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PubMed2001

Predicting admission rates to secure forensic psychiatry services.

BACKGROUND: The planning and development of secure forensic psychiatry services for mentally disordered offenders in England and Wales has proceeded independently within different regional areas. However, certain mental disorders, offenders, and offending behaviour are all more prevalent in geographical areas characterized by socio-economic deprivation and social disorganization. Failure to consider these factors has led to inadequate service provision in some areas and inequity in funding. A new model is required to predict admissions to these services as an aid to resource allocation. METHOD: Actual admissions (N = 3155) to high and medium secure psychiatric services for seven of 14 (pre-reorganization) Regional Health Authorities, 1988-94. Expected admissions were calculated for each district using 1991 census data adjusted for under-enumeration. Standardized psychiatric admission ratios were calculated and a range of social, health status, and service provision data were used as explanatory variables in a regression analysis to determine variation between districts. RESULTS: Actual psychiatric admissions varied from 160% above to 62% below expected for age, sex, and marital status, according to patients' catchment area of origin, measured according to deciles of the distribution of underprivileged area scores at ward level. The most powerful explanatory variables included a composite measure of social deprivation, ethnicity and availability of low secure beds at regional level. CONCLUSION: Admission rates to secure forensic psychiatry services demonstrate a linear correlation with measures of socio-economic deprivation in patients catchment area of origin. A model was developed to predict admissions from District Health Authorities and is recommended for future use in resource allocation. Identification of factors that explain higher admission rates of serious offenders with mental disorder from deprived areas is a priority for future research.

Adult↗

PubMed2003

Potential mechanisms of avian sex manipulation.

The aim of this review is to consider the potential mechanisms birds may use to manipulate the sex of their progeny, and the possible role played by maternal hormones. Over the past few years there has been a surge of reports documenting the ability of birds to overcome the rigid process of chromosomal sex determination. However, while many of these studies leave us in little doubt that mechanisms allowing birds to achieve this feat do exist, we are only left with tantalizing suggestions as to what the precise mechanism or mechanisms may be. The quest to elucidate them is made no easier by the fact that a variety of environmental conditions have been invoked in relation to sex manipulation, and there is no reason to assume that any particular mechanism is conserved among the vast diversity of species that can achieve it. In fact, a number of intriguing proposals have been put forward. We begin by briefly reviewing some of the most recent examples of this phenomenon before highlighting some of the more plausible mechanisms, drawing on recent work from a variety of taxa. In birds, females are the heterogametic sex and so non-Mendelian segregation of the sex chromosomes could conceivably be under maternal control. Another suggestion is that follicles that ultimately give rise to males and females grow at different rates. Alternatively, the female might selectively abort embryos or 'dump lay' eggs of a particular sex, deny certain ova a chance of ovulation, fertilization or zygote formation, or selectively provision eggs so that there is sex-specific embryonic mortality. The ideas outlined in this review provide good starting points for testing the hypotheses both experimentally (behaviourally and physiologically) and theoretically.

Animals↗

PubMed2001

Comprehensive dental care for children with rampant caries under general anaesthesia.

OBJECTIVE: Critical reflection on treatment strategy for dental rehabilitation of young children with rampant caries using day-stay general anaesthesia at a university dental clinic. DESIGN: Cross-sectional analysis of 98 cases. SETTING: The study was undertaken at the university paediatric dental clinic of Leuven, Belgium. SAMPLE AND METHODS: The sample consisted of 98 healthy patients referred for dental treatment under general anaesthesia with a mean age of 4.8 (+/- 1.1) years and mean dmft-score of 9.3 (+/- 3.0). Data were obtained by history taking, clinical examination, questionnaires (filled in by parents) and standardized data records (filled in by dentists and nurses in the recovery area and day-stay clinic). RESULTS: Most patients were referred by their private dentist (74.5%) because of a need for extensive dental treatment in an uncooperative child. Induction of anaesthesia was upsetting in a significant number of cases (68% of children). The mean duration of the whole procedure was 80.9 (+/- 24.7) minutes. A mean number of 7.2 (+/- 2.9) primary teeth were filled and 1.8 (+/- 2.0) extracted per patient. Post-operative problems (nausea/vomiting, temperature rise) were seen in only 8.2% of the patients. CONCLUSIONS: The technique used at this centre allows for extensive dental treatment of young children with a high level of acceptability and minimal morbidity, using day-stay general anaesthesia. Based on this review, it became clear that less upsetting methods for the induction of anaesthesia need to be explored. Criteria for the administration of antibiotics need to be defined more clearly and the use of stainless steel crowns should be envisaged for restorations on primary molars. The global outcome of this treatment provision in children at high caries risk should be evaluated over a longer period, including an evaluation of oral health status, restorative treatment (conservation vs. extraction) and behavioural aspects.

