Fast and destructive density currents created by ocean-entering volcanic eruptions

Volcanic eruptions on land create hot and fast pyroclastic density currents, triggering tsunamis or surges that travel over water where they reach the ocean. However, no field study has documented what happens when large volumes of erupted volcanic material are instead delivered directly into the ocean. We show how the rapid emplacement of large volumes of erupted material onto steep submerged slopes triggered extremely fast (122 kilometers per hour) and long-runout (>100 kilometers) seafloor currents. These density currents were faster than those triggered by earthquakes, floods, or storms, and they broke seafloor cables, cutting off a nation from the rest of the world. The deep scours excavated by these currents are similar to those around many submerged volcanoes, providing evidence of large eruptions at other sites worldwide.

Assessing maternal alcohol consumption in pregnancy: comparison of confidential postnatal maternal interview and measurement of alcohol biomarkers in meconium

OBJECTIVE

Knowledge of alcohol consumption in pregnancy is important for early identification of children with fetal alcohol spectrum disorder. We investigated whether alcohol biomarkers fatty acid ethyl esters (FAEEs) and ethyl glucuronide (EtG) in meconium are predicted by maternal or newborn demographics and/or correlate with confidential early postnatal self-report of alcohol consumption in pregnancy.

DESIGN

Anonymised, observational population-based study.

SETTING

Inner-city maternity unit, Glasgow, UK.

PATIENTS

Singleton mother/infant dyads delivering every fourth day.

INTERVENTIONS

Mother: confidential postnatal interview. Baby: meconium sample for FAEEs and EtG.

RESULTS

840/908 mothers consented. 370 (46.4%) reported alcohol consumption in pregnancy, generally of modest amount; for 114 (13.6%) this was after 20 weeks' gestation. Alcohol consumption in later pregnancy was more commonly reported by older (31.3 vs 29.5 years) women of white British ethnicity (p<0.05); their babies were on average 118 g heavier (p=0.032). FAEEs were identified in all meconium samples; concentration was ≥600 ng/g in 39.6%. EtG concentration was ≥30 ng/g in 14.5%. Neither biomarker was associated with maternal age, body mass index or socioeconomic status but when EtG was ≥30 ng/g, the mother was less likely to identify as white British (71.3% vs 81.8%, p=0.028). Sensitivities of FAEEs ≥600 ng/g and EtG ≥30 ng/g were 43.1% and 11.6%, respectively for postnatal self-report of alcohol use in later pregnancy (specificities 60.6% and 84.8%).

CONCLUSIONS

FAEEs and EtG measured in meconium have low sensitivity and specificity for self-reported alcohol consumption after 20 weeks' gestation in an unselected Scottish population.

Assessing maternal alcohol consumption in pregnancy: does phosphatidylethanol measured from day 5 newborn blood spot cards have any value? An observational, population-based study

OBJECTIVE

Prenatal alcohol exposure (PAE) places children at risk of fetal alcohol spectrum disorder (FASD) but ascertainment of PAE is problematic. Early intervention for children at risk of FASD may help mitigate long-term difficulties. Phosphatidylethanol (PEth), a metabolite of alcohol, is incorporated into red cell membranes and can be measured in dried blood spot (DBS) cards. In the UK, DBS samples are collected on day 5 for routine newborn screening. We sought to examine if PEth measured from DBS correlates with postnatal maternal self-report of alcohol consumption in pregnancy.

DESIGN

Observational population-based study. Comparison of infant PEth concentration and self-report of maternal alcohol use during pregnancy.

SETTING

Large maternity unit in Glasgow, Scotland.

PARTICIPANTS

All singleton mother-infant dyads delivered during each fourth consecutive 24-hour period.

INTERVENTIONS

Mother: direct, confidential, immediate postnatal interview by a single researcher examining alcohol use during pregnancy. Infant: one extra DBS collected coincident with routine newborn screening if bleeding continued.

RESULTS

92.5% of eligible mothers agreed to participate. 510 DBS were obtained of which 502 were successfully analysed. 216 (43%) samples contained PEth at a concentration of ≥8 ng/mL and 148 (29.5%) at ≥20 ng/mL. The sensitivity of PEth ≥8 ng/mL and ≥20 ng/mL in identifying women who self-reported modest alcohol use after 36 weeks' gestation was 50% and 36.4%, respectively.

CONCLUSION

PEth measured from DBS obtained on day 5 of life does not reliably identify modest PAE after 36 weeks' gestation from maternal self-report.

Effect of financial voucher incentives provided with UK stop smoking services on the cessation of smoking in pregnant women (CPIT III): pragmatic, multicentre, single blinded, phase 3, randomised controlled trial

OBJECTIVE

To examine effectiveness, cost effectiveness, generalisability, and acceptability of financial incentives for smoking cessation during pregnancy in addition to variously organised UK stop smoking services.

DESIGN

Pragmatic, multicentre, single blinded, phase 3, randomised controlled trial (Cessation in Pregnancy Incentives Trial phase 3 (CPIT III)).

SETTING

Seven UK stop smoking services provided in primary and secondary care facilities in Scotland, Northern Ireland, and England.

PARTICIPANTS

944 pregnant women (age ≥16 years) who self-reported as being smokers (at least one cigarette in the past week) when asked at first maternity visit, less than 24 weeks' gestation, and notified to the trial team by routine stop smoking services.

INTERVENTIONS

Participants in the control group were offered the standard stop smoking services, which includes the offer of counselling by specially trained workers using withdrawal orientated therapy and the offer of free nicotine replacement therapy. The intervention was the offer of usual support from the stop smoking services and the addition of up to £400 ($440; €455) of LoveToShop financial voucher incentives for engaging with current stop smoking services or to stop smoking, or both, during pregnancy.

MAIN OUTCOME MEASURES

Self-reported smoking cessation in late pregnancy (between 34 and 38 weeks' gestation) corroborated by saliva cotinine (and anabasine if using nicotine replacement products). Results were adjusted for age, smoking years, index of multiple deprivation, Fagerström score, before or after covid, and recruitment site. Secondary outcomes included point and continuous abstinence six months after expected date of delivery, engagement with stop smoking services, biochemically validated abstinence from smoking at four weeks after stop smoking date, birth weight of baby, cost effectiveness, generalisability documenting formats of stop smoking services, and acceptability to pregnant women and their carers.

RESULTS

From 9 January 2018 to 4 April 2020, of 4032 women screened by stop smoking services, 944 people were randomly assigned to the intervention group (n=471) or the control group (n=470). Three people asked for their data to be removed. 126 (27%) of 471 participants stopped smoking from the intervention group and 58 (12%) of 470 from the control group (adjusted odds ratio 2.78 (1.94 to 3.97) P<0.001). Serious adverse events were miscarriages and other expected pregnancy events requiring hospital admission; all serious adverse events were unrelated to the intervention. Most people who stopped smoking from both groups relapsed after their baby was born.

CONCLUSIONS

The offer of up to £400 of financial voucher incentives to stop smoking during pregnancy as an addition to current UK stop smoking services is highly effective. This bolt-on intervention supports new guidance from the UK National Institute for Health and Care Excellence, which includes the addition of financial incentives to support pregnant women to stop smoking. Continuing incentives to 12 months after birth is being examined to prevent relapse.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN15236311.

Minimizing sample bias due to stigmatized behaviours: the representativeness of participants in a cohort study of alcohol in pregnancy

BACKGROUND

Stigmatized behaviours are often underreported, especially in pregnancy, making them challenging to address. The Alcohol and Child Development Study (ACDS) seeks to inform prevention of foetal alcohol harm, linking self-report as well as a maternal blood alcohol biomarker with child developmental outcomes. Samples were requested using passive, generic consent. The success of this approach at minimizing bias is presented comparing characteristics of women who provided samples to those who did not.

