and information about the study. Women were eligible to participate if they were aged 16 years and over, were expecting their first child, were between weeks 24 and 34 of pregnancy, were able to communicate in English and lived in the local areas. Once eligibility was established and consent obtained, women then were asked to fill in a registration form with their contact information to allow the nurses to make further arrangements for the baseline data collection and random allocation to study group.From around 2700 mothers who were approached, a total of 667 first-time mothers at 24-34 weeks of pregnancy were recruited for the main study. Four hundred and nine mothers were interviewed at their home before giving birth at the baseline and were included in this particular study. Another 258 mothers who also participated in the HBT were excluded, as we were not able to conduct the survey before they gave birth.A face-to-face interview with participating mothers was conducted by one of four research nurses at their home, prior to randomisation. The interview lasted 20 to 30 minutes and included a range of questions in relation to the general health, physical activity and nutrition of the mothers, as well as demographic information.To assess mothers' awareness of the breastfeeding recommendation and their intended duration of exclusive breastfeeding, they were asked the following questions:"What do you understand to be the recommended age to which you should continue to exclusively breastfeed your child?""Do you plan to breastfeed your child?""To what age do you plan to exclusively breastfeed your child?"In addition, the mothers were asked the main reasons for their decision to breastfeed, or not to breastfeed with an open-ended question. The face validity of the questions had been pilot-tested by some mothers and reviewed by breastfeeding experts in the field.Other study variables, including age, employment status, education level, marital status, language spoken at home, and country of birth, were asked using the standard questions from the NSW Health Survey .Statistical analyses were carried out using the computer package Stata 10 . RelatioThe main characteristics of the participating mothers are shown in Table Among all 409 participating mothers, 61% knew the recommendation of exclusive breastfeeding for the first six months of life, and 39% either did not know or answered incorrectly. Only 42% of all mothers intended to meet the recommendation, however 94% (384) of the mothers did plan to initiate breastfeeding. Among the mothers who knew the recommendation, 61% intended to meet the recommendation, compared to only 11% among those mothers who were not aware of the recommendation.21 = 14.9, p < 0.001), marital status (married or de facto) , and a higher level of education . Marital status and employment status of the mothers were also found to be associated with their intention to meet the recommendation of exclusive breastfeeding for 6 months . Awareness of the recommendation was very strongly associated with mothers' intention to breastfeed exclusively for six months .Table The only factor associated with awareness of the recommendation on multivariate analysis was mother's level of education Table . MothersThe main reasons given by the mothers for planning to breastfeed or not breastfeed are summarised into several themes, showing some representative examples, in Table "Breastfeeding is best, nutritious, convenient, cheaper and (helps the) bonding between mother and child.""Breastfeeding can help mother back to her normal weight quicker, prevent breast cancer and boost the immune system.""...Good for baby. God made milk special for a baby, (it's) natural, protects the baby from illness.""No time, have to work"; "I would be embarrassed in public" and "Can't stand the thought of it. Freaks me out."Mothers who did not plan to breastfeed (6%) gave reasons for not breastfeeding such as: Among the 25 mothers who did not plan to breastfeed, 21 were less than 24 years old, 10 were unemployed, only 15 completed the school certificate or less and only 9 knew the six months exclusive breastfeeding recommendation.In this cross-sectional analysis we used data collected antenatally from 409 first-time mothers participating in the Healthy Beginnings Trial in southwestern Sydney. We found that a substantial proportion of the mothers (39%) did not know the current recommended duration of exclusive breastfeeding, and only 41% intended to meet the recommendation to breastfeed exclusively for six months. Awareness of the breastfeeding recommendation was significantly associated with the mother's intention to exclusively breastfeed her child. However, whether the intention to breastfeed is transferred to practice remains to be tested in future research.Breastfeeding is widely acknowledged to have health benefits for mothers and babies -4. Our sTo our knowledge, to date there is no research into mothers' awareness of the WHO breastfeeding recommendation and its association with the antenatal intention to breastfeed. Since the intention to breastfeed is a positive predictor for actual duration of breastfeeding -18, explThe negative effects of early weaning on children and mothers remain a significant public health concern. An analysis of data from the 2001 Australian National Health Survey found that fewer than 50% of infants were receiving breastfeeding milk at six months , which iTo date, most studies on breastfeeding awareness have focused on the health benefits of breastfeeding and infant feeding practices ,7,9,10. This study provides empirical evidence linking mothers' awareness of the breastfeeding recommendations and their intention to meet the recommendation. While our study had a relatively large sample of 409 first-time mothers, its generalisability is limited due to the locality of the study area. Southwest Sydney is the most socially and economically disadvantaged area of metropolitan Sydney . We acknPotentially, our findings have a number of important policy implications for breastfeeding interventions. Efforts to encourage mothers to meet the recommendations should focus on improving mothers' knowledge and understanding of the recommendations, and address the concerns expressed by mothers about the quantity and quality of breast milk for the recommended duration. The effectiveness of targeted health promotion programs needs to be tested, particularly among young, unemployed and less educated mothers. There is a need to improve their perceptions, attitudes and knowledge, and also to change social norms in relation to breastfeeding practices.In addition, appropriate public health policies to help mothers to breastfeed to at least six months, and to remove the barriers to breastfeeding, will be required to meet the WHO recommendations. The Australian Government's proposed 18 weeks paid maternity leave is a good start, but falls short of the required length, and falls particularly short of some Scandinavian and European countries' maternity leave entitlements of 50 to 64 weeks. For women who need to or choose to return earlier to work, the workplace needs to be able to provide child care and to facilitate breastfeeding on demand. Strategies recommended in the NSW Breastfeeding Policy Directive  provide The authors declare that they have no competing interests.LMW, LB, CR and GA conceived the HBT, and contributed to the development of the trial and the procurement of the funding.In this study, LMW undertook literature review, data analysis and interpretation and wrote the original draft. JS provided advice on data analysis. LB, CR, GA and JS made significant comments on the draft. All authors have read and approved the final manuscript.