Ambulatory Surgical Procedures↗

PubMed1999

HIV counselling and testing: overemphasizing high acceptance rates a threat to confidentiality and the right not to know.

OBJECTIVE: To examine factors affecting the readiness for HIV-related voluntary confidential counselling and testing (VCT). METHODS: In a population-based HIV survey in selected urban and rural areas in Zambia, adults aged > or = 15 years were selected by stratified random cluster sampling. The participants were asked to provide a saliva sample for anonymous HIV testing (n=4812, consent rate 93.5%) and, as a part of an interview, were asked about previous HIV testing experience and if they wished to be counselled and tested for HIV. Those indicating interest (initially willing) were provided with an invitation letter to see a counsellor. In rural areas, VCT was provided by personnel brought in from outside the local community, whereas in urban areas it was provided by locally recruited staff. RESULTS: The overall HIV test rate was 6.5%, but rates appeared to be considerably biased towards higher educational groups. The proportion initially willing was 37% while 3.6% actually came for counselling and were tested (9.3% of those initially willing), of which 47% returned for the result. Actual use was four to five times higher in rural compared with urban areas. Self-perceived risk and high-risk behaviour were positively associated with initial willingness but not with actual use. CONCLUSIONS: The readiness for VCT in the general population was found to be very low. Provision factors such as concerns about confidentiality and length of time waiting for the test result contributed to the low utilization rate. Results of this study contrast sharply with reported VCT acceptance rates of 70-90% among women attending antenatal care in Zambian and in other African populations, suggesting an urgent need to evaluate testing policy and practice of antenatal VCT in particular.

AIDS Serodiagnosis↗

PubMed2001

[Schizophrenia and cognitive behavioral psychotherapy].

OBJECTIVE: To distinguish between different approaches of cognitive-behavioural therapy (CBT) for schizophrenia depending on the goals, objectives and methods of these approaches, then to discuss efficacy studies. METHOD: A summary of information collected through electronic (MEDLINE, PSYchlit) and bibliographic research. RESULTS: CBTs all broadly attempt to bring a better cognitive, behavioural and emotional adjustment to the psychotic experience by suggesting to the patient a new explanatory model of psychosis: the vulnerability-stress model. These approaches involve different levels and goals. Some focus on correcting basic cognitive deficits or modifying the psychotic symptoms and the related distress. At the other end of the spectrum, metacognitive therapies aim to modify and restructure dysfunctional self and environment schemas to enable the development of better-adjusted and generally applied cognitive strategies. A few studies with limited power and methods have shown the efficiency of those therapies. CONCLUSION: CBTs prove to be a promising additive treatment. They have been shown to improve social adjustment and quality of life, and to diminish psychotic symptoms and the related distress. They address all positive, negative, cognitive, behavioural, and emotional symptoms while considering the stage of the disease and the patient's special needs. Further research is needed to establish the duration, the best provision frequency, and the specificity of these approaches.

Cognitive Behavioral Therapy↗

PubMed1997

Development of a neurological rehabilitation environment: an observational study.