METHODS

All pregnant women in the study city were sent a Patient Information Sheet (PIS) with their first NHS obstetric appointment letter. The PIS informed them that the NHS would like to take an extra blood sample for research purposes, unless they opted out. Neither the women nor the midwives were informed that the samples might be tested for an alcohol biomarker. This paper examines the extent to which women who provided the extra sample were representative of women where no sample was provided, in terms of routinely collected information: age; body mass index; area-based deprivation; previous pregnancies, abortions and caesarians; smoking status and carbon monoxide level; self-reported alcohol use, gestation and birth weight of their baby. Chi-square and Mann-Whitney U tests were used to compare groups.

RESULTS

3436 (85%) of the 4049 pregnant women who attended their appointment provided the extra sample. Women who did not were significantly younger (p < 0.001), more materially deprived (p < 0.001), and less likely to be considered for intervention based on self-reported alcohol use (p < 0.001). There were no significant differences between the two groups on other routine data.

CONCLUSIONS

The use of passive consent without disclosure of the specific research focus resulted in a high level of sample provision. There was no evidence that study blinding was breached, and women who provided a sample were more likely to report alcohol consumption. Passive consent to draw additional blood for research purposes at routine antenatal venipuncture reduced sampling bias compared to asking women to give blood for an alcohol study. This methodology may be useful for other stigmatised behaviours.

State of science: the future of work - ergonomics and human factors contributions to the field

This article is concerned with scholarly ergonomics and human factors (E/HF) contributions to date to the field of research inquiry known as the 'future of work'. The review considers E/HF perspectives on how the nature of work is changing and what this means for the practice of E/HF and for human performance and wellbeing at work. This field of research has attracted much attention from scholars from various disciplines as flexible working arrangements and casualised employment, in particular, have come under the microscope during the COVID-19 pandemic. The article begins by setting out the future of work field, focussing on the mega trends and future of work forces that are most relevant to the discipline. Next, E/HF contributions to this field are identified and discussed. Surprisingly, given the E/HF tradition as a system discipline fundamentally concerned with the study of human work, and as a contributor to transdisciplinary research related to the design of work systems, a search of the scholarly literature found few contributions outside of the automation systems field that addressed the future of work and E/HF directly. A research agenda is presented to address gaps in current knowledge in a number of key future of work domains. Practitioner's Summary: We reflect on E/HF contributions to the 'future of work' field and how the practice of E/HF needs to consider the changing nature of work. We outline future of work concerns and suggest research areas for further E/HF attention towards the design of decent and sustainable work for all. Abbreviations: E/HF: ergonomics and human factors; ILO: International Labour Organisation; COVID-19.

Challenging the view that lack of fibre causes childhood constipation

OBJECTIVES

To assess evidence supporting the view that 'low fibre causes childhood constipation'.

DESIGN

Triangulation integrated three approaches: a systematic review NICE guideline CG99 examining effectiveness of increasing fibre; a cohort study, Avon Longitudinal Study of Parents and Children (ALSPAC), to assess if constipation (or hard stools) can precede fibre intake at weaning; and a literature search for twin studies to calculate heredity.

SETTING

CG99 examined the literature regarding the effectiveness of increasing fibre. ALSPAC asked parents about: hard stools at 4 weeks, 6 months and 2.5 years and constipation at age 4-10 years, as well as fibre intake at 2 years. Twin studies and data from ALSPAC were pooled to calculate concordance of constipation comparing monozygotic and dizygous twin pairs.

PARTICIPANTS

CG99 reported six randomised controlled trials (RCTs). ALSPAC hard stool data from 6796 children at 4 weeks, 9828 at 6 months and 9452 at 2.5 years plus constipation data on 8401 at 4-10 years were compared with fibre intake at 2 years. Twin studies had 338 and 93 twin pairs and ALSPAC added a further 45.

RESULTS

Increasing fibre did not effectively treat constipation. Hard stools at 4 weeks predated fibre and at 6 months predicted lower fibre intake at 2 years (p=0.003). Heredity explained 59% of constipation.

CONCLUSIONS

RCTs indicate that increasing fibre is not an effective treatment for constipation in children. Hard stools can precede and predict later fibre intake. Genetic inheritance explains most childhood constipation. Extended treatment with stool softeners may improve fibre intake and limit long-term damaging sequelae of constipation.

Incentives for smoking cessation in pregnancy

Issue/problem

Most pregnant smokers reply ‘Yes' when asked ‘Do you want to stop smoking?'. This is usually an honest answer but often without intention. About 10% who intend to quit are likely to attend smoking cessation services. Even with good quality counselling and the offer of nicotine replacement therapy only about 3-5% quit. How can the other 90% be reached?

There are two approaches: Redirect counselling away from specialist cessation practitioners and build capacity among all health care workers. This is attractive spreading counselling to health care workers who meet pregnant smokers during routine consultations requiring little resource after training for example General Practitioners, Midwives and Obstetricians. However limited time for training and subsequent counselling endangers the quality and quantity of counselling delivered.Increase the proportion of women who intend to quit smoking during pregnancy by providing a financial incentive payment for engaging with specialist cessation practitioners and quitting.

This policy allows counselling to be delivered by specialists and potentially draws in a larger proportion of pregnant smokers, as many as 50%.

Results

Financial incentives have increased the proportion of smokers who quit by late pregnancy in two large randomised controlled trials. The proportion increased by more than 100%. Local service pilots of financial incentives have seen marked increases in smokers who attend and quit.

Lessons

There are a number of ways to increase smoking cessation among pregnant women. Research evidence should be translated into effective service models to decide which strategy is most cost-effective.

Key messages

Counselling is important; however, it has to be sufficient and of good quality. Drawing more pregnant smokers into cessation services will increase the proportion who intend and manage to quit. This may work better than expecting all health care workers to give effective counselling.

Strategies to commit senior subcontractor managers in participatory ergonomics interventions

The commitment of managers is one of the facilitators of participatory ergonomics (PE). However, to achieve this, practical practitioners' strategies vary depending on the organizational context and type of stakeholder and are poorly described in the literature. The purpose of this paper is to describe and to analyze the process and strategies that led to senior managers commitment during a decision-making intervention in a subcontracting context. A reflexive practice method was used to describe strategies implemented during a multi-site research project focusing on musculoskeletal disorders prevention in the meat processing sector. A 3 levels commitment method was developed which included: each subcontractor individually, subcontractors together, and subcontractors with their main contractor. Four strategies from the literature were firstly implemented: the creation of a steering committee, the identification of tendencies to act, the transfer of knowledge and moderation of collective discussion. An additional new strategy based on the sharing of a common interest - knife sharpening and maintenance was necessary to achieve the commitment. These results reinforce the importance of stakeholder strategies commitment in PE. A greater consideration for developing a valid framework is needed.

Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study

BACKGROUND

Although many women stop smoking in pregnancy, others continue, causing harm to maternal and child health. Smoking behaviour is influenced by many factors, including the role of women's significant others (SOs) and support from health-care professionals (HPs).

OBJECTIVES

To enhance understanding of the barriers to, and facilitators of, smoking cessation and the feasibility and acceptability of interventions to reach and support pregnant women to stop smoking.

