Mortality,Morbidity and Health-Seeking Behaviour during the Ebola Epidemic 2014–2015 in Monrovia Results from a Mobile Phone Survey

Between March 2014 and July 2015 at least 10,500 Ebola cases including more than 4,800 deaths occurred in Liberia, the majority in Monrovia. However, official numbers may have underestimated the size of the outbreak. Closure of health facilities and mistrust in existing structures may have additionally impacted on all-cause morbidity and mortality. To quantify mortality and morbidity and describe health-seeking behaviour in Monrovia, Médecins sans Frontières (MSF) conducted a mobile phone survey from December 2014 to March 2015. We drew a random sample of households in Monrovia and conducted structured mobile phone interviews, covering morbidity, mortality and health-seeking behaviour from 14 May 2014 until the day of the survey. We defined an Ebola-related death as any death meeting the Liberian Ebola case definition. We calculated all-cause and Ebola-specific mortality rates. The sample consisted of 6,813 household members in 905 households. We estimated a crude mortality rate (CMR) of 0.33/10,000 persons/day (95%CI:0.25–0.43) and an Ebola-specific mortality rate of 0.06/10,000 persons/day (95%-CI:0.03–0.11). During the recall period, 17 Ebola cases were reported including those who died. In the 30 days prior to the survey 277 household members were reported sick; malaria accounted for 54% (150/277). Of the sick household members, 43% (122/276) did not visit any health care facility. The mobile phone-based survey was found to be a feasible and acceptable alternative method when data collection in the community is impossible. CMR was estimated well below the emergency threshold of 1/10,000 persons/day. Non-Ebola-related mortality in Monrovia was not higher than previous national estimates of mortality for Liberia. However, excess mortality directly resulting from Ebola did occur in the population. Importantly, the small proportion of sick household members presenting to official health facilities when sick might pose a challenge for future outbreak detection and mitigation. Substantial reported health-seeking behaviour outside of health facilities may also suggest the need for adapted health messaging and improved access to health care.     

Morbidity in Canadian Indian and non-Indian children in the first year of life.

A cohort study of health status was undertaken to determine the patterns of morbidity in the first year of life for Indian and non-Indian infants living in southern Ontario. The annual incidence of office-reported health problems was 8.0 episodes for the 99 Indians and 4.5 for the 316 non-Indians studied. The risk of illness of most diagnostic categories was more than 1.5 times greater and the rate of hospital admission 4 times greater for the Indian infants. There was no difference between the two cohorts in the rates of visits to hospital emergency departments. The main cause of illness in both cohorts was respiratory tract infection; lower respiratory tract infections, particularly pneumonia, were a major health problem among the Indian infants. Only 36% of the Indian infants compared with 68% of the non-Indian infants attended five or more well-baby examinations. Part of the difference in morbidity between the Indian and non-Indian infants may be attributed to environmental factors, health care behaviour and geographic constraints.     

Reproductive health status, knowledge, and access to health care among female migrants in Shanghai, China

As the largest labour flow in human history, the recent rise in migration in China has opened up unprecedented opportunities for millions of Chinese to rearrange their lives. At the same time, this process has also posed great challenges to Chinese migrants, especially female migrants, who not only face a bias against 'outsiders' but also have a greater need for reproductive health-related services in their migratory destinations. Based on data collected via multiple sources in Shanghai, China's largest metropolis, this study profiles the changing characteristics of female migrants, presents data on self-reported symptoms of reproductive health-related problems and knowledge on reproductive health issues, compares maternal and child health measures between migrants and local residents, and examines factors related to reproductive health knowledge and migrants' access to health care in urban China. Results of this study show a relatively low level of self-reported reproductive health problems among female migrants, coupled with a relatively high level of ignorance in knowledge related to STD. Both self-reported health status and knowledge of reproductive health are related to migrants' educational attainment and length of stay in the urban destination. This study also finds ample evidence that female migrants' access to urban health care is limited by a number of institutional barriers.     