BACKGROUND: Engagement in therapeutic activity among stroke inpatients is advocated by many rehabilitation professionals. However, there is a lack of published evidence to indicate whether this is currently being achieved. OBJECTIVE: To investigate the extent and types of 'rehabilitation' activities on a new neurological rehabilitation ward, and examine change in patients' behaviour related to the new environment and new initiatives. DESIGN: Five one-week observation periods were conducted over two years, with a total of 67 patients being observed. A comparison was made with results of an earlier study of stroke patients' activities conducted at the same hospital. RESULTS: Patients spent an average 43 min per day with therapists (9% of the working day) and this was only marginally supplemented by self-exercise (2% of the working day--approximately 10 min). However, the provision of a new rehabilitation environment was associated with a marked decrease in the time patients spent at their bedsides, and a decrease in time spent passively gazing or watching others. CONCLUSIONS: Overall there was some positive change in patients' behaviour. We suggest that structured guidance is required from the whole multidisciplinary team to stimulate more self-directed therapy practice and recreation.

Adolescent↗

PubMed2006

Illness-related behaviour and utilization of oral health services among adult city-dwellers in Burkina Faso: evidence from a household survey.

BACKGROUND: In sub-Saharan Africa, the availability and accessibility of oral health services are seriously constrained and the provision of essential oral care is limited. Reports from the region show a very low utilization of oral health care services, and visits to dental-care facilities are mostly undertaken for symptomatic reasons. The objectives of the present study were to describe the prevalence of oral symptoms among adults in Ouagadougou, capital city of Burkina Faso and the use of oral health services and self-medication in response to these symptoms and to measure the associations between predisposing, enabling and needs factors and decisions to seek oral health care. METHODS: The conceptual design of the study was derived from both the Andersen-Newman model of health care utilization and the conceptual framework of the WHO International Collaborative Study of Oral Health Outcomes. Data were obtained by two-stage stratified sampling through four areas representative of different stages of urbanization of Ouagadougou. The final study population comprised 3030 adults aged 15 years or over and the response rate was 65%. RESULTS: Overall, 28% of the respondents had experienced an oral health problem during the past 12 months; a high proportion (62%) reported pain or acute discomfort affecting daily life. In response to symptoms, only 28% used oral health facilities, 48% used self-medication and 24% sought no treatment at all. Multivariate analyses revealed that several socio-economic and socio-cultural factors such as religious affiliation, material living conditions and participation in a social network were significantly associated with the use of oral health care services by adults who had experienced oral health problems during the previous year. CONCLUSION: The proportion of people who have obtained oral health care is alarmingly low in Ouagadougou and self-medication appears to be an important alternative source of care for adult city-dwellers. Decision-makers in sub-Saharan countries must seek to ensure that access to essential oral health care is improved.

Adolescent↗

PubMed2001

Surveys on sexual health: recent developments and future directions.

The increasingly widespread adoption of the term sexual health reflects a move away from the medicalisation of this specialty. The focus has shifted from clinical practice to lifestyle and behaviour; from clinician to client, and from treatment to prevention. This article discusses these themes, identifying their implications for sexual health research. Recent times have seen, for example, a growing number of studies combining biological and behavioural measures conducted by interdisciplinary teams able to combine biomedical measurements of morbidity with insights into the subjective interpretations of symptoms and consequences. Considerable progress has been made, too, in mounting community based studies, and much has been achieved in gaining compliance and refining sampling methods. Integrated sexual health services, encompassing more than contraceptive or prophylactic service provision, have provided the impetus to investigation of the costs and benefits of coordinated family planning and genitourinary medicine services. Despite its broader focus, there remain opportunities for sexual health research to expand its remit. Studies to date may have focused too narrowly on pathological, to the neglect of health enhancing, consequences of sexual behaviour.

Adolescent↗

PubMed2005

Human behaviour and the epidemiology of parasitic zoonoses.

