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Understanding risk factors for death from Covid-19 is key to providing good quality clinical care. We assessed the presenting characteristics of the ‘first wave’ of patients with Covid-19 at Royal Oldham Hospital, UK and undertook logistic regression modelling to investigate factors associated with death. Of 470 patients admitted, 169 (36%) died. The median age was 71 years (interquartile range 57–82), and 255 (54.3%) were men. The most common comorbidities were hypertension (n = 218, 46.4%), diabetes (n = 143, 30.4%) and chronic neurological disease (n = 123, 26.1%). The most frequent complications were acute kidney injury (AKI) (n = 157, 33.4%) and myocardial injury (n = 21, 4.5%). Forty-three (9.1%) patients required intubation and ventilation, and 39 (8.3%) received non-invasive ventilation. Independent risk factors for death were increasing age (odds ratio (OR) per 10 year increase above 40 years 1.87, 95% confidence interval (CI) 1.57–2.27), hypertension (OR 1.72, 95% CI 1.10–2.70), cancer (OR 2.20, 95% CI 1.27–3.81), platelets <150 × 103/μl (OR 1.93, 95% CI 1.13–3.30), C-reactive protein ≥100 μg/ml (OR 1.68, 95% CI 1.05–2.68), >50% chest radiograph infiltrates (OR 2.09, 95% CI 1.16–3.77) and AKI (OR 2.60, 95% CI 1.64–4.13). There was no independent association between death and gender, ethnicity, deprivation level, fever, SpO2/FiO2, lymphopoenia or other comorbidities. These findings will inform clinical and shared decision making, including use of respiratory support and therapeutic agents.
To explore community perceptions on maternal and child nutrition issues in Sub-Saharan Africa.
Thirty focus groups with men and women from three communities facilitated by local researchers.
One urban (Soweto, South Africa) and two rural settings (Navrongo, Ghana and Nanoro, Burkina Faso) at different stages of economic transition.
Two hundred thirty-seven men and women aged 18–55 years, mostly subsistence farmers in Navrongo and Nanoro and low income in Soweto.
Differences in community concerns about maternal and child health and nutrition reflected the transitional stage of the country. Community priorities revolved around poor nutrition and hunger caused by poverty, lack of economic opportunity and traditional gender roles. Men and women felt they had limited control over food and other resources. Women wanted men to take more responsibility for domestic chores, including food provision, while men wanted more involvement in their families but felt unable to provide for them. Solutions suggested focusing on ways of increasing control over economic production, family life and domestic food supplies. Rural communities sought agricultural support, while the urban community wanted regulation of the food environment.
To be acceptable and effective, interventions to improve maternal and child nutrition need to take account of communities’ perceptions of their needs and address wider determinants of nutritional status and differences in access to food reflecting the stage of the country’s economic transition. Findings suggest that education and knowledge are necessary but not sufficient to support improvements in women’s and children’s nutritional status.
Involuntary admission and treatment is often a traumatic experience for patients and there is a wide variation in attitudes towards care even when patients are recovered.
The purpose of this large prospective study was to identify clinical predictors of attitudes towards care during involuntary admission.
Three hundred and ninety-one consecutively admitted involuntarily patients to three psychiatric inpatient units over a 30-month period were invited to participate in the study. Comprehensive assessments at admission and 3 months after discharge were attained including measures of symptoms, insight, functioning, attitudes towards involuntary admission and coercive experiences. Multiple linear regression modelling was used to determine the optimal explanatory variables for attitudes towards care.
Two hundred and sixty-three individuals participated at baseline and 156 (59%) successfully completed follow-up assessments. Individuals improved significantly over time clinically and in their attitudes towards their care. At baseline greater insight (P < 0.001) and less symptoms (P = 0.02) were associated with more positive attitudes towards care as was older age (P = 0.001). At follow-up, greater insight (P < 0.001), less symptoms (P = 0.02) and being older (P = 0.04) were associated with more positive attitudes towards care. More positive attitudes towards care at follow-up were associated with greater improvements in insight over time (P < 0.001) and having a diagnosis of an affective psychosis (P = 0.0009).