DESIGN

Four parts: (1) a description of interventions in the UK for smoking cessation in pregnancy; (2) three systematic reviews (syntheses) of qualitative research of women's, SOs' and HPs' views of smoking in pregnancy using meta-ethnography (interpretative approach for combining findings); (3) semistructured interviews with pregnant women, SOs and HPs, guided by the social-ecological framework (conceptualises behaviour as an outcome of individuals' interactions with environment); and (4) identification of new/improved interventions for future testing.

SETTING

Studies in reviews conducted in high-income countries. Qualitative research was conducted from October 2013 to December 2014 in two mixed urban/rural study sites: area A (Scotland) and area B (England).

PARTICIPANTS

Thirty-eight studies (1100 pregnant women) in 42 papers, nine studies (150 partners) in 14 papers and eight studies described in nine papers (190 HPs) included in reviews. Forty-one interviews with pregnant women, 32 interviews with pregnant women's SOs and 28 individual/group interviews with 48 HPs were conducted.

MAIN OUTCOME MEASURES

The perceived barriers to, and facilitators of, smoking cessation in pregnancy and the identification of potential new/modified interventions.

RESULTS

Syntheses identified smoking-related perceptions and experiences for pregnant women and SOs that were fluid and context dependent with the capacity to help or hinder smoking cessation. Themes were analysed in accordance with the social-ecological framework levels. From the analysis of the interviews, the themes that were central to cessation in pregnancy at an individual level, and that reflected the findings from the reviews, were perception of risk to baby, self-efficacy, influence of close relationships and smoking as a way of coping with stress. Overall, pregnant smokers were faced with more barriers than facilitators. At an interpersonal level, partners' emotional and practical support, willingness to change smoking behaviour and role of smoking within relationships were important. Across the review and interviews of HPs, education to enhance knowledge and confidence in delivering information about smoking in pregnancy and the centrality of the client relationship, protection of which could be a factor in downplaying risks, were important. HPs acknowledged that they could best assist by providing support and understanding, and access to effective interventions, including an opt-out referral pathway to Stop Smoking Services, routine carbon monoxide screening, behavioural support and access to pharmacotherapy. Additional themes at community, organisational and societal levels were also identified.

LIMITATIONS

Limitations include a design grounded in qualitative studies, difficulties recruiting SOs, and local service configurations and recruitment processes that potentially skewed the sample.

CONCLUSIONS

Perceptions and experiences of barriers to and facilitators of smoking cessation in pregnancy are fluid and context dependent. Effective interventions for smoking cessation in pregnancy should take account of the interplay between the individual, interpersonal and environmental aspects of women's lives.

FUTURE WORK

Research focus: removing barriers to support, improving HPs' capacity to offer accurate advice, and exploration of weight concerns and relapse prevention. Interventions focus: financial incentives, self-help and social network interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004170.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Conceptualizing workplace cyberbullying: Toward a definition for research and practice in nursing

AIMS

To explore nurses' understandings and perceptions of workplace cyberbullying, in order to develop a relevant and meaningful definition of the phenomenon for future research and practice.

BACKGROUND

Although previous research places nurses at an elevated risk of exposure to traditional workplace bullying, there is a notable absence of research investigating workplace cyberbullying within this profession. Considering the detrimental outcomes experienced by the targets of workplace cyberbullying, this is an issue that warrants focus.

METHODS

Utilizing relevant scenarios as prompts, semi-structured interviews were conducted with 16 nurses (practising and in training) to explore their understanding of the concept and dynamics of workplace cyberbullying.

RESULTS

Three high-level themes were identified and discussed: (1) cyber-specific features that make cyberbullying more damaging than traditional bullying; (2) the importance of context; and (3) the work environment factors that facilitate the occurrence of workplace cyberbullying.

CONCLUSIONS

Our refined definition facilitates the investigation of a broader and more inclusive range of behaviours that targets may experience as workplace cyberbullying, and our findings in general highlight potential antecedents in common with traditional workplace bullying.

IMPLICATIONS FOR NURSING MANAGEMENT

Given the work environment and the challenges faced by the nursing profession, a system-wide approach to intervention and management is recommended, along with utilizing a nursing-specific definition.

Early childhood risk factors for constipation and soiling at school age: an observational cohort study

OBJECTIVE

Constipation and soiling are common in childhood. This study examines the comorbidity between childhood constipation and soiling and early childhood risk factors for these problems.

DESIGN

The sample comprised 8435 participants from the Avon Longitudinal Study of Parents and Children with maternally reported measures of constipation (six time points between 4 and 10 years) and soiling (five time points between 4 and 9 years). We used latent class analysis to extract longitudinal patterns of constipation and soiling. We examined whether the latent classes are differentially associated with maternally reported risk factors in early childhood (stool consistency, breast feeding, socioeconomic background, gestation, birth weight, developmental level and age at initiation of toilet training) using multinomial logistic regression models.

RESULTS

We extracted four latent classes: 'normative' (74.5%: very low probability of constipation or soiling), 'constipation alone' (13.2%), 'soiling alone' (7.5%) and 'constipation with soiling' (4.8%). Hard stools at 2½ years were associated with increased odds of constipation alone. Developmental delay at 18 months was associated soiling alone and constipation with soiling, but not constipation alone. We found limited evidence of associations with socioeconomic background and no evidence of associations with age at initiation of toilet training, breast feeding, gestational age or birth weight.

CONCLUSION

Constipation alone was the most prevalent pattern in this cohort. Treatment for hard stools in early childhood is needed to prevent chronic constipation at school age. Constipation with soiling was less common than soiling alone. Further research is needed into the causes of non-retentive soiling.

Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis

CONTEXT

Sudden infant death syndrome (SIDS) is a leading cause of postneonatal infant mortality. Our previous meta-analyses showed that any breastfeeding is protective against SIDS with exclusive breastfeeding conferring a stronger effect.The duration of breastfeeding required to confer a protective effect is unknown.

OBJECTIVE

To assess the associations between breastfeeding duration and SIDS.

DATA SOURCES

Individual-level data from 8 case-control studies.

STUDY SELECTION

Case-control SIDS studies with breastfeeding data.

DATA EXTRACTION

Breastfeeding variables, demographic factors, and other potential confounders were identified. Individual-study and pooled analyses were performed.

RESULTS

A total of 2267 SIDS cases and 6837 control infants were included. In multivariable pooled analysis, breastfeeding for <2 months was not protective (adjusted odds ratio [aOR]: 0.91, 95% confidence interval [CI]: 0.68-1.22). Any breastfeeding ≥2 months was protective, with greater protection seen with increased duration (2-4 months: aOR: 0.60, 95% CI: 0.44-0.82; 4-6 months: aOR: 0.40, 95% CI: 0.26-0.63; and >6 months: aOR: 0.36, 95% CI: 0.22-0.61). Although exclusive breastfeeding for <2 months was not protective (aOR: 0.82, 95% CI: 0.59-1.14), longer periods were protective (2-4 months: aOR: 0.61, 95% CI: 0.42-0.87; 4-6 months: aOR: 0.46, 95% CI: 0.29-0.74).

LIMITATIONS

The variables collected in each study varied slightly, limiting our ability to include all studies in the analysis and control for all confounders.

CONCLUSIONS

Breastfeeding duration of at least 2 months was associated with half the risk of SIDS. Breastfeeding does not need to be exclusive to confer this protection.