The behaviour of Homo sapiens has a pivotal role to play in the macro and microepidemiology of emerging or re-emerging parasitic zoonoses. Changing demographics and the concomitant alterations to the environment, climate, technology, land use and changes in human behavior, converge to favour the emergence and spread of parasitic zoonoses. The recent unprecedented movements of people, their animals and their parasites around the world, introduce and mix genes, cultural preferences, customs, and behavioral patterns. The increasing proclivity for eating meat, fish, crabs, shrimp, molluscs raw, undercooked, smoked, pickled or dried facilitates a number of protozoan (Toxoplasma), trematode (Fasciola sp., Paragonimus spp., Clonorchis sp., Opisthorchis spp., Heterophyes sp., Metagonimus sp., Echinostoma spp., Nanophyetus sp.) cestode (Taenia spp, Diphyllobothrum sp.) and nematode (Trichinella spp., Capillaria spp., Gnathostoma spp., Anisakis sp., Parastrongylus spp.) caused zoonoses. The increasing world population and the inability to keep pace with the provision of adequate sanitation and clean, safe drinking water, has led to an increased importance of waterborne zoonoses, such as those caused by Giardia, Cryptosporidium and Toxoplasma. Our close relationship with and the numerous uses to which we put companion animals and their ubiquitous distribution has resulted in dogs and cats unwitting participation in sharing over 60 parasite species including: Giardia, Cryptosporidium, Toxoplasma, most foodborne trematode species, Diphyllobothrum, Echinococcus spp., Ancylostoma and Toxocara. Changing human behaviour through education, to encourage the proper cooking of food, which may have cultural and social significance, will remain as challenging as controlling stray and feral pet populations, improving hygiene levels and the provision of safe drinking water and the proper use of sanctuary facilities. Long pre-patent periods and the normally insidious sub-clinical nature of most zoonoses makes advice requiring behavioural change for their control a difficult task. Our clearer understanding of the heterogeneity of susceptibility to infection, the complex genetic variations of people and parasite species and the development of molecular epidemiological tools is shedding more light on transmission routes and the spectrum of disease that is observed. Improved and new serological, molecular and imaging diagnostic tests and the development of broad spectrum chemotherapeutic agents has led to the attenuation of morbidity and mortality due to parasitic zoonoses in economically advantaged regions. Such advancements, in partnership with supportive behavioural change, has the potential for a sustainable global reduction in the burden of ill health due to parasitic zoonoses. Whether this will materialise is a challenge for us all.

Animals↗

PubMed2005

The importance of microclimate variation in determining size, growth and survival of avian offspring: experimental evidence from a cavity nesting passerine.

Organisms are expected to balance energy allocation in such a way that fitness is maximized. While much research has focussed on allocation strategies of reproducing parents, in particular birds, relatively little attention has been paid to how nestlings allocate energy while in the nest. Nestling birds are faced with a trade-off between devoting energy to growth or to thermoregulation, and in altricial species it is likely that the thermal environment of the nest site influences the nature of this trade-off. Here, we experimentally investigate how altering the microclimate of nests affects the growth, size and survival, as well as cell-mediated immune (CMI) response, of nestling tree swallows (Tachycineta bicolor) in a temperate environment. We place air-activated heating pads in nests of swallows when young were between 4 days and 16 days of age, and compared performance of offspring to control nests. Our manipulation raised temperatures of heated nests by approximately 5 degrees C compared to control nests. Offspring in heated nests had enhanced survival while in the nest, and we also found that they were heavier and had longer ninth primary feathers at 16 days of age. In addition, heating nest boxes resulted in significantly faster growth of primaries, and there was a trend for growth rates of mass to also be higher in heated nests. There were no significant differences between heated and control nests in growth rate or size of tarsus at age 16 days, and we speculate that this lack of response to elevated nest temperatures may be due to growth of skeletal structures being limited by other factors such as calcium availability. We also found no difference between heated and control nests in CMI response. Nonetheless, our results show overall that increasing temperatures of nests has significant benefits that enhance the fitness of offspring. As provisioning rates to offspring did not differ between heated and control nests, we suspect that the beneficial effects of heating were not the consequence of changes in parental behaviour. Our results provide insight into factors, other than food supply, that have important consequences in determining reproductive success of birds breeding in temperate environments.