The best predictors of positive attitudes towards care during and after involuntary admission are illness related factors, such as levels of insight and improvement in insight, rather than service or legislation related factors, such as the use of coercive measures, seclusion and restraint.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
To assess the effect of rural-to-urban migration on nutrition transition and overweight/obesity risk among women in Kenya.
Secondary analysis of data from nationally representative cross-sectional samples. Outcome variables were women’s BMI and nutrition transition. Nutrition transition was based on fifteen different household food groups and was adjusted for socio-economic and demographic characteristics. Stepwise backward multiple ordinal regression analysis was applied.
Kenya Demographic and Health Survey 2014.
Rural non-migrant, rural-to-urban migrant and urban non-migrant women aged 15–49 years (n 6171).
Crude data analysis showed rural-to-urban migration to be associated with overweight/obesity risk and nutrition transition. After adjustment for household wealth, no significant differences between rural non-migrants and rural-to-urban migrants for overweight/obesity risk and household consumption of several food groups characteristic of nutrition transition (animal-source, fats and sweets) were observed. Regardless of wealth, migrants were less likely to consume main staples and legumes, and more likely to consume fruits and vegetables. Identified predictive factors of overweight/obesity among migrant women were age, duration of residence in urban area, marital status and household wealth.
Our analysis showed that nutrition transition and overweight/obesity risk among rural-to-urban migrants is apparent with increasing wealth in urban areas. Several predictive factors were identified characterising migrant women being at risk for overweight/obesity. Future research is needed which investigates in depth the association between rural-to-urban migration and wealth to address inequalities in diet and overweight/obesity in Kenya.
Longitudinal maternal mental health data are needed from high HIV prevalence settings. The Siyakhula Cohort (SC) is a population-based cohort of HIV-positive and negative mothers (n=1506) with HIV-negative children (n=1536) from rural South Africa. SC includes 767 HIV-negative mothers; 465 HIV-positive in pregnancy; 272 HIV-positive since pregnancy (n=2 missing HIV status). A subgroup (n=890) participated in a non-randomized breastfeeding intervention [Vertical Transmission Study (VTS)]; the remaining (n=616) were resident in the same area and received antenatal care at the time of the VTS, but were not part of the VTS, instead receiving the standard of care Prevention of Mother-to-Child Transmission (PMTCT) Programme. In secondary analysis we investigated the prevalence of, and factors associated with, psychological morbidity amongst mothers who were still the primary caregiver of the child (1265 out of 1506) at follow-up (7–11 years post-birth). We measured maternal depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder Scale-7) and parenting stress (Parenting Stress Index-36), using standardized cut-offs and algorithms. In total, 75 (5.9%) mothers met criteria for depression, 37 (2.9%) anxiety and 134 (10.6%) parenting stress. Using complete case logistic regression (n=1206 out of 1265 mothers) as compared to being HIV-negative, testing HIV-positive in pregnancy doubled odds of depression [adjusted odd ratios (aOR)=1.96 [1.0–3.7] P=0.039]. Parenting stress was positively associated with acquisition of HIV after pregnancy (aOR=3.11 [1.9–5.2] P<0.001) and exposure to household crime (aOR=2.02 [1.3–3.2] P=0.003); negatively associated with higher maternal education (aOR=0.29 [0.1–0.8] P=0.014), maternal employment (aOR=0.55 [0.3–0.9] P=0.024). Compared with the standard of care PMTCT, VTS mothers had reduced odds of parenting stress (aOR=0.61 [0.4–0.9] P=0.016). Integrating parental support into mostly bio-medical treatment programmes, during and beyond pregnancy, is important.
Observational tasks that require photometry of large numbers of objects, or over large fields, are still best approached using photographic photometry. Nevertheless, there are well-known problems in using photographic emulsions as two-dimensional detectors; these include their non-linearity and unknown photometric zero-points. The non-linearity can be calibrated using standard sensitometer techniques but the provision of photometric zero-points (and the verification of the validity of the intensity calibration) can be done properly only by providing a sequence of standards down to the plate limit. One approach to this latter problem, that has recently been revived by Racine (1969), is to use a sub-beam prism as originally suggested by Pickering (1891).