The stage of change approach for implementing ergonomics advice - Translating research into practice

The Stage of Change (SOC) approach has been proposed as a method to improve the implementation of ergonomics advice. However, despite evidence for its efficacy there is little evidence to suggest it has been adopted by ergonomics consultants. This paper investigates barriers and facilitators to the implementation, monitoring and effectiveness of ergonomics advice and the adoption of the SOC approach in a series of focus groups and a subsequent survey of members of the Human Factors Societies of Australia and New Zealand. A proposed SOC assessment tool developed for use by ergonomics practitioners is presented. Findings from this study suggest the limited application of a SOC based approach to work-related musculoskeletal injury prevention by ergonomics practitioners is due to the absence of a suitable tool in the ergonomists' repertoire, the need for training in this approach, and their limited access to relevant research findings. The final translation of the SOC assessment tool into professional ergonomics practice will require accessible demonstration of its real-world usability to practitioners and the training of ergonomics practitioners in its application.

Intervention development to reduce musculoskeletal disorders: Is the process on target?

Work related musculoskeletal disorders remain an intractable OHS problem. In 2002, Haslam proposed applying the stage of change model to target ergonomics interventions and other health and safety prevention activities. The stage of change model proposes that taking into account an individual's readiness for change in developing intervention strategies is likely to improve uptake and success. This paper revisits Haslam's proposal in the context of interventions to reduce musculoskeletal disorders. Effective MSD interventions require a systematic approach and need to take into account a combination of measures. Research evidence suggests that in practice, those charged with the management of MSDs are not consistently adopting such an approach. Consequently, intervention development may not represent contemporary best practice. We propose a potential method of addressing this gap is the stage of change model, and use a case study to illustrate this argument in tailoring intervention development for managing MSDs.

Are financial incentives cost-effective to support smoking cessation during pregnancy?

AIMS

To investigate the cost-effectiveness of up to £400 worth of financial incentives for smoking cessation in pregnancy as an adjunct to routine health care.

DESIGN

Cost-effectiveness analysis based on a Phase II randomized controlled trial (RCT) and a cost-utility analysis using a life-time Markov model.

SETTING

The RCT was undertaken in Glasgow, Scotland. The economic analysis was undertaken from the UK National Health Service (NHS) perspective.

PARTICIPANTS

A total of 612 pregnant women randomized to receive usual cessation support plus or minus financial incentives of up to £400 vouchers (US $609), contingent upon smoking cessation.

MEASUREMENTS

Comparison of usual support and incentive interventions in terms of cotinine-validated quitters, quality-adjusted life years (QALYs) and direct costs to the NHS.

FINDINGS

The incremental cost per quitter at 34-38 weeks pregnant was £1127 ($1716).This is similar to the standard look-up value derived from Stapleton & West's published ICER tables, £1390 per quitter, by looking up the Cessation in Pregnancy Incentives Trial (CIPT) incremental cost (£157) and incremental 6-month quit outcome (0.14). The life-time model resulted in an incremental cost of £17 [95% confidence interval (CI) = -£93, £107] and a gain of 0.04 QALYs (95% CI = -0.058, 0.145), giving an ICER of £482/QALY ($734/QALY). Probabilistic sensitivity analysis indicates uncertainty in these results, particularly regarding relapse after birth. The expected value of perfect information was £30 million (at a willingness to pay of £30 000/QALY), so given current uncertainty, additional research is potentially worthwhile.

CONCLUSION

Financial incentives for smoking cessation in pregnancy are highly cost-effective, with an incremental cost per quality-adjusted life years of £482, which is well below recommended decision thresholds.

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

BACKGROUND

Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.

AIM

To understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design.

DESIGN

Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.

SETTING

UK.

PARTICIPANTS

The qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking.

METHODS

(1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test.

RESULTS

Out of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A 'ladder' logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical 'ladder' towards smoking cessation and breastfeeding. Incentive interventions provide opportunity 'rungs' to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women's capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave 'healthily' risk them feeling pressurised and failing. To avoid 'losing face', women may disengage.

LIMITATIONS

Included studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population.

CONCLUSIONS

Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012001980.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Incentives to promote breastfeeding: a systematic review

BACKGROUND AND OBJECTIVES

Few women in industrialized countries achieve the World Health Organization's recommendation to breastfeed exclusively for 6 months. Governments are increasingly seeking new interventions to address this problem, including the use of incentives. The goal of this study was to assess the evidence regarding the effectiveness of incentive interventions, delivered within or outside of health care settings, to individuals and/or their families seeking to increase and sustain breastfeeding in the first 6 months after birth.

METHODS

Searches of electronic databases, reference lists, and grey literature were conducted to identify relevant reports of published, unpublished, and ongoing studies. All study designs published in English, which met our definition of incentives and that were from a developed country, were eligible for inclusion. Abstract and full-text article review with sequential data extraction were conducted by 2 independent authors.

RESULTS

Sixteen full reports were included in the review. The majority evaluated multicomponent interventions of varying frequency, intensity, and duration. Incentives involved providing access to breast pumps, gifts, vouchers, money, food packages, and help with household tasks, but little consensus in findings was revealed. The lack of high-quality, randomized controlled trials identified by this review and the multicomponent nature of the interventions prohibited meta-analysis.

CONCLUSIONS

This review found that the overall effect of providing incentives for breastfeeding compared with no incentives is unclear due to study heterogeneity and the variation in study quality. Further evidence on breastfeeding incentives offered to women is required to understand the possible effects of these interventions.

Financial incentives for smoking cessation in pregnancy: randomised controlled trial

OBJECTIVE

To assess the efficacy of a financial incentive added to routine specialist pregnancy stop smoking services versus routine care to help pregnant smokers quit.

DESIGN

Phase II therapeutic exploratory single centre, individually randomised controlled parallel group superiority trial.

SETTING

One large health board area with a materially deprived, inner city population in the west of Scotland, United Kingdom.

PARTICIPANTS

612 self reported pregnant smokers in NHS Greater Glasgow and Clyde who were English speaking, at least 16 years of age, less than 24 weeks pregnant, and had an exhaled carbon monoxide breath test result of 7 ppm or more. 306 women were randomised to incentives and 306 to control.

INTERVENTIONS

The control group received routine care, which was the offer of a face to face appointment to discuss smoking and cessation and, for those who attended and set a quit date, the offer of free nicotine replacement therapy for 10 weeks provided by pharmacy services, and four, weekly support phone calls. The intervention group received routine care plus the offer of up to £400 of shopping vouchers: £50 for attending a face to face appointment and setting a quit date; then another £50 if at four weeks' post-quit date exhaled carbon monoxide confirmed quitting; a further £100 was provided for continued validated abstinence of exhaled carbon monoxide after 12 weeks; a final £200 voucher was provided for validated abstinence of exhaled carbon monoxide at 34-38 weeks' gestation.

MAIN OUTCOME MEASURE

The primary outcome was cotinine verified cessation at 34-38 weeks' gestation through saliva (<14.2 ng/mL) or urine (<44.7 ng/mL). Secondary outcomes included birth weight, engagement, and self reported quit at four weeks.

RESULTS

Recruitment was extended from 12 to 15 months to achieve the target sample size. Follow-up continued until September 2013. Of the 306 women randomised, three controls opted out soon after enrolment; these women did not want their data to be used, leaving 306 intervention and 303 control group participants in the intention to treat analysis. No harms of financial incentives were documented. Significantly more smokers in the incentives group than control group stopped smoking: 69 (22.5%) versus 26 (8.6%). The relative risk of not smoking at the end of pregnancy was 2.63 (95% confidence interval 1.73 to 4.01) P<0.001. The absolute risk difference was 14.0% (95% confidence interval 8.2% to 19.7%). The number needed to treat (where financial incentives need to be offered to achieve one extra quitter in late pregnancy) was 7.2 (95% confidence interval 5.1 to 12.2). The mean birth weight was 3140 g (SD 600 g) in the incentives group and 3120 (SD 590) g in the control group (P=0.67).