In 2004, hog farming operations were introduced in the village of Sarsfield in the eastern part of Ottawa, Canada. This study evaluates the health-related quality of life (HRQOL), and the prevalence of respiratory conditions among adults and children who lived in proximity to this farm.A cross-sectional survey was administered to a random sample of residents from seven rural communities in the eastern part of Ottawa, Canada. We analyzed self-reported questionnaire data obtained from 723 adults and 285 children/adolescents. HRQOL was assessed using the SF-36 survey instrument, while data were also collected for sociodemographic characteristics, the prevalence of selected health conditions, and lifestyle related behaviours  of participants. Variations in self-reported health according to the residential distance to the hog farm were evaluated using logistic regression and analysis of variance methods.For the most part, the prevalence of selected health conditions among adults and children was not associated with how far they lived from the farm. No associations were observed with migraines, respiratory conditions , and allergies. However, a higher prevalence of depression was noted among those who lived within 3 km of the farm relative to those who lived more than 9 km away . Furthermore, individuals who lived closer to the IHF were more likely to worry about environmental issues such as water quality, outdoor and indoor smells, and air pollution. This level of worry also contributed to lower HRQOL scores for individuals who lived closer to the farm. It was also observed that the prevalence of depression was much higher among those who indicated a concern about environmental issues (18.2%) when compared to those who did not (8.0%).While our findings suggest that living in close proximity to an IHF may adversely affect HRQOL these should be interpreted cautiously due to a lack of direct measures of environmental exposures, and possible biases inherent in the use of self-reported health measures. Over the last two decades there has been a marked change in hog farming operations in Canada that has mirrored that in other developed countries. Once predominated by small family owned farms, the productions of hogs is now characterized by large scale intensive farming operations that involve hundreds, if not thousands, of sows. These intensive farming operations can generate pollution and odours that may threaten both human health and the nearby environment. Pollution emitted into the air include hydrogen sulphide, ammonia, dusts, endotoxins as well as complex mixes of volatile organic compounds (VOCs) .Numerous studies have demonstrated that the respiratory health of farm workers exposed to high levels of these pollutants can be adversely affected. Detailed reviews of these occupational studies have been published by Donham et al , and OlsMore recently, investigations have been undertaken to characterize health effects among nearby residents of hog and other livestock farms. Odours generated from these farms are of particular concern to these residents, and they have been shown to result in more tension, more depression, more anger, more fatigue and less vigour among those living closer to hog farming operations . Other sThe evidence compiled to date is suggestive that emissions from intensive hog farming operations may adversely affect the health and mood of nearby residents. Many of these studies have had important limitations. The most common limitation has been relatively small sample sizes, which provide limited statistical power to compare prevalence estimates between areas for rare health conditions. Other limitations have included: the inability to adjust risk estimates for potential confounders, the lack of a standard instrument for the assessment of quality of life, a reliance on volunteers rather than a population based-sample, and the lack of direct measures of exposures.A particular challenge to studying health effects among neighbouring residents of industrial hog farming operations is to derive objective measures of exposure and health outcomes. With self-reported data, associations may be found because an environmental exposure causes ill health. Alternatively, associations may be due in part, or in whole, to the increased reporting of symptoms or health conditions because the study participants are aware of the hazard. This phenomenon, termed "awareness bias" by Moffatt et al , necessiWith this background in mind, we present our findings from a self-reported health survey administered to residents in the geographical vicinity of a large-scale intensive hog farm outside Ottawa, Canada. The aim of this study was to determine whether hog farming operations adversely affects the health of nearby residents. Our questionnaire  were collected from one participating adult member of the household.Adult participants were also asked whether they had any of a number of health conditions that persisted for at least 6 months, and had been diagnosed by a health professional. This list consisted of several respiratory conditions including asthma, wheeze, chronic bronchitis, wheeze, sinusitis and rhinitis. Participants were also asked about whether they had been diagnosed with cardiovascular conditions, gastrointestinal disorders, or mental health conditions such as depression, anxiety, and migraines. Questionnaire data collected enabled us to classify individuals according to their cigarette smoking habits, and their body mass index. One adult household member provided information on behalf of the children about their general health status and the prevalence of respiratory conditions.Health related quality of life (HRQOL) was assessed with the widely-used SF-36 survey instrument. This suTo evaluate the extent of possible awareness bias, adult participants were asked to indicate from a pre-specified list of 18 items what had been sources of worry for them in the past year. IHF related worries included outdoor smells, air pollution, or water pollution. Finally, the survey included an open-ended question at the end whereby participants could provide any additional comments.In October 2005, questionnaire packages were assembled and delivered to the selected households by a survey team of two individuals. The survey was presented as a