Receiving an education is essential for children living in poverty to fulfil their potential. Success in the early years of schooling is important as children who repeat grade one are particularly at risk for future dropout. We examined early life factors associated with grade repetition through logistic regression and explored reasons for repeating a grade through parent report. In 2012–2014 we re-enrolled children aged 7–11 years in rural KwaZulu-Natal who had been part of an early life intervention. Of the 894 children included, 43.1% had repeated a grade, of which 62.9% were boys. Higher maternal education (aOR 0.44; 95% CI 0.2–0.9) and being further along in the birth order (aOR 0.46; 95% CI 0.3–0.9) reduced the odds of grade repetition. In addition, maternal HIV status had the strongest effect on grade repetition for girls (aOR 2.17; 95% CI 1.3–3.8), whereas for boys, it was a fridge in the household (aOR 0.59; 95% CI 0.4–1.0). Issues with school readiness was the most common reason for repeating a grade according to parental report (126/385, 32.7%), while school disruptions was an important reason among HIV-exposed boys. Further research is needed to elucidate the pathways through which HIV affects girls’ educational outcomes and potentially impacts on disrupted schooling for boys. Our results also highlight the importance of preparation for schooling in the early years of life; future research could focus on gaining a better understanding of mechanisms by which to improve early school success, including increased quality of reception year and investigating the protective effect of older siblings.
Whose responsibility is it to tackle climate change? ‘Everyone’s and no one’s’, we might glibly reply. Responsibility is diffused across scales, social groups, sectors, countries and generations. The causes of climate change are implicated in everyday acts of production and consumption and relate to the ways in which societies organise their transportation, housing, energy, water and food systems. Recognising the complex and diffuse agencies and authorities that address climate change, the world of climate politics is no longer limited to the activities of national governments, international organisations and interstate bargaining between states. Increasingly, subnational governments, non-governmental organisations, businesses and individuals are taking responsibility into their own hands, experimenting with bold new approaches to the governance of climate change (Betsill & Bulkeley 2004; Andonova, Betsill & Bulkeley 2009; Selin & VanDeveer 2009b; Bulkeley & Newell 2010; Hoffmann 2011; Bulkeley et al. 2013). The governance of climate change now takes a seemingly bewildering array of forms: carbon markets, certification standards, voluntary workplace schemes, emissions registries, carbon labelling, urban planning codes and so on. Critical to this transformation of the politics of climate change has been the emergence of new forms of transnational governance that cut across traditional state-based jurisdictions, operate across public-private divides and seek to develop new approaches and techniques through which responses are developed. What sets these initiatives apart from other forms of transnational relations is how they not only influence others, but also how they directly intervene in the governing of global affairs in ways that defy conventional understandings of international relations.
This chapter examines the political dynamics underpinning the emergence of TCCG. In the first section of the chapter, we undertake a temporal analysis of the growth of TCCG, focusing on its parallel evolution with the international climate change regime and the broader political-economic shifts outlined in the previous chapter. In the second section of the chapter, our analysis turns to consider the patterns and drivers of private, hybrid and public transnational initiatives over time and to consider the governance functions that are being pursued in these different forms of TCCG. Through this analysis, we seek to capture the process through which climate politics has pluralised by describing and offering explanations for the growth of institutional diversity over time.
In doing so, the three theoretical lenses discussed in Chapter 3 serve as guides for our analysis. The agency-centred perspective is particularly helpful for highlighting the interests of the actors that populate climate politics, their sources of influence and factors underpinning the demand and supply of new forms of transnational governance. The social and system dynamics perspective helps to explain the diffusion of common practices and governance techniques through communities of environmental practitioners and policymakers. Finally, the critical political theory perspective sheds light on the marketisation of a substantial cluster of TCCG initiatives, the ideological underpinnings of these initiatives and the particular constellations of public and private forces that animate them. We use the TCCG database and illustrative case-studies to interrogate these issues illuminating the relationship between the agency of different actors, market logics, functional imperatives and normative contexts.