CONCLUSION

This phase II randomised controlled trial provides substantial evidence for the efficacy of incentives for smoking cessation in pregnancy; as this was only a single centre trial, incentives should now be tested in different types of pregnancy cessation services and in different parts of the United Kingdom.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN87508788.

Understanding workplace violence: the value of a systems perspective

Workplace violence is a leading form of occupational injury and fatality, but has received little attention from the ergonomics research community. The paper reports findings from the 2012 New Zealand Workplace Violence Survey, and examines the workplace violence experience of 86 New Zealand organisations and the perceptions of occupational health and safety professionals from a systems perspective. Over 50% of respondents reported violence cases in their organisation, with perpetrators evenly split between co-workers and external sources such as patients. Highest reported levels of violence were observed for agriculture, forestry and construction sectors. Highest risk factor ratings were reported for interpersonal and organisational factors, notably interpersonal communication, time pressure and workloads, with lowest ratings for environmental factors. A range of violence prevention measures were reported, although most organisations relied on single control measures, suggesting unmanaged violence risks were common among the sample.

Development of an early nurse led intervention to treat children referred to secondary paediatric care with constipation with or without soiling

Background

Constipation is a common chronic childhood condition referred to secondary care. Effective treatment requires early intervention, prolonged medication to soften stools and behavioural support to achieve a regular habit of sitting on the toilet to pass a stool. The purpose of this audit and service development was to assess routine consultant paediatrician-led care against minimum standards and if appropriate to develop a nurse-led intervention. The new care package could then be tried out within general paediatric clinics in Glasgow as a service evaluation. NICE guideline (CG99) has a research recommendation to compare nurse-led care with routine consultant-led care.

Methods

Design was an audit then development of a nurse-led intervention followed by a service evaluation. Participants were children (age 0–13 years), referred by their General Practitioner (GP) to the Royal Hospital for Sick Children Glasgow, with constipation the main problem in the GP letter. The audit covered appointment waiting times, intervention provided, initial follow-up and parental satisfaction with routine consultant-led practice. The nurse-led intervention focused on self-help psychology practice with NICE guideline medical support. This was compared with routine consultant paediatrician care in a service evaluation.

Results

The audit found consultant-led care had long waiting times, delayed initial follow-up and variable intervention. The new nurse-led intervention is described in detail. The nurse-led intervention performed well compared with consultant-led care. Less ‘nurse-led’ children, 3/45 (7%), were still constipated passing less than 3 stools per week compared with 8/58 (14%) receiving consultant-led care. Less ‘nurse-led’ parents, 10/45 (22%), reported their child having pain passing stools in the previous week compared with consultant-led care, 26/58 (45%). The proportion of children, over 4 years, free from soiling accidents was similar, 15/23 (65%) in the nurse-led group and 18/29 (62%) with consultant-led care. Parental satisfaction was slightly better in the nurse-led group.

Conclusion

It is difficult to achieve minimum standards using routine consultant-led care for children referred by their GP with constipation. Nurse-led early intervention is feasible and has produced promising results in a service evaluation. An exploratory trial is planned to develop a teaching module, robust outcomes including costs and benefits, and methodology for a definitive trial recommended by NICE.

Monitoring population levels of alcohol consumption in pregnant women: a case for using biomarkers

A challenge to biochemically monitoring alcohol consumption in pregnancy is the prohibitive costs of collecting thousands of blood samples. This pilot study looks at the feasibility of using residual samples to monitor chronic and acute alcohol consumption in pregnancy. Residual anomalies screening samples (n = 150, 2006/7) were tested for carbohydrate-deficient transferrin (CDT, chronic marker) and ethyl glucuronide (EtG, acute marker). Valid readings were obtained for CDT but not EtG. These results pave the way for a larger representative study, to provide, for the first time, a national biochemical baseline estimate of chronic alcohol consumption in the pregnant population.

Give It Up For Baby: outcomes and factors influencing uptake of a pilot smoking cessation incentive scheme for pregnant women

Background

The use of incentives to promote smoking cessation is a promising technique for increasing the effectiveness of interventions. This study evaluated the smoking cessation outcomes and factors associated with success for pregnant smokers who registered with a pilot incentivised smoking cessation scheme in a Scottish health board area (NHS Tayside).

Methods

All pregnant smokers who engaged with the scheme between March 2007 and December 2009 were included in the outcome evaluation which used routinely collected data. Data utilised included: the Scottish National Smoking Cessation Dataset; weekly and periodic carbon monoxide (CO) breath tests; status of smoking cessation quit attempts; and amount of incentive paid. Process evaluation incorporated in-depth interviews with a cross-sectional sample of service users, stratified according to level of engagement.

Results

Quit rates for those registering with Give It Up For Baby were 54% at 4 weeks, 32% at 12 weeks and 17% at 3 months post partum (all data validated by CO breath test). Among the population of women identified as smoking at first booking over a one year period, 20.1% engaged with Give It Up For Baby, with 7.8% of pregnant smokers quit at 4 weeks. Pregnant smokers from more affluent areas were more successful with their quit attempt. The process evaluation indicates financial incentives can encourage attendance at routine advisory sessions where they are seen to form part of a wider reward structure, but work less well with those on lowest incomes who demonstrate high reliance on the financial reward.

Conclusions

Uptake of Give It Up For Baby by the target population was higher than for all other health board areas offering specialist or equivalent cessation services in Scotland. Quit successes also compared favorably with other specialist interventions, adding to evidence of the benefits of incentives in this setting. The process evaluation helped to explain variations in retention and quit rates achieved by the scheme.

This study describes a series of positive outcomes achieved through the use of incentives to promote smoking cessation amongst pregnant smokers.

Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children

BACKGROUND

Faecal incontinence is a common and potentially distressing disorder of childhood.

OBJECTIVES

To assess the effects of behavioural and/or cognitive interventions for the management of faecal incontinence in children.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 28 October 2011), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and CINAHL, and handsearching of journals and conference proceedings, and the reference lists of relevant articles. We contacted authors in the field to identify any additional or unpublished studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials of behavioural and/or cognitive interventions with or without other treatments for the management of faecal incontinence in children.

DATA COLLECTION AND ANALYSIS

Reviewers selected studies from the literature, assessed study quality, and extracted data. Data were combined in a meta-analysis when appropriate.

MAIN RESULTS

Twenty one randomised trials with a total of 1371 children met the inclusion criteria. Sample sizes were generally small. All studies but one investigated children with functional faecal incontinence. Interventions varied amongst trials and few outcomes were shared by trials addressing the same comparisons.Combined results of nine trials showed higher rather than lower rates of persisting symptoms of faecal incontinence up to 12 months when biofeedback was added to conventional treatment (OR 1.11 CI 95% 0.78 to 1.58). This result was consistent with that of two trials with longer follow-up (OR 1.31 CI 95% 0.80 to 2.15). In one trial the adjunct of anorectal manometry to conventional treatment did not result in higher success rates in chronically constipated children (OR 1.40 95% CI 0.72 to 2.73 at 24 months).In one small trial the adjunct of behaviour modification to laxative therapy was associated with a significant reduction in children's soiling episodes at both the three month (OR 0.14 CI 95% 0.04 to 0.51) and the 12 month assessment (OR 0.20 CI 95% 0.06 to 0.65).

AUTHORS' CONCLUSIONS

There is no evidence that biofeedback training adds any benefit to conventional treatment in the management of functional faecal incontinence in children. There was not enough evidence on which to assess the effects of biofeedback for the management of organic faecal incontinence. There is some evidence that behavioural interventions plus laxative therapy, rather than laxative therapy alone, improves continence in children with functional faecal incontinence associated with constipation.