general health questionnaire. The survey team visited each eligible home up to three times to establish contact. The visits were coordinated to ensure that the interview teams visited the homes at different times of the day, and if contact was not established during the initial visit, a weekend visit was made. On the third visit, if contact was not made, the questionnaire package was left in the mailbox of the home.Both English and French language questionnaires were made available. Each adult member of the household was asked to complete a questionnaire, while one adult was asked to supply information for all children that resided in the home. Participants were asked to complete the questionnaire at their leisure, and return it with a postage paid envelope that was provided. We accepted all questionnaires returned by December 31, 2005.In May 2006, a second SF-36 questionnaire was mailed to households that indicated they would be willing to participate in subsequent surveys. This allowed us to evaluate changes in health related quality of life that might exist due to seasonal variations. No analyses of the second survey are presented in this paper, largely because no appreciable differences in SF-36 scores were observed using a matched design approach.Responses from the questionnaires were entered into a database using a double data entry method. Where discrepancies were found, manual resolution was used to ensure the proper value would be used in the analysis. The number of questionnaires for which manual resolution was undertaken was relatively small (approximately 30 questionnaires).Questionnaires were delivered to a total of 829 households, and of these, 37 refused to accept the materials. At least one questionnaire was completed and returned by mail by 419 (50.5%) households. Data were collected for 741 adults and 285 children. From these questionnaires, we excluded those (n = 7) where the residential address could not be ascertained and a further 11 for whom their age could not be ascertained. When compared to Canadian census data for the study region, survey participants were more likely to be female, and over the age of 45, and have French as their mother tongue. Rates of employment were similar between census and survey data for the area.Descriptive statistics for each questionnaire item were generated to identify outliers or data anomalies. For each participant with available address, geographical information system (GIS) methods were used to calculate the distance between their homes and the IHF. We created a categorical variable to classify participants according to their residential distance to the hog farm. For adults, the distance categories were < 3, 3 - < 9, and ≥ 9 km. We choose these cutpoints for three important reasons. First, the selection of the cutpoints of <3, 3-<9 and 9> km grouped the number of participants into nearly equal groups  thereby optimizing statistical power to compare disease prevalence rates across three distance groupings. Second, the study was initiated, in part, from concerns about the potential health concerns among residents of Sarsfield. The selection of a 3 km buffer essentially placed all residents of Sarsfield in the smallest distance category, while grouping participants from the other villages in the upper distance groupings. In particular, the mean distance between the residence and the IHF among Sarsfield participants was 2.1 km (Range 0.5 -3.1). As there were far fewer children than adults in the study, and given the prevalence of the health conditions under study, and the need to adjust for other covariates we opted to use two rather than three distance categories. The third reason for selecting a range of within 3 km was that recent research has demonstrated a high prevalence of reporting malodour among those who lived within 1.5 miles (2.4 km) from industrial swine operations . In our Multivariable logistic regression was used to evaluate associations between residential distance to the hog farm, and the self-reported prevalence of various health conditions. Odds ratios generated from these regression models were adjusted for the possible confounding influence of other risk factors including: age, sex, cigarette smoking, and body mass index (BMI). BMI was treated as a potential confounding factor as several studies have found associations between it and respiratory symptoms, as well as mood disorders including depression. However, it made little difference to our measures of association and ultimately was dropped in the final models. We also examined the influence of socioeconomic status using household income on the risk estimates as previous work has shown that the validity of self-reported measures of health may vary by SES, and SES is associated with other determinants of health including diet, hygiene, and smoking. The standard errors of the odds ratios were adjusted for correlations arising from multiple questionnaires returned from the same household through the use of the method of generalized estimating equations. Statistical significance was assessed through inspection of the 95% confidence intervals of the odds ratios. We applied similar methods to compare the prevalence of childhood respiratory conditions.Analysis of variance methods were used to compare SF-36 scores according to proximity to the IHF. The method of least squares was used to produce estimates for each of the SF-36 domains within each distance category adjusted for age, sex and income. To evaluate the possible role of awareness bias, stratified analysis was performed by grouping subjects according to whether they experienced any IHF related worries, or not.The total number of households in the sampling frame within each community is presented in Table Sociodemographic characteristics according to distance from the hog farm for the adult participants are provided in Table For the most part, there were no statistically significant associations found between proximity to the IHF and the prevalence of several respiratory conditions Table . An incrAdults who lived within 3 km of the IHF were nearly twice as likely to report having been diagnosed with depression compared to those who lived at least 9 kilometres from the farm  Table . HoweverComparison of the prevalence of selected health conditions