Unmet need for additional medical care for sick children in mother's view in rural Bangladesh: implications for improving child health services

While a country's health policy aims to provide health services to all who need them, very little in known about unmet need for additional medical care from users' perspectives in Bangladesh. This study examined unmet medical need (defined as whether a mother felt that, to manage sickness, her child had required medical care that was not available, regardless of reasons and medical care sought) of 2123 under-15 sick children by illness and child's socioeconomic characteristics in rural Bangladesh. The 1996 Health and Socioeconomic Survey conducted in Matlab recorded children's chronic (a disease or a condition lasting 3 months or more) and acute (a disease or a condition with a rapid onset and a short, severe course) morbidity, medical care sought to combat illness and unmet needs for additional medical services in mothers' views to manage the illness. The survey also recorded household socioeconomic data. Logistic regression was used to examine the data. The results reveal that unmet needs for additional medical care were 5.4% for children with acute illnesses, and 30.2% for children with chronic illnesses. For chronic illnesses, seeking medical care to manage illness from any health provider outside the home reduced unmet medical needs. Economic inequalities existed for both acute and chronic illnesses: the odds ratio of unmet medical needs for sick children of the least poor households was 0.42 (95% CI: 0.28-0.64) times that for sick children of the very poor households. The critically high unmet needs for children's chronic morbidity reveal that the chronic disease control programme in Bangladesh needs urgent revisiting and strengthening.     

Pregnancy-Related Health Information-Seeking Behaviors Among Rural Pregnant Women in India: Validating the Wilson Model in the Indian Context

Objectives: Understanding health information-seeking behaviors and barriers to care and access among pregnant women can potentially moderate the consistent negative associations between poverty, low levels of literacy, and negative maternal and child health outcomes in India. Our seminal study explores health information needs, health information-seeking behaviors, and perceived information support of low-income pregnant women in rural India. Methods: Using the Wilson Model of health information-seeking framework, we designed a culturally tailored guided interview to assess information-seeking behaviors and barriers to information seeking among pregnant women. We used a local informant and health care worker to recruit 14 expectant women for two focus group interviews lasting 45 minutes to an hour each. Thirteen other related individuals including husbands, mothers, mothers-in-law, and health care providers were also recruited by hospital counselors for in-depth interviews regarding their pregnant wives/daughters and daughters-in-law. Interviews were transcribed and analyzed by coding the data into thematic categories. Results: The data were coded manually and emerging themes included pregnancy-related knowledge and misconceptions and personal, societal, and structural barriers, as well as risk perceptions and self-efficacy. Lack of access to health care and pregnancy-related health information led participants to rely heavily on information and misconceptions about pregnancy gleaned from elder women, friends, and mothers-in-law and husbands. Doctors and para-medical staff were only consulted during complications. All women faced personal, societal, and structural level barriers, including feelings of shame and embarrassment, fear of repercussion for discussing their pregnancies with their doctors, and inadequate time with their doctors. Conclusion: Lack of access and adequate health care information were of primary concern to pregnant women and their families. Policy Implications: Our study can help inform policies and multi-sectoral approaches that are being taken by the Indian government to reduce maternal and child morbidity and burdens.     

Effects of antipsychotics,antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia,depression and bipolar disorder

People with severe mental illness have a considerably shorter lifespan than the general population. This excess mortality is mainly due to physical illness. Next to mental illness‐related factors, unhealthy lifestyle, and disparities in health care access and utilization, psychotropic medications can contribute to the risk of physical morbidity and mortality. We systematically reviewed the effects of antipsychotics, antidepressants and mood stabilizers on physical health outcomes in people with schizophrenia, depression and bipolar disorder. Updating and expanding our prior systematic review published in this journal, we searched MEDLINE (November 2009 ‐ November 2014), combining the MeSH terms of major physical disease categories (and/or relevant diseases within these categories) with schizophrenia, major depressive disorder and bipolar disorder, and the three major psychotropic classes which received regulatory approval for these disorders, i.e., antipsychotics, antidepressants and mood stabilizers. We gave precedence to results from (systematic) reviews and meta‐analyses wherever possible. Antipsychotics, and to a more restricted degree antidepressants and mood stabilizers, are associated with an increased risk for several physical diseases, including obesity, dyslipidemia, diabetes mellitus, thyroid disorders, hyponatremia; cardiovascular, respiratory tract, gastrointestinal, haematological, musculoskeletal and renal diseases, as well as movement and seizure disorders. Higher dosages, polypharmacy, and treatment of vulnerable (e.g., old or young) individuals are associated with greater absolute (elderly) and relative (youth) risk for most of these physical diseases. To what degree medication‐specific and patient‐specific risk factors interact, and how adverse outcomes can be minimized, allowing patients to derive maximum benefits from these medications, requires adequate clinical attention and further research.     