Incorporating organisational safety culture within ergonomics practice

This paper conceptualises organisational safety culture and considers its relevance to ergonomics practice. Issues discussed in the paper include the modest contribution that ergonomists and ergonomics as a discipline have made to this burgeoning field of study and the significance of safety culture to a systems approach. The relevance of safety culture to ergonomics work with regard to the analysis, design, implementation and evaluation process, and implications for participatory ergonomics approaches, are also discussed. A potential user-friendly, qualitative approach to assessing safety culture as part of ergonomics work is presented, based on a recently published conceptual framework that recognises the dynamic and multi-dimensional nature of safety culture. The paper concludes by considering the use of such an approach, where an understanding of different aspects of safety culture within an organisation is seen as important to the success of ergonomics projects. STATEMENT OF RELEVANCE: The relevance of safety culture to ergonomics practice is a key focus of this paper, including its relationship with the systems approach, participatory ergonomics and the ergonomics analysis, design, implementation and evaluation process. An approach to assessing safety culture as part of ergonomics work is presented.

Smoking cessation during pregnancy: the influence of partners, family and friends on quitters and non-quitters

This research compared pregnant quitters' and non-quitters' accounts of how partners, family and friends influenced their smoking cessation attempts. Qualitative secondary data analysis was carried out on a purposive sample of motivational interview transcripts undertaken by research midwives with pregnant women as part of SmokeChange, a smoking cessation intervention. Interviews with all quitters in the intervention group (n = 12) were analysed comparatively with interviews from a matched sample of non-quitters (n = 12).The discourses of both revealed similarity in how their partners, family and friends influenced their cessation efforts: salient others were simultaneously perceived by both groups of women as providing drivers and barriers to quit attempts; close associates who smoked were often perceived to be as supportive as those who did not. However, women who quit smoking during pregnancy talked more about receiving active praise/encouragement than those who did not. While close associates play an important role in women's attempts to stop smoking during pregnancy, the support they provide varies; further research is needed to develop a better understanding of how key relationships help or hinder cessation during pregnancy.

Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial

OBJECTIVE

To assess the clinical effectiveness and cost effectiveness of a policy to provide breastfeeding groups for pregnant and breastfeeding women.

DESIGN

Cluster randomised controlled trial with prospective mixed method embedded case studies to evaluate implementation processes.

SETTING

Primary care in Scotland.

PARTICIPANTS

Pregnant women, breastfeeding mothers, and babies registered with 14 of 66 eligible clusters of general practices (localities) in Scotland that routinely collect breastfeeding outcome data.

INTERVENTION

Localities set up new breastfeeding groups to provide population coverage; control localities did not change group activity.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

any breast feeding at 6-8 weeks from routinely collected data for two pre-trial years and two trial years.

SECONDARY OUTCOMES

any breast feeding at birth, 5-7 days, and 8-9 months; maternal satisfaction.

RESULTS

Between 1 February 2005 and 31 January 2007, 9747 birth records existed for intervention localities and 9111 for control localities. The number of breastfeeding groups increased from 10 to 27 in intervention localities, where 1310 women attended, and remained at 10 groups in control localities. No significant differences in breastfeeding outcomes were found. Any breast feeding at 6-8 weeks declined from 27% to 26% in intervention localities and increased from 29% to 30% in control localities (P=0.08, adjusted for pre-trial rate). Any breast feeding at 6-8 weeks increased from 38% to 39% in localities not participating in the trial. Women who attended breastfeeding groups were older (P<0.001) than women initiating breast feeding who did not attend and had higher income (P=0.02) than women in the control localities who attended postnatal groups. The locality cost was pound13 400 (euro14 410; $20 144) a year.

CONCLUSION

A policy for providing breastfeeding groups in relatively deprived areas of Scotland did not improve breastfeeding rates at 6-8 weeks. The costs of running groups would be similar to the costs of visiting women at home.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44857041.

Comparison of CO breath testing and women's self-reporting of smoking behaviour for identifying smoking during pregnancy

Background

Healthcare services often use a carbon monoxide (CO) breath test to validate self-reported smoking and to assess reductions in smoking habit. A cut-off level of ≥ 8 parts per million (p.p.m.) is used to identify smoking. This cut-off requires further validation in pregnant women.

Methods

Data on self-reported smoking were assessed in conjunction with breath CO levels. Subjects in the study were 2548 women attending antenatal booking during 12 months.

Results

546/2584 (21.4%) women self-reported as current smokers. A cut-off of 8 ppm identified only 325/546 self-reported smokers (sensitivity 59.4%). 27/2002 self-reported non-smokers had levels greater than 8 ppm (specificity 98.7%). Sensitivity and specificity analysis revealed that CO cut-off levels of 2 or 3 p.p.m. resulted in the best sensitivity and specificity for discriminating apparent smokers and non-smokers. A cut-off of 2 p.p.m. would have identified 468/546 of self-reported smokers (sensitivity 86%). 206/2002 self-reported non-smokers had levels > 2 ppm (specificity 90 %). If all these women were 'true' smokers, the real prevalence of smoking in pregnancy was 26.5% (752/2548) and 27% of true smokers provided false answers to the self-reported question at maternity booking.

Conclusion

At 8 ppm, many smokers are missed and there may be gross underestimating of levels of smoking in a pregnant population. Results emphasise the need to support a lower cut-off level for the breath CO test closer to 2 or 3 p.p.m. These cut-offs may be more appropriate in the antenatal clinic setting, and are in line with recent recommendations in the non-pregnant population.

Smoking habits of parents attending a children's hospital

This exploratory study surveyed 418 parents attending a paediatric hospital in order to establish their smoking habits and preparedness to quit. We found that 27% were current smokers, of whom 81% were willing to try and quit in the near future. These and the parent's other responses to a questionnaire will be used to develop a programme of smoking cessation for parents attending a children's hospital.

The effect of health visitors on breastfeeding in Glasgow

BACKGROUND

The UNICEF Baby Friendly Initiative includes a community component to help women who want to breastfeed. This study aimed to document the health visitor role in promoting and supporting breastfeeding in Glasgow during 2000 and the effect it had on breastfeeding rates.

METHODS

Glasgow, UK, has a population of 906,000, with approximately 10,000 births per year. Glasgow has high levels of material deprivation and traditionally low breastfeeding rates. This was a cross-sectional study in January 2000 which used a postal questionnaire to document individual health visitors' interventions, activities and attitude towards breastfeeding. Infant's breastfeeding data collected routinely by the Child Health Surveillance programme from 1 August 1998 to 28 February 1999 was directly matched with interventions, activities and attitudes reported by their own health visitor.

RESULTS

146/216 (68%) health visitors completed and returned the questionnaire. 5401 child health records were eligible and 3,294 (58.2%) could be matched with health visitors who returned questionnaires. 2145 infants had the first visit from 8 to 20 days of age and the second 3 to 7 weeks later. At the first postnatal visit 835 of 2145 (39%) infants were breastfed (median age of 13 days) and 646 (30%) continued to breastfeed at the second visit (median age 35 days). Infants being breastfed at the first visit were significantly more likely to be fed infant formula at the second visit if their health visitors had had no breastfeeding training in the previous two years (OR1.74 95%CI 1.13, 2.68).

CONCLUSION

It is essential that Health Visitors are specially trained to support breastfeeding postnatally.