among children, as reported by their parents is provided in Table In table Our study found no statistically significant associations between self-reported prevalence of respiratory health conditions and residential proximity to the intensive hog farm for either children or adults. On the other hand, individuals who lived closer to the farm reported a reduced HRQOL, and an increased prevalence of depression. Our findings for these two outcomes are consistent with previous studies that evaluated the health of residents who neighbour large scale farming operations. In particular, a previous study that examined respiratory health among residents who lived near hog farming operation in North Carolina found that those who lived within a 2 mile radius of hog farms were more likely to report headaches and have a poorer quality of life when compared to those who lived near cattle farms, at least 2 miles from other farming operations This US Some important strengths of our study included the ability to construct a sampling list of virtually all households in the targeted communities, a relatively large number of participants (723 adults and 285 children), and the use of standardized instrument (SF-36) to evaluate health related quality of life. We used wording similar to recently conducted national health surveys. By so doing, we employed questions that had previously been validated in both English and French and allowed for a comparison of disease prevalence estimates to those for the province of Ontario.A limitation of our study was the modest participation rates of those who were asked to complete the questionnaires. Roughly one half of households invited to participate did so. We expended considerable effort to maximize participation. This included: contacting community groups to inform them of the study, inviting members of community groups to assist with the delivery of the questionnaires, a cover letter prepared by the regional medical officer of health advertising the study, door-to-door delivery of questionnaire packages, publicizing the study in local newspapers, community centres and on the internet, providing contact information for individuals who wanted additional information, providing a postage paid envelope for questionnaires to be returned, and mailing postcards to contacted homes to remind individuals to return the survey. Participation may have been compromised in part due to the property assessment notices that were delivered to residents shortly before the survey was delivered. Dramatic increases in property values, common in this assessment, may have discouraged participation in a health survey sponsored by a local level of government. Comparisons of the survey population to data for the study region based on census data indicate that women, and those over 45 are overrepresented in the study sample. This likely reflects in part, the fact that such individuals were more likely to be at home when the initial visit was made by the survey team. The lower response rates make it difficult to generalize the self-reported health measures obtained from the survey to the entirety of the target population. Given that participation varied between communities, and hence distance to the IHF, it is possible that our presented associations may be biased.Comparisons of sociodemographic characteristics between those who lived within 3 km of the IHF to those who lived further away revealed important differences. Namely, those in closer proximity to the hog farm, had lower household incomes, and lower educational attainment. Being in a low socioeconomic group is a well recognized risk factor for depression. This maUnfortunately, this study did not have any direct exposure measures. It was assumed that person who lived < 3 km from the farm were more highly exposed than others. Variations in exposure may have existed due to differences in elevation, meteorology (wind), time spent indoors or outdoors, availability of air conditioning and the amount of time spent at home. Further efforts to enhance the characterization of these exposures at a more refined spatial level would enhance the ability to detect associations. Despite this limitation, it is important to note that this study was conducted as a first step to explore whether excesses in several health conditions were evident in the town of Sarsfield which was closest to the farm. Further, it was a valuable undertaking to gauge the extent to which residents in this community were willing to participate in an ongoing health assessment. Stronger studies that would include objective outcome measures determine through clinical testing or biological sampling would necessitate an increased level of commitment to participate among residents. Our modest levels of participation suggest that undertaking such a study would prove difficult.Our findings suggest that living in close proximity to an IHF may adversely affect residents' health-related quality of life. These findings should be interpreted cautiously due to a lack of direct measures of environmental exposures, participation bias, and limitations of using self-reported measures of health status. Further research in this population should incorporate environmental monitoring data.The authors declare that they have no competing interests.PV was the principal investigator of the study and participated in the design of the study, the development of the questionnaire, the statistical analysis of the data, and the writing of the paper. AA participated in the design of the study, assisted in the development of the questionnaire and contributed to the writing and interpretation of the findings. LC performed statistical programming, assisted in the writing of the manuscript and the interpretation of the results. SH was the coordinator of the study and assisted in the training of interviewers, data entry, some statistical analyses, and assistance in the preparation of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Cumberland_english_q. A copy of the questionnaire used in the studyClick here for file