Recommendations for ensuring early thrombolytic therapy for acute myocardial infarction. The Heart and Stroke Foundation of Canada,the Canadian Cardiovascular Society and the Canadian Association of Emergency Physicians for the Emergency Cardiac Care Coalition.

OBJECTIVE: To recommend practical steps to ensure early thrombolytic therapy and thereby reduce mortality and morbidity associated with acute myocardial infarction (AMI). OPTIONS: Various factors were considered that influence time to thrombolysis related to patients, independent practitioners and health care systems. OUTCOMES: Reduction in morbidity and mortality associated with AMI. EVIDENCE: Early initiation of thrombolytic therapy reduces morbidity and mortality associated with AMI. The ECC Coalition analysed the factors that might impede early implementation of thrombolytic therapy. VALUES: Published data were reviewed, and recommendations were based on consensus opinion of the Emergency Cardiac Care (ECC) Coalition. The ECC Coalition comprises 20 professional, nongovernment and government organizations and has a mandate to improve emergency cardiac care services through collaboration. BENEFITS, HARMS AND COSTS: Early thrombolytic therapy reduces morbidity and mortality associated with AMI. Implementation of the recommendations will result in reduced time to thrombolytic therapy, streamlining of current practices and enhanced cooperation among health care professionals to expedite care. Depending on existing practices, implementation may require protocol development, and public and professional education. Although costs are associated with educating the public and health care professionals, they are outweighed by the financial and social benefits of reduced morbidity and mortality. RECOMMENDATIONS: Early recognition of AMI symptoms by the public and health care professionals, early access to the emergency medical services system and early action by emergency care providers in administering thrombolytic therapy (within 30 minutes after the patient''s arrival at the emergency department). VALIDATION: No similar consensus statements or practice guidelines for thrombolytic therapy in Canada are available for comparison.     

Brazilian public policies for reproductive health: family planning, abortion and prenatal care

This study is an ethical reflection on the formulation and application of public policies regarding reproductive health in Brazil. The Integral Assistance Program for Women's Health (PAISM) can be considered advanced for a country in development. Universal access for family planning is foreseen in the Brazilian legislation, but the services do not offer contraceptive methods for the population in a regular and consistent manner. Abortion is restricted by law to two cases: risk to the woman's life and rape. This reality favors the practice of unsafe abortion, which is the third largest cause of maternal death in Brazil. Legal abortion is regulated by the State and the procedure is performed in public health centers. However, there is resistance on the part of professionals to attend these women. Prenatal care is a priority strategy for promoting the quality of life of these women and of future generations. Nonetheless, it is still difficult for these women to access the prenatal care services and to have the required number of consultations. Moreover, managers and health professionals need to be made aware of the importance of implementing the actions indicated by the public policies in the area of sexual and reproductive health, favoring respect for autonomy in a context of personal freedom.     

Domiciliary night nursing service: luxury or necessity?

The nursing records of the 242 patients who used the domiciliary night nursing care service in Newham Health District showed that three distinct groups of patients were nursed during 1979 at a cost of 8.8 pounds a day. Forty-three elderly chronically sick and five disabled patients aged under 50 received care for more than 28 days, 63 patients had terminal cancer, and 131 needed short-term care or observation. Data were also collected from a one-day survey of patients receiving care. This domiciliary care enabled the chronically sick and disabled to retain their independence and remain at home. Referrals from casualty departments and general practitioners avoided admission to acute beds. On account of the lack of continual surveillance the service is unsuitable for the elderly mentally ill.     

Does the Hispanic health advantage extend to better management of hypertension? The role of socioeconomic status,sociobehavioral factors,and health care access

Hispanics in the United States (and foreign-born Hispanics in particular) have relatively favorable health given their lower socioeconomic status compared to, for example, non-Hispanic whites. This phenomenon is often called the Hispanic health paradox (HHP). This study examines whether the previously documented HHP in hypertension prevalence extends to its management using clinical and self-reported measures from the 2007–2012 National Health and Nutrition Examination Surveys. Multivariate models adjusting for demographic, socioeconomic, and sociobehavioral characteristics show an advantage among foreign-born Mexicans in hypertension prevalence relative to non-Hispanic whites (adjusted OR = 0.85). However, compared to non-Hispanic whites, foreign-born Mexicans were 38% less likely to receive treatment recommendations and, when advised to undergo treatment, were 60% less likely to adhere to treatment. Adjusting for health care access and utilization dramatically reduces disparities in hypertension control between foreign-born Mexicans and non-Hispanic whites, suggesting that insufficient systematic access to and use of quality health care erodes the HHP and contributes to the deterioration of health throughout the immigrant experience. Without appropriate interventions, particularly in health care access and utilization, poorer hypertension management among foreign-born Mexicans may negatively affect the Hispanic health profile, increase risk of cardiovascular disease-related mortality, and erode the Hispanic health advantage in the future.     