Investigating risk factors for slips, trips and falls in New Zealand residential construction using incident-centred and incident-independent methods

Slip, trip and fall (STF) incidents, particularly falls from a height, are a leading cause of injury in the New Zealand residential construction industry. The most common origins of falls from a height in this sector are ladders, scaffolding and roofs, while slipping is the most frequent fall initiating event category. The study aimed to provide detailed information on construction industry STF risk factors for high-risk tasks, work equipment and environments, as identified from an earlier analysis of STF claims data, together with information to be used in the development of interventions to reduce STF risk in New Zealand residential construction. The study involved the use of both incident-centred and incident-independent methods of investigation, including detailed follow-up investigations of incidents and observations and interviews with workers on construction sites, to provide data on a wide range of risk factors. A large number of risk factors for residential construction STFs were identified, including factors related to the work environment, tasks and the use and availability of appropriate height work equipment. The different methods of investigation produced complementary information on factors related to equipment design and work organization, which underlie some of the site conditions and work practices identified as key risk factors for residential construction STFs. A conceptual systems model of residential construction STF risk is presented.

Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: a case-control study

OBJECTIVE

To examine the hypothesis that bedsharing with an infant is associated with an increased risk of sudden infant death syndrome (SIDS).

STUDY DESIGN

A 1:2, case:control study in Scotland UK, population 5.1 million, including 123 infants who died of SIDS between January 1, 1996 and May 31, 2000, and 263 controls. The main outcome measure was sharing a sleep surface during last sleep.

RESULTS

Sharing a sleep surface was associated with SIDS (multivariate OR 2.89, 95% CI 1.40, 5.97). The largest risk was associated with couch sharing (OR 66.9, 95% CI 2.8, 1597). Of 46 SIDS infants who bedshared during their last sleep, 40 (87%) were found in the parents' bed. Sharing a bed when <11 weeks (OR 10.20, 95% CI 2.99, 34.8) was associated with a greater risk, P = .010, compared with sharing when older (OR 1.07, 95% CI 0.32, 3.56). The association remained if mother did not smoke (OR 8.01, 95% CI 1.20, 53.3) or the infant was breastfed (OR 13.10, 95% CI 1.29, 133).

CONCLUSIONS

Bedsharing is associated with an increased risk of SIDS for infants <11 weeks of age. Sharing a couch for sleep should be strongly discouraged at any age.

Investigating slips, trips and falls in the New Zealand dairy farming sector

The paper presents findings from 39 detailed follow-up investigations of slips, trips and falls (STF) incurred by individuals working in New Zealand's dairy farming industry. The study sought to identify the key contributory risk factors for STF in this sector to provide evidence to support intervention design, and to determine the effectiveness of the investigative methodology used to achieve these objectives. Findings from the follow-up investigations included an analysis of factors related to the underfoot surface, underfoot hazard and footwear. Of note here was the propensity for STF-involved workers to not see or identify an underfoot hazard due to concurrent visual task distractions, and for workers to use footwear that both lacked effective tread and was unsuitable for the task and underfoot surface. Key latent risk factors and their interactions identified included problems associated with time pressure and related time-saving behaviours and the presence of design errors that, for example, required workers to climb onto equipment to view aspects of the task they were working on. The paper concludes that the potential resource and logistical problems associated with conducting detailed STF investigations are outweighed by the opportunity to collect rich data on key risk factors and their interactions in STF research.

Evaluation in industry of a draft code of practice for manual handling

This paper reports findings from a study which evaluated the draft New Zealand Code of Practice for Manual Handling. The evaluation assessed the ease of use, applicability and validity of the Code and in particular the associated manual handling hazard assessment tools, within New Zealand industry. The Code was studied in a sample of eight companies from four sectors of industry. Subjective feedback and objective findings indicated that the Code was useful, applicable and informative. The manual handling hazard assessment tools incorporated in the Code could be adequately applied by most users, with risk assessment outcomes largely consistent with the findings of researchers using more specific ergonomics methodologies. However, some changes were recommended to the risk assessment tools to improve usability and validity. The evaluation concluded that both the Code and the tools within it would benefit from simplification, improved typography and layout, and industry-specific information on manual handling hazards.

Used infant mattresses and sudden infant death syndrome in Scotland: case-control study

OBJECTIVE

To examine the proposition that a used infant mattress is associated with an increased risk of sudden infant death syndrome.

DESIGN

Case-control study.

SETTING

Scotland (population 5.1 million, with about 53 000 births a year).

PARTICIPANTS

131 infants who died of sudden infant death syndrome between 1 January 1996 and 31 May 2000 and 278 age, season, and obstetric unit matched control infants.

MAIN OUTCOME MEASURES

Routine use of an infant mattress previously used by another child and place of last sleep.

RESULTS

Routine use of an infant mattress previously used by another child was significantly associated with an increased risk of sudden infant death syndrome (multivariate odds ratio 3.07, 95% confidence interval 1.51 to 6.22). Use of a used infant mattress for last sleep was also associated with increased risk (6.10, 2.31 to 16.12). The association was significantly stronger if the mattress was from another home (4.78, 2.08 to 11.0) than if it was from the same home (1.64, 0.64 to 4.2).

CONCLUSION

A valid significant association exists between use of a used infant mattress and an increased risk of sudden infant death syndrome, particularly if the mattress is from another home. Insufficient evidence is available to judge whether this relation is cause and effect.

International Child Care Practices Study: infant sleeping environment

BACKGROUND

The International Child Care Practices Study (ICCPS) has collected descriptive data from 21 centres in 17 countries. In this report, data are presented on the infant sleeping environment with the main focus being sudden infant death syndrome (SIDS) risk factors (bedsharing and infant using a pillow) and protective factors (infant sharing a room with adult) that are not yet well established in the literature.

METHODS

Using a standardised protocol, parents of infants were surveyed at birth by interview and at 3 months of age mainly by postal questionnaire. Centres were grouped according to geographic location. Also indicated was the level of SIDS awareness in the community, i.e. whether any campaigns or messages to "reduce the risks of SIDS" were available at the time of the survey.

RESULTS

Birth interview data were available for 5488 individual families and 4656 (85%) returned questionnaires at 3 months. Rates of bedsharing varied considerably (2-88%) and it appeared to be more common in the samples with a lower awareness of SIDS, but not necessarily a high SIDS rate. Countries with higher rates of bedsharing appeared to have a greater proportion of infants bedsharing for a longer duration (>5 h). Rates of room sharing varied (58-100%) with some of the lowest rates noted in centres with a higher awareness of SIDS. Rates of pillow use ranged from 4% to 95%.

CONCLUSIONS

It is likely that methods of bedsharing differ cross-culturally, and although further details were sought on different bedsharing practices, it was not possible to build up a composite picture of "typical" bedsharing practices in these different communities. These data highlight interesting patterns in child care in these diverse populations. Although these results should not be used to imply that any particular child care practice either increases or decreases the risk of SIDS, these findings should help to inject caution into the process of developing SIDS prevention campaigns for non-Western cultures.