Owing to the stigma associated with sexually transmitted infections, patients may prefer to keep their illness private, and choose instead to try self-treatment remedies from the internet. However, such remedies may prove hazardous if the sellers do not provide detailed advice on adverse effects, or on avoiding transmission and re-infection. We conducted an internet search to determine the availability of treatments for STIs and the nature of information provided by vendors of these treatments.We conducted a systematic internet search using five different search engines in February 2007. The search term included the words "self treatment" and the name of six different common STIs. We visited the vendors' websites and recorded any information on the formulation, adverse effects, cautions, and prevention of infection.We identified a total of 77 treatments from 52 different companies, most of which were sold from the UK and US. The available remedies were predominantly for topical use and consisted mainly of homeopathic remedies. Only a small proportion of the web-listed products gave details on adverse effects, contraindications and interactions . Similarly, web vendors seldom provided advice on treatment of sexual contacts (20% of chlamydia and 25% of gonorrhea treatments) or on preventive measures (13%). Conversely, evidence of effectiveness was claimed for approximately 50% of the products.While treatments for certain STIs are widely available on the internet, purchasers of such products may potentially suffer harm because of the lack of information on adverse effects, interactions and contra-indications. Moreover, we consider the paucity of preventive health advice to be a serious omission, thereby leading to patients being needlessly exposed to, and potentially re-infected with the causative pathogens. Chlamydia trachomatis, secondary syphilis, genital warts and genital herpes in the UK over the past years  self treatment' as the search term, where [infection] was substituted by one of the following STIs: genital warts, HPV, genital herpes, chlamydia, gonorrhea and syphilis. There are a variety of search engines available for the retrieval of information from the internet. To increase the likelihood of finding treatments for STIs, we used five search engines: n the UK . Clusty Clusty, we also explored the first two pages of all the relevant 'clusters'. We visited websites that offered treatment of STIs (with or without offering concurrent diagnostic tests) and retrieved product data onto a database with predefined fields  on how to treat the conditions (i.e. e-books). We only researched the websites and the products offered up to the point where payment was required. On completion of the database, we aggregated the collected data and descriptively summarized the general characteristics of the available treatments.A total of 77 products from a total of 52 companies were identified in the search (Table The types of active compounds present in the products identified were: homeopathic (73%), mainly for genital warts and herpes; antibiotics (8%) for the treatment of Chlamydia and Gonorrhea; and some chemical compounds (5%), like podophyllum and imiquimod for the treatment of genital warts. Information on the active compound was not available for 14%. Of the homeopathic remedies two (for the treatment of herpes) contained dilutions of viruses  that claimed to stimulate natural immunity to clear the infection. Two other websites offered e-books on proven treatments of genital warts with remedies that could be made with products home available; but there was not enough information on the websites to determine the exact nature of these products.Overall, side effects were discussed in 22% of the products, contraindications in 25% and interactions with other drugs in 9%. The reporting of these was better for treatments of bacterial infections for which it was also more likely that an online medical consultation was offered or that advice to seek medical attention in case of treatment failure would be given if treatment failed. Where side effects were discussed this related to skin irritation; also the commonest contraindication, when mentioned, was pregnancy and breastfeeding. However, in the seven products where drug interactions were available four were related to antibiotics in which a pre-treatment form or some sort of virtual consultation was required.Inversely, there were claims of beneficial properties in almost 50% of the products, either by stating its effectiveness or by referring to approval by a regulatory body or the compliance with manufacturing regulations. Where studies were cited, these were hard to track down or referred to empirical research. Testimonial from other patients was widely used by most of the websites as a form of qualitative evidence.Recommendation that sexual partners should also be treated or advice regarding prevention  was rarely given (13% had preventive messages). Partner treatment was recommended in 20% of treatments for chlamydia and 25% for gonorrhea . Of the 4 products sold through a single eBay trader, there were at least 29 confirmed buyers over the past 90 days who left positive feedback. This is likely to be a significant underestimate though as purchasers of such products may prefer not leave their details on the seller's feedback page.Also, this study only focuses on one source of alternative treatment for STIs (i.e. the internet) and it does not address questions regarding accessibility and usage of these alternative sources. While we did not actually purchase any products, other researchers have reported success in buying both prescription drugs and alternative therapies from Internet merchants.Unfortunately, we are unable to explain the characteristics of people that may access treatment for STIs in this way, but merely speculate that if treatments are being sold and bought on the internet means that there are people willing to use alternative ways of accessing treatment. It is possible that people who use the internet for such therapies are already well-versed with preventative measures and may be purchasing the treatment for both themselves and their partners. Conversely, the lack of information from web traders on prevention may well be a cynical way of ensuring repeat visits from their customer base. Further research may be needed to determine the role that alternative therapies and lay systems play in the treatment of STIs and therefore be able to asses the overall impact that these may have in their epidemiology and