Lifestyle modifications to prevent and control hypertension. 4. Recommendations on physical exercise training. Canadian Hypertension Society,Canadian Coalition for High Blood Pressure Prevention and Control,Laboratory Centre for Disease Control at Health Canada,Heart and Stroke Foundation of Canada

OBJECTIVE: To provide updated, evidence-based recommendations for health care professionals concerning the effects of regular physical activity on the prevention and control of hypertension in otherwise healthy adults. OPTIONS: People may engage in no, sporadic or regular physical activity that may be of low, moderate or vigorous intensity. For sedentary people with hypertension, the options are to undertake or maintain regular physical activity and to avoid or moderate medication use; to use another lifestyle modification technique; to commence or continue antihypertensive medication; or to take no action and remain at increased risk of cardiovascular disease. OUTCOMES: The health outcomes considered were changes in blood pressure and in morbidity and mortality rates. Because of insufficient evidence, no economic outcomes were considered. EVIDENCE: A MEDLINE search was conducted for the period 1966-1997 with the terms exercise, exertion, physical activity, hypertension and blood pressure. Both reports of trials and review articles were obtained. Other relevant evidence was obtained from the reference lists of these articles, from the personal files of the authors and through contacts with experts. The articles were reviewed, classified according to study design and graded according to level of evidence. VALUES: A high value was placed on avoidance of cardiovascular morbidity and premature death caused by untreated hypertension. BENEFITS, HARMS AND COSTS: Physical activity of moderate intensity involving rhythmic movements with the lower limbs for 50-60 minutes, 3 or 4 times per week, reduces blood pressure and appears to be more effective than vigorous exercise. Harm is uncommon and is generally restricted to the musculoskeletal injuries that may occur with any repetitive activity. Injury occurs more often with jogging than with walking, cycling or swimming. The costs include the costs of appropriate shoes, garments and equipment, but these were not specifically measured. RECOMMENDATIONS: (1) People with mild hypertension should engage in 50-60 minutes of moderate rhythmic exercise of the lower limbs, such as brisk walking or cycling, 3 or 4 times per week to reduce blood pressure, (2) Exercise should be prescribed as an adjunctive therapy for people who require pharmacologic therapy for hypertension, especially those who are not receiving beta-blockers. (3) People who do not have hypertension should participate in regular exercise as it will decrease blood pressure and reduce the risk of coronary artery disease, although there is no direct evidence that it will prevent hypertension. VALIDATION: These recommendations agree with those of the World Hypertension League, the American College of Sports Medicine, the report of the US Surgeon General on physical activity and health, and the US National Institutes of Health Consensus Development Panel on Physical Activity and Cardiovascular Health. These guidelines have not been clinically tested. SPONSORS: The Canadian Hypertension Society, the Canadian Coalition for High Blood Pressure Prevention and Control, the Laboratory Centre for Disease Control at Health Canada, and the Heart and Stroke Foundation of Canada.     

Sociodemographic and morbidity indicators of need in relation to the use of community health services: observational study.

OBJECTIVE: To examine whether the sociodemographic and morbidity characteristics of populations influence their use of the following community heath services: district nursing, health visiting, chiropody, community maternity, community mental illness, and the professions allied to medicine. DESIGN: Observational study. SETTING: Nationally representative sample of provider trusts in England. MAIN OUTCOME MEASURES: Activity levels for each service calculated for enumeration districts within the catchment areas of the sample of trusts and standardised to allow for differences in age structure. Regression analysis to determine whether the standardised activity rates for each service could be predicted by a range of socio-demographic and morbidity proxies. RESULTS: Morbidity or deprivation, or both, seemed to influence the use of services in each of the care programmes examined. CONCLUSIONS: The allocation of funds for community health services should allow for differences in the health and socio-demographic characteristics of health authorities.     