'You feel helpless, that's exactly it': parents' and young people's control beliefs about bed-wetting and the implications for practice

'You feel helpless, that's exactly it': parents' and young people's control beliefs about bed-wetting and the implications for practice Young people wet the bed when they fail to wake up to a full bladder. The causes of bed-wetting are far from certain and this uncertainty is reflected in the diversity of treatments on offer and the lack of any guarantee that treatment will work in a particular case. Most young people are sad and ashamed about the bed-wetting and want it to stop, but they vary widely in their belief in their own capacity to influence the situation, and in their optimism about what the future holds. The problem can persist into adolescence or even adulthood, with far reaching social and emotional consequences, both for the young people and their families. In an ethnographic study involving 19 families 'perceived helplessness' emerged as a key issue permeating the whole system and often activating a downward spiral, leading to abdication of effort and responsibility by the young people themselves, by their parents and sometimes by health care professionals. Informed by the insights gained from this study and an extensive review of the literature on perceived control the Family Perspectives on Bed Wetting Questionnaire has been developed to explore family members' feelings, degree of concern and dimensions of perceived control relating to: effort, ability, luck, important others and the unknown. This questionnaire was used as a basis for structured interviews with family members in a longitudinal survey, involving 40 families attending one of nine community-based, nurse-led enuresis clinics in Greater Glasgow. It was found that only 38% of the young people were entering into treatment with the belief that they had the ability to be dry at night. This became self-fulfilling, with only 33% achieving initial success of 14 consecutive dry nights in a 16-week period (chi-squared test, P=0.029). Seventy per cent of young people felt that luck was important, while most parents felt that luck had little part to play. Implications for practice include the need to assess the families' readiness to engage in treatment, to create opportunities for effective control and to encourage realistic expectations.

The incidence and prevalence of HIV infection among childbearing women living in Edinburgh city, 1982-1995

OBJECTIVE

To track the complete course of the HIV epidemic among women from the city of Edinburgh who delivered babies during 1982-1995.

METHODS

The performance of the modified Serodia HIV test on dried blood spots from archived neonatal metabolic screening cards stored for up to 11 years was evaluated by testing 221 cards from neonates whose mothers' HIV infection status was already known (100 HIV-positive, 121 HIV-negative). Unlinked anonymous HIV testing of cards from neonates born during 1982-1989 was then performed and the resulting prevalence data were combined with existing data from 1990-1995. Maximum and minimum limits of HIV incidence among women during the 36-month period prior to delivery were calculated using data held on a clinical database of HIV-infected pregnant women that had been generated under strict conditions of confidentiality; these data included the date of the woman's first HIV-positive and, if available, last HIV-negative specimen.

RESULTS

The evaluation revealed a sensitivity of 91%, not clearly related to storage time, and a specificity of 100%. HIV infection first entered Edinburgh's childbearing population during the early 1980s with prevalence peaking at 0.4% in 1986 and then decreasing to 0.1% in 1995; a similar incidence profile was seen during this period. Since 1986, the first full year that HIV testing was available, 78% of all infections were known during the pregnancy, 13% were identified retrospectively, and only 10% (10 cases) remain unaccounted for. For infected cases during 1984-1987, 78% were injecting drug users (IDU) and only 22% acquired their infection sexually; this distribution had reversed by 1992-1995.

CONCLUSION

HIV testing of neonatal metabolic screening cards stored for up to 11 years can yield results of sufficient accuracy for epidemiological purposes. There has been a substantial decline in the prevalence and incidence of HIV since the mid-1980s. Although new infections are still occurring, the numbers are small. The decline may largely be explained by the impact of preventive measures on the spread of HIV amongst IDU, and thus from IDU to their sexual partners.

Epidemiology and detection of HIV-1 among pregnant women in the United Kingdom: results from national surveillance 1988-96

OBJECTIVE

To describe the epidemiology of HIV-1 infection in pregnant women in the United Kingdom.

DESIGN

Serial unlinked serosurveillance for HIV-1 in neonatal specimens and surveillance through registers of diagnosed maternal and paediatric infections from reporting by obstetricians, paediatricians, and microbiologists.

SETTING

United Kingdom, 1988-96.

SUBJECTS

Pregnant women proceeding to live births and their children.

MAIN OUTCOME MEASURES

Time trends in prevalence of HIV-1 seropositivity in newborn infants (as a proxy for infection in mothers); the proportions of mothers with diagnosed HIV-1 infections, and their characteristics.

RESULTS

HIV-1 prevalence among mothers in London rose sixfold between 1988 and 1996 (0.19% of women tested; 1 in 520 in 1996). Apart from in Edinburgh and Dundee, levels remained low in Scotland (0.025%; 1 in 3970) and elsewhere in the United Kingdom (0.016%; 1 in 1930). Over a third of births to infected mothers in 1996 occurred outside London. In London the reported infections were predominantly among black African women, whereas in Scotland most were associated with drug injecting. The contribution of reported infection among African women increased over time as that of drug injecting declined. In Scotland 51% of mothers' infections were diagnosed before the birth. In England, despite a national policy initiative in 1992 to increase the antenatal detection rate of HIV, no improvement in detection was observed, and in 1996 only 15% of previously unrecognised HIV infections were diagnosed during pregnancy.

CONCLUSIONS

HIV-1 infection affects mothers throughout the United Kingdom but is most common in London. Levels of diagnosis in pregnant women have not improved. Surveillance data can monitor effectively the impact of initiatives to reduce preventable HIV-1 infections in children.

Case-control study of sudden infant death syndrome in Scotland, 1992-5

OBJECTIVE

To investigate the relation between routine infant care practices and the sudden infant death syndrome in Scotland.

METHODS

National study of 201 infants dying of the sudden infant death syndrome (cases) and 276 controls by means of home interviews comparing methods of infant care and socioeconomic factors.

RESULTS

Sleeping prone (odds ratio 6.96 (95% confidence interval 1.51 to 31.97) and drug treatment in the previous week (odds ratio 2.33 (1.10 to 4.94)) were more common in the cases than controls on multivariate analysis. Smoking was confirmed as a significant risk factor (odds ratio for mother and father both smoking 5.19 (2.26 to 11.91)). The risk increased with the number of parents smoking (P < 0.0001), with the number of cigarettes smoked by mother or father (P = 0.0001), and with bed sharing (P < 0.005). A new finding was an increased risk of dying of the syndrome for infants who slept at night on a mattress previously used by another infant or adult (odds ratio 2.51 (1.39 to 4.52)). However, this increased risk was not established for mattresses totally covered by polyvinyl chloride.

CONCLUSIONS

Sleeping prone and parental smoking are confirmed as modifiable risk factors for the sudden infant death syndrome. Sleeping on an old mattress may be important but needs confirmation before recommendations can be made.

A review of school vision screening in Glasgow

OBJECTIVES

To assess to what extent the primary school vision screening programme was being carried out in the years 1993-94 and 1994-95, what the prevalence of eye defects was in the primary schools and how many children had a positive screening test.

DESIGN

Summary sheets of the results of screening were returned by each school nurse.

SETTING

All 315 mainstream primary schools served by Greater Glasgow Health Board.

SUBJECTS

All school nurses working in these schools.

RESULTS

Large numbers of tests were being performed but the screening programme was not fully carried out in 10% of schools in 1993-94 and in 68% in 1994-95, although the number of schools where some screening was performed did increase. The years were not directly comparable due to a change in the age groups screened. When a class was screened 94-96% of children were tested. The rate of positive screening varied from 4% to 15.6% and varied with age and locality. Fewer abnormalities were found at five years than in the older age groups (Primary 1-7.6%, Primary 4-11.4%, and Primary 7-9.7%) and fewer abnormalities were detected in the North-West area where a pre-school orthoptic screening programme was operating (4% in the North-West compared with 11% in the South where no pre-school screening was carried out).

CONCLUSION

If the recommended programme is carried out, then 95% of children at age five years could be tested at a stage when amblyopia is still potentially treatable. The reasons for the programme not being completed require to be addressed. Variations between areas need to be confirmed and the reasons for them identified. Further evaluation of the programme is required, exploring the accuracy of it and the long-term outcomes.