transmission control.Regulatory agencies' websites in the UK and US warn consumers of the problems of purchasing treatments through the internet and of the doubtful quality of some of the products ,21. It hThe marketing and professional regulations of some of these products or companies may not be as tight as those provided by registered pharmaceutical companies and the medical establishment, thus resulting in lack of information about side-effects, contraindications or interactions. Furthermore, because of the lack of contact with health care professionals, a valuable opportunity for patient education and prevention advice is lost.As regulation of vendors on the Internet is unlikely to ever be successful, we propose that the public should be educated on the dangers of using self-treatment of STIs, particularly where preventative measures are essential in stopping re-infection. Government agencies could explore the possibility of using the same search engines that are used by potential customers of these products, ensuring that similar searches also return prominent links to promotional sites warning of the dangers and giving appropriate preventive advice.HPV Human Papilloma VirusSTI Sexually transmitted infectionUK United KingdomUS United StatesThe author(s) declare that they have no competing interests.All authors participated in the design and data collection. RV drafted the manuscript with input from SS and YKL. All authors have read and approved the final manuscriptThe pre-publication history for this paper can be accessed here:


ISBN: 978-0-262-20167-4, $29.95The Great Lead Water Pipe Disaster.The adverse health outcomes associated with lead exposure were known in ancient times, but knowledge of adverse effects associated with high levels of exposure to lead and the realization that subtle (and not so subtle) effects may be occurring at much lower may not be readily seen by even the most astute scientists and physicians. This is the essential thesis of Werner Troesken’s In his well-researched and well-referenced text, Troesken develops his thesis on the effects of lead exposure in the context of the late 19th- and early 20th-century United States and United Kingdom. He begins with an anecdote on the mysterious death of Michael Galler, a resident of New York City, in 1868. The tale is filled with intrigue and even the suggestion that he might have been murdered by his wife. But eventually Troesken comes to implicate slow but insidious poisoning by lead leached from pipes delivering water to Galler’s home. Galler’s physician did not note any overt signs of “classic” lead poisoning, but exhumation and autopsy of Galler’s body revealed additional evidence of the ravages of long-term, low-level lead.This prologue foreshadows the development of the book, as Troesken uses a combination of case studies of individual patients coupled with municipal water supply monitoring records and other scientific data to weave the tapestry of his thesis. Troesken’s story unfolds slowly, as did the development of understanding of the problem itself: It took nearly 50 years, from the 1880s through the early 1930s, before the medical and scientific community fully recognized the impact associated with low-level lead exposure. Initially, few believed that the levels of lead found in municipal water supplies could cause any harm at all. Although high exposures were known to cause effects, the observed low levels were deemed innocuous. Yet data showed higher fractions of spontaneous abortion, neurologic effects, and digestive problems in regions with lead water-delivery systems and acidic water supplies than in comparable regions without these factors. It took the development of epidemiology to uncover the associations.Troesken offers compelling insight into the workings of both the medical and scientific communities and their interaction with the political structure of the time period. Although scientists and physicians were wrestling with the subtle and sometimes conflicting data on health outcomes associated with lead exposure, politicians, urban planners, and city leaders were wrestling with the costs, both fiscal and political, of assessing and fixing the problem. Readers may find similarities in this conflict between science and politics with current issues on climate change. As with climate change, early data collected on the effects of lead were uncertain and contradictory. However, eventually the scientific and medical communities came to a consensus that the lead pipe delivery systems were to blame, paralleling current thought on climate change data.A professional historian, Troesken delves deeply into background material, seeking out primary references, private journals of physicians, and original data collected by numerous municipal water suppliers during this period. Although quite concerned with proper referencing and attribution, Troesken still makes the tale interesting, albeit somewhat tough sledding at points. The level of detail and the number of tables presented likely preclude this volume from reaching the best-seller list and may limit its accessibility to the lay reader. The end notes, which are likely to be skipped on a cursory reading, often add valuable insight and nuance to the story. The most challenging material, particularly the statistical analyses reflecting the impact of lead exposure on fetal mortality using regression methods, is relegated to one of three appendices totaling nearly 40 pages in length. In the end, however, environmental health scientists as well as those with keen interest in environmental health issues will doubtless find their efforts in getting through the material well rewarded.Although an excellent read overall, the book is not without flaws. I was troubled by the mixing of units for lead concentration given in the text—grains per gallon, parts per million, and so on. Although in each case Troesken uses the unit appropriate for the era in which the data were collected, the constant switching back and forth was at times annoying and made interpretation more difficult. There are a few other minor flaws, but these are quibbles. On balance, Troesken’s book is quite solid and is recommended to all those interested in the history of this specific problem or of public health epidemiology in general.