Analysis of Variance↗

PubMed2005

Assessing and communicating the health and judicial impact of alcohol use.

BACKGROUND: Alcohol consumption places an increasing burden on health services, criminal justice agencies and private industry throughout the UK. Despite a national strategy to tackle alcohol-related harm, there remains a lack of epidemiology on alcohol use and related harms at local levels. Utilising national data sources and existing research studies, Regional Public Health Observatories are appropriately placed to calculate such measures and examine their relationship with deprivation. METHODS: For the North West of England, borough and health locality data were extracted from national sources. Alcohol consumption utilised lifestyle survey data and estimates of related harm were calculated by applying existing alcohol attributable fractions to deaths, hospital episodes and crime data. Contribution of alcohol to reduction in life expectancy was also calculated and all measures were correlated with deprivation. RESULTS: For the North West, the annual burden of alcohol was estimated at over 3700 deaths, 56,700 hospital episodes and 71,000 crimes. Annual alcohol-related death rates for men varied from 0.43 to 1.17 per 1000 between Local Authorities and there was a six-fold variation in alcohol-related crime rate between areas. For males, alcohol reduced life expectancy by more than five months in the area worst affected. For both sexes, more deprived areas had significantly higher levels of alcohol-related hospital episodes, crime, and contribution to reduced life expectancy. CONCLUSIONS: Alcohol-related harm requires urgent, multi-agency attention at local levels throughout the UK. Applying appropriate research methods to national data sources provides limited but valuable local measures of alcohol use and its impact on health and crime. Regional Public Health Observatories can facilitate partnership working through such provision of national intelligence tailored to support local and regional action. Application of these techniques also helps identify additional requirements for better local intelligence on health-related behaviours and the necessity for consistency across local health and behaviour surveys.

Adolescent↗

PubMed1988

Behaviour of intraocular gases.

The changes in volume of intraocular bubbles of air, sulphur hexafluoride, perfluoropropane and mixtures of these gases, were studied in human eyes, following vitrectomy for treatment of retinal detachment. The implications of these findings, for the provision of optimal internal tamponade in the treatment of retinal detachment, are discussed.

Air↗

PubMed2001

Family carers and the adult head-injured: a critical review of carers' needs.

PRIMARY OBJECTIVE: To appraise recent literature on the topic of perceived needs of family carers of head-injured adult relatives. MEDLINE (1966-2000), EMBASE PSYCHIATRY (1987-1999), CINAHL (1982-January 2000) and PSYCHLIT (1967-1999) databases were searched. MAIN OUTCOMES AND RESULTS: A total of 13 papers were reviewed, of which six employed standardized research methods. The remainder used researcher developed questionnaires. Needs described by carers as important were predominantly related to information. Most unmet needs were linked to the provision of emotional support. There were significant differences in the perceived needs and their fulfilment between parental and spousal carers. In addition, unfulfilled needs could be predicted by behavioural problems in patients. CONCLUSIONS: The design and variation in methodology of most studies reviewed limits the generalization of reported data. Further research is required to fully identify both common and individual needs of family carers of the head-injured.

Adult↗

PubMed1998

Resource implications for oral care of patients with HIV.

OBJECTIVES: The aim was to investigate the attitudes of people with HIV infection towards their own dental care provision and the possible implications for future resource allocation. DESIGN: Sixty-nine HIV positive subjects attending support groups in London were interviewed. Past and current dental visiting behaviour, problems encountered in obtaining dental care and preferred site of delivery for dental care were investigated. RESULTS: Showed that a majority (74%) changed dentist or stopped attending following diagnosis with HIV, either due to fear of or actual refusal of treatment, a desire to attend a more sympathetic dentist or to attend a specialist clinic. Forty-five per cent withheld information about their status. Subjects expressed a desire to receive regular dental care and had definite preferences as to the site of delivery, 45% preferring general practice, 48% specialist clinics. CONCLUSIONS: Future resource allocation should be used for continued support and education of general dental practitioners willing to treat HIV positive patients, and for accessible specialist referral centres. Hospital clinics could also provide regular routine care, especially in areas of large HIV populations. An improved awareness of and access to community dental clinics appears to be needed, with efforts focused on achieving an informed and educated patient population through education programmes.