Age of mother and pregnancy outcome in the 1981 Arkansas birth cohort

Higher levels of obstetric risk observed among teenage mothers seem to be an artifact of lower socioeconomic status and inferior access to health care rather than biological immaturity. In a study of matched Arkansas birth-infant death records for 1978, the proxy variables for health access (month care started and number of visits) have the strongest association with each of the dependent variables. The indicators of social status (education, race, and marital status) have a weaker association, and there is virtually no age effect observable once the affects of socioeconomic status and health access have been controlled for. A series of stepwise regression analyses shows that the multiple partial for health access indicators and mortality is 0.036, while the same coefficients for social status indicators and age are 0.001 and 0.006, respectively. Similar results are obtained using the other dependent variables. Health consequences of adolescent pregnancy usually include higher rates of malnutrition and prematurity and lower birth weight. It seems that the elevated morbidity and mortality among newborns delivered by teenagers are not a result of biologic factors. After the effects of lower status and health care access have been removed, the apparent biological disadvantages attributed to teenagers disappear, and, in the case of mortality and birth weight, are replaced by a slight advantage. This advantage is observed through the use of statisitical controls and will not be observed in the population at large unless there are changes in the policies governing access to contraception, abortion, and health care by adolescents, especially those at the youngest ages.     

Community Health Seeking Behavior for Suspected Human and Animal Rabies Cases,Gomma District,Southwest Ethiopia

Background

Timely presentation to appropriate health service provider of sick animals/humans from zoonotic diseases like rabies is important for early case/outbreak detection and management. However, data on community’s health seeking practice for rabies in Ethiopia is limited. Therefore the objective of this study was to determine community’s health seeking behavior on rabies, Southwest Ethiopia.

Methods

A cross-sectional survey was conducted from January 16-February 14, 2015 to collect data from 808 respondents where the respondents were selected using multistage sampling technique. Data were collected using interviewer administered structured questionnaire by trained epidemiology graduate level students. Data were entered to Epidata version 3.1 and analyzed using SPSS version 20 for windows.

Result

Eight hundred three (99.4%) respondents participated in the study. Out of 28 respondents who reported their family members’ exposure to rabies, 8 of them replied that the exposed family members sought treatment from traditional healers. More than nine in ten respondents perceived that humans and domestic animals with rabies exposure should seek help of which 85% of them suggested modern health care facilities as the preferred management option for the sick humans and domestic animals. However, among those who reported sick domestic animals, near to 72% of them had either slaughtered for human consumption, sold immediately, visited traditional healer, given home care or did nothing for the sick domestic animals.

Conclusion

Majority of the respondents had favorable perception of seeking treatment from modern health care facilities for rabies. However, significant number of them had managed inappropriately for the sick domestic animals from rabies. Hence, raising awareness of the community about management of sick domestic animals from rabies and the need for reporting to both human and animal health service providers is needed.     

Burden of Chagas disease in Brazil, 1990–2016: findings from the Global Burden of Disease Study 2016

Chagas disease continues to be an important cause of morbidity, mortality and disability in several Latin American countries, including Brazil. Using findings from the Global Burden of Disease Study 2016 (GBD, 2016), we present years of life lost, years lived with disability, and disability-adjusted life years due to Chagas disease in Brazil, by sex, age group, and Brazilian states, from 1990 to 2016. Results are reported in absolute numbers and age-standardized rates (per 100,000 population) with 95% uncertainty intervals. In 2016, 141,640 disability-adjusted life years (95% uncertainty intervals: 129,065–155,941) due to Chagas disease were estimated in Brazil, with a relative reduction of 36.7% compared with 1990 (223,879 disability-adjusted life years (95% uncertainty intervals: 209,372–238,591)). Age-standardized disability-adjusted life year rates declined at the national level (?69.7%) and in all Brazilian states between 1990 and 2016, but with different regional patterns. The decrease in the disability-adjusted life year rates was driven primarily by a consistent reduction in the years of life lost rates, the main component of total disability-adjusted life years for Chagas disease. The highest fatal and non-fatal burden due to Chagas disease was observed among males, the elderly, and in those Brazilian states encompassing important endemic areas for vector transmission in the past. Despite the consistent reduction in its burden during the period, Chagas disease is still an important and neglected cause of health lost due to premature mortality and disability in Brazil. Efforts should be made to maintain the political interest and sustainability of surveillance and control actions for Chagas disease, prevent the risk of re-emergence of vector transmission in endemic areas, and provide health care to chronically infected individuals, including early diagnosis and treatment interventions.     