The objective of this study was to assess the cognitive functions of Indian children with acute lymphoblastic leukemia (ALL), periodically after initiation of treatment since prospective longitudinal research in this area on the Indian population has not been adequately documented. Unlike many western studies that have targeted survivors of ALL, we aimed to bring out the cognitive outcome after initiation of treatment. The cognitive functions of 19 patients diagnosed to have ALL were assessed using standardized tests after induction chemotherapy, and periodically thereafter following the second course of treatment comprising central nervous system-directed radiotherapy, and chemotherapy using intrathecal methotrexate. The study found a statistically significant decline in the intelligence quotient and a deficit in the cognitive function of analytical reasoning. This preliminary study supports findings of an earlier Indian study and many studies conducted in the west. Since the life expectancy of these children has increased and most of them have long-term survival, and even cure, we suggest that identifying and managing children with cognitive difficulties are important in the rehabilitation of these children. Until four decades ago, children diagnosed to have acute lymphoblastic leukemia (ALL) had a life expectancy of less than 1 year. Death often resulted not from the original hematological disease but from its progression within the central nervous system (CNS). Now, aboDuring long-term follow-up of children treated for ALL that had CNS-directed RT [18 Grey (Gy) in 10 fractions] and chemotherapy using ITMTX in our institution, there were reports from parents that children were unable to attend to simple tasks or their eye-hand coordination was poor or their memory was unsatisfactory or their arithmetic ability was inadequate. These reports were substantiated by the school teachers′ reports of these children. This observation was further supported by cognitive deficits found on objective psychometric tests. Hence, we attempted a systematic prospective longitudinal study, since research in this area on the Indian population has not been adequately documented. The objective of the present study was to assess the cognitive functions of Indian children with ALL, periodically after initiation of treatment. The present study, in contrast to many western studies that have targeted survivors of ALL, has attempted to bring out the cognitive outcome after initiation of treatment.A total of 371 ALL patients (children) were sent to the clinical psychologist over a period of 6½ years.A sample of 77 patients from this pool of 371 children diagnosed to have ALL from the Paediatric Oncology Department of our institution was included in the study. Inclusion criteria were patients 6-12 years old and knowing the local language, i.e., Kannada. Exclusion criteria were patients with history of CNS disease; sensory motor deficits; and a concurrent neurological or psychiatric disorder and/or mental retardation (MR). The remaining 294 patients could not be included in the study due to not fulfilling selection criteria, not reporting after first contact, not keeping appointments or not being cooperative for assessments.The 77 patients were fairly homogeneous in terms of the socioeconomic status, i.e., they mostly belonged to the lower socioeconomic status group. Financial aid was mobilized through several resources available.In the Indian population, family ties are apparently strong and it is the cultural practice to bond closely, especially in a crisis such as caring for a sick child. Parents and other significant persons were counseled regarding handling of stress and the need to provide emotional support to the sick child. All efforts were made to create a homely atmosphere for the patient during hospitalization. Return to school as soon as possible was advised so that the children would be able to get back into a normal routine as before. Thus, these patients were given apparently adequate care before, during and after treatment. With regard to the above, it is apparent that the sample of 77 patients was also homogeneous in terms of family/social relationships and emotional bonding.A single-group outcome study with multiple assessments was used where each patient was his or her own control. All 77 patients were treated with a multicentric protocol (MCP 841) of the National Cancer Institute.After diagnosis and the first course of treatment, i.e., induction chemotherapy, and before the commencement of the second course of treatment (CNS-directed RT with ITMTX), patients without history of CNS disease, sensory motor deficits and a concurrent neurological disorder were sent to the clinical psychologist. Patients fulfilling the remaining selection criteria were then included in the study. The rationale, nature, aims and implications of the study were then explained to the parent(s), and their consent to participate in the study was obtained.Subsequently, psychological tests appropriate for this 6-12 year age group were chosen: The Bender gestalt test (BGT) for young children; colored After completion of the second course of treatment, i.e., CNS-directed RT (18 Gy in 10 fractions) and ITMTX, patients were assessed periodically, resulting in multiple assessments. There were three further assessments that were identical to the initial psychological assessment, with an interval between assessments of at least 6 months to overcome practice effect. During these subsequent assessments, the patients were either on maintenance treatment or follow-up in an outpatient clinic. The assessments, however, did not interfere with the routine treatment protocol for ALL while on treatment and with investigative medical procedures