Our knowledge of transnational governance has been fundamentally shaped by the theoretical perspectives and methodological approaches that have been used to study it (O’Neill et al. 2013, 444). Primarily using a case-study approach revolving around a few high-profile examples, research on transnational governance has focused on the ways in which actors have sought to engage with different forms of transnational governance, the various functions that such arrangements seek to perform and their potential consequences in terms of legitimacy and effectiveness. Such approaches have yielded significant insights into these aspects of transnational governance but cannot, by their very nature, achieve a more comprehensive or systematic view. As O’Neill et al. (2013) suggest, such approaches may be ill-equipped to deal with the challenges of ‘complexity and uncertainty, vertical linkages across multiple scales, horizontal linkages across issue areas, and (often rapidly) evolving problem sets and institutional initiatives’ that beset global environmental governance research, such that new methodological approaches are required. If we regard transnational governance initiatives as having something in common – in terms of what they are seeking to accomplish, or in terms of the ways in which they are organised and constituted – we suggest that methodological innovations capable of creating a more comprehensive account of the overall phenomenon are required.
In order to develop such a broader understanding of the extent and nature of transnational governance in the climate change domain, our approach extends beyond small n case-studies or surveys of one particular type of transnational arrangement through the construction and analysis of a database of sixty transnational climate governance initiatives. This approach enables an analysis of the contours of transnational climate governance in a way that has not been possible within existing methodological approaches, allowing for a more thorough description of who and what are involved, where it is taking place, and how and why it is being pursued.
One thing should already be clear from the preceding chapters: transnational climate governance is qualitatively different from the standard multilateral model that has characterised the last two decades of climate change governance. The multilateral model is a hierarchical one; it functions through the generally accepted legitimate authority of nation-states to act on issues that transcend borders. In the multilateral process, a legally binding global treaty engages all nation-states in a common (and hopefully enforceable) purpose. In theory, there is an assumption of smooth vertical development of policy that draws on the legitimate, traditional authority of nation-states, both in constructing the international treaty and formulating national regulations. International law translates to national regulation, which directs domestic actions at more local levels. Alternatives to the authority and legitimacy of the multilateral process are rarely considered quite simply because the global system has functioned through this process for over a century (Denemark & Hoffmann 2008) despite criticisms about the interests served by this system and whose order it seeks to preserve (Cox 1987; Murphy 1994; Cox & Sinclair 1996). The emergence and functioning of TCCG asks us to question and engage questions of authority and legitimacy with a more critical eye, to understand how, in Hajer’s (2003) words, we can have policy without a polity, or how, as Rosenau asks, a range of actors can govern without the legal authority to do so (Rosenau & Czempiel 1992).
Our intention at the outset of this project was to move beyond the focus on individual cases or particular segments of the world of TCCG in order to examine what we might be able to discover collectively about this phenomenon. In this final chapter, we return to this overarching theme and identify the ways in which our analysis of TCCG contributes to ongoing debates in the field.
Underpinning this contribution, we suggest, are two novel aspects of our work. First, the book provides the first analysis of transnational governance that includes both an extensive database of a large number and a diverse array of particular case-studies. Existing research in the field of transnational governance has been mostly based on either individual examples or a small number of cases; whereas these can provide rich and nuanced analyses, there is nevertheless a significant value added in attempting to say something about this phenomenon as a whole. While we have not been able to survey the entire universe of cases in the transnational climate governance arena, a task that would be difficult to undertake given that much of this activity is relatively unknown, we have devised a strategy to maximise the diversity of cases we explore. In the sense that the approach we have developed includes the full variety of forms of TCCG, we thus suggest that it can be regarded as representative of the phenomenon as a whole. The database approach has enabled us to see patterns in the types of initiatives that predominate in TCCG, in terms of the types of actors, the issues upon which they focus, the forms of institutionalisation, the practices of governance, the claims to legitimacy and the geographical reach of TCCG initiatives.