Patient Referral Patterns and the Spread of Hospital-Acquired Infections through National Health Care Networks

Rates of hospital-acquired infections, such as methicillin-resistant Staphylococcus aureus (MRSA), are increasingly used as quality indicators for hospital hygiene. Alternatively, these rates may vary between hospitals, because hospitals differ in admission and referral of potentially colonized patients. We assessed if different referral patterns between hospitals in health care networks can influence rates of hospital-acquired infections like MRSA. We used the Dutch medical registration of 2004 to measure the connectedness between hospitals. This allowed us to reconstruct the network of hospitals in the Netherlands. We used mathematical models to assess the effect of different patient referral patterns on the potential spread of hospital-acquired infections between hospitals, and between categories of hospitals (University medical centers, top clinical hospitals and general hospitals). University hospitals have a higher number of shared patients than teaching or general hospitals, and are therefore more likely to be among the first to receive colonized patients. Moreover, as the network is directional towards university hospitals, they have a higher prevalence, even when infection control measures are equally effective in all hospitals. Patient referral patterns have a profound effect on the spread of health care-associated infections like hospital-acquired MRSA. The MRSA prevalence therefore differs between hospitals with the position of each hospital within the health care network. Any comparison of MRSA rates between hospitals, as a benchmark for hospital hygiene, should therefore take the position of a hospital within the network into account.     

Is self-reported morbidity related to the circadian clock?

Morningness and eveningness preference, an endogenous component of the circadian clock, is characterized by an interindividual difference in circadian phase and requires of humans a specific timing of behavior. The biological rhythms of morning and evening types are consequently phase shifted with fixed socioeconomic constraints. The impact of this phase shift on health is widely debated. The purpose of the authors' study was to determine the influence of morningness/eveningness preference on self-reported morbidity and health in an active population. A total of 1165 nonshift workers of the French national electrical and gas company, enrolled in the GAZEL cohort and aged 51.3+/-3.3 years, were included in this study. They replied by mail with a completed questionnaire, including morningness/eveningness preference, self-reported morbidity, subjective sleep patterns, and daytime somnolence and sleeping schedules for 3 weeks, during the spring of 1997. Annual self-reported health impairments were assessed with the annual general questionnaire of the GAZEL cohort for 1997. After adjustment for age, sex, and occupational status, morningness-like and eveningness-like participants reported a specific worse self-reported morbidity. Whereas morningness was associated with worse sleep (p = 0.0001), eveningness was associated with feeling less energetic (p = 0.04) and physical mobility (p = 0.02). These relationships were observed even in good sleepers, except for physical mobility. After adjustment for confounding variables, eveningness-like participants reported more sleep (p = 0.0004) and mood (p = 0.00018) disorders than morningness-like participants. Morningness/eveningness preference was related to specific chronic complaints of insomnia: morningness was related with difficulty in maintaining sleep (p = 0.0005) and the impossibility to return to sleep in the early morning (p = 0.0001) (sleep phase-advance syndrome); eveningness was related to difficulty in initiating sleep (p = 0.0001) and morning sleepiness (p = 0.0001). In good sleepers, morningness was related with sleep phase-advance syndrome (p = 0.0001) and eveningness with morning sleepiness (p = 0.0001). In conclusion, the expression (phase advance or delay) of the circadian clock could be related to worse self-reported morbidity and health. These findings must be verified by further epidemiological studies, but they suggest that the impossibility to return to sleep in the early morning is not only associated with age.     

Effect of feeding frequency on food intake and growth of Arctic charr, Salvelinus alpinus L.

Social interactions and dominance hierarchy effects are important factors governing rates of growth of Arctic charr, Salvelinus alpinus L. The effects of hierarchy were increased as access to food became more restricted, i.e. feeding frequency was reduced, but these effects could not be attributed to direct competition for food since fish were fed to satiation at each feeding period. The results suggest that, whilst some fish on the restricted feeding regime were able to maintain good rates of growth, feeding by the majority of the fish was inhibited by the presence of larger individuals. Due to the importance of these hierarchy effects it was not possible to demonstrate physiological adaptations in fish allowed infrequent access to food.