while on follow-up. Patients were sent to the clinical psychologist whenever they came to the outpatient clinic. Patients did not have CNS disease or systemic relapse of ALL during these assessments.t test, for comparing means of two correlated samples[P value less than 0.05 was considered statistically significant.Only the data of patients that were repeatedly assessed were considered for statistical analysis. The nonparametric test, viz., Wilcoxon′s signed-rank test, for paired sample differences and the d samples were useSeventy-seven patients that were included in the study completed the first assessment. However, at the second assessment, 19 patients completed the BGT and CPM; and of the 19, 11 patients completed the BKT. Seven and 3 patients out of the 19 completed all the tests at the third and fourth assessments, respectively. The 19 patients that were available for the second assessment were apparently similar to the remaining 58 patients in the various socio-demographic variables.The marked decline in the number of patients over the duration of the study was due to several psycho-social factors such as time constraints, long distance of travel, family/social responsibilities, etc.Thus, 19 patients from the initial pool of 77 patients that could be repeatedly assessed were considered for statistical analysis. Of the 19 patients studied, 14 were males and 5 were females. The mean age of the group was 9.46 ± 1.56 years. The second assessment was carried out about 10 months  after the first assessment. The range was 6-22 months. The third assessment was done about 12 months  after the second assessment and 23 months  after the first assessment. The ranges were 6-22 and 12-44 months, respectively.t values for paired sample differences in the variables as measured by the BGT and CPM between the first and second assessments. As mentioned earlier, there were 19 patients that completed the BGT and CPM at the second assessment. As given in the table, there was no significant change in the age equivalent scores on the BGT, although an increment in the scores was evident at the second assessment as compared to the first. However, there was a significant decrease in the CPM values at the 0.01 level at the second assessment as compared to the first. The comparison of mean values of the IQ as measured by the BKT between the first and second assessments is shown in [t values for paired sample differences in the variables as measured by the BGT and CPM between the second and third assessments. As mentioned earlier, 7 patients completed both the tests at the third assessment. As indicated in shown in . As mentAt the fourth assessment, the number of patients reduced to 3. Since there were only 3 patients at the fourth assessment, the findings on this assessment could not be statistically analyzed.Unlike many western studies that have targeted survivors of ALL, the present study aimed to bring out the cognitive outcome after initiation of treatment. As pointed out earlier, psychological assessment of ALL children in a prospective longitudinal study has many practical problems. Since they came from faraway rural areas, the follow-up was difficult; and in view of their illness, it was sometimes difficult to engage them for long periods of time due to easy fatigability. However, the present study was an attempt to systematically examine the cognitive outcome of these children since prospective longitudinal research in this area on the Indian population has not been adequately documented.et al.,[In the present study, on the BGT, comparing the first and second; and second and third assessments Tables  and 3, tet al., did not et al., This couOn the CPM, comparing the first and second; and second and third assessments Tables  and 3, tOn the BKT, comparing the first and second assessments, there was evidence suggesting that the IQs of subjects had significantly decreased after the second course of treatment . The IQ These preliminary findings support earlier work done in India by the All India Institute of Medical Sciences (AIIMS) and in t1016et al.,[It was apparent from a qualitative pattern analysis of the cognitive functions on the BKT across the first to third assessments, that the cognitive functions maximally affected were mainly nonverbal functions, those of conceptual thinking and nonverbal reasoning; while those of numerical reasoning and visuo-motor coordination were affected to a lesser extent. The CPM, as mentioned earlier, showed evidence for a statistically significant decline in analytical reasoning Tables  and 3, o16121417231223et al., deficitsPrevious western studies have shoSince the life expectancy of these children has increased and most children have long-term survival and even cure, we suggest that identifying children with cognitive difficulties and parental counseling could be3The present study is undoubtedly preliminary in nature, considering that the findings are based on a small sample of patients. Moreover, the tests used for the assessment of cognitive functions are rarely used currently, especially for research. Hence, the use of newer and more comprehensive batteries of tests, with vernacular translations, standardized on Indian children, on a larger sample; and comparing outcomes with other socioeconomic groups are needed. Unlike the previous Indian study, which waIn conclusion, given that the sample was apparently homogeneous in terms of the socioeconomic status, family/social relationships, and emotional bonding, the present study, though preliminary in nature, gives evidence for a significant IQ decline and a deficit in the cognitive function of analytical reasoning in children with ALL that have undergone CNS-directed RT and ITMTX. Further research in this area is warranted.