Adolescent↗

PubMed2004

The Victorian Active Script Programme: promising signs for general practitioners, population health, and the promotion of physical activity.

BACKGROUND: The Active Script Programme (ASP) aimed to increase the number of general practitioners (GPs) in Victoria, Australia who deliver appropriate, consistent, and effective advice on physical activity to patients. To maximise GP participation, a capacity building strategy within Divisions of General Practice (DGPs) was used. The objectives of the programme were to (a) train and support GPs in advising sedentary patients, and (b) develop tools and resources to assist GPs. OBJECTIVE: To evaluate the effectiveness of the ASP. METHODS: A systems approach was used to promote capacity in Victorian general practice. Economic analyses were incorporated into the programme's evaluation. Participants were selected DGPs and their GP members. The programme worked with DGPs to train GPs and provide relevant resources. The main outcome measures were (a) changes in GP knowledge and behaviour and (b) cost effectiveness, based on modelled estimates of numbers of patients advised and adopting physical activity and gaining the associated health benefits. RESULTS: GP awareness and provision of physical activity advice increased. Although the programme's reach was modest, based on actual GP involvement, the cost effectiveness figures (138 Australian dollars per patient to become sufficiently active to gain health benefits, and 3647 Australian dollars per disability adjusted life year saved) are persuasive. CONCLUSIONS: The ASP increased DGPs' capacity to support GPs to promote physical activity. There is a strong economic argument for governments to invest in such programmes. However, caution is warranted about the maintenance of patients' activity levels. Programme refinement to encourage GPs to use community supports more effectively will guide future development. Further research on long term patient adherence through a multisectorial approach is warranted.

Adult↗

PubMed1998

A review of the pharmacoeconomics of pharmaceutical care.

Numerous studies have demonstrated that the therapeutic use of drugs results in adverse outcomes and contributes to high rates of morbidity and mortality. The causes of drug-related problems are multifactorial and their assessment has been based on factors such as inappropriate prescribing, inappropriate delivery, inappropriate patient behaviour, patient idiosyncrasy and inappropriate monitoring. The cost in the ambulatory setting has been estimated to exceed total prescription pharmaceutical use. Pharmaceutical care is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. It describes the process through which a pharmacist cooperates with a patient and other healthcare professionals in designing, implementing and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient. This article evaluates published studies related to the economic analysis of pharmaceutical care in enhancing the value of pharmaceuticals. While numerous descriptive articles exist, our review found no studies which met accepted pharmacoeconomic criteria. A small number of studies measured process variables and/or quality of life, but only one considered costs. Barriers to optimising the economic value of pharmaceutical care were also explored. Common methodological shortcomings indicated a need for improvement in future studies. There is little published research to date which demonstrates the pharmacoeconomic benefits of pharmaceutical care. Evidence does exist that clinical pharmacy services have positive economic benefits, and it is this evidence that, at present, supports the assertion that pharmaceutical care has potential to increase the value of pharmaceuticals in society by minimising drug-related morbidity and mortality. Thus, well conducted research is required to determine the economic impact of pharmaceutical care.

Humans↗

PubMedDate not supplied

Evaluation stages and design steps for knowledge-based systems in medicine.

After the early experiments in artificial intelligence a methodology is emerging around advanced systems for the management of medical knowledge. The stress is moving away from the implementation of prototypes to the evaluation. It is possible to adapt and to apply this to field evaluation techniques already developed in similar contexts of knowledge management (books, drugs, epidemiology, consultants, etc.). The time is ready for a further step: to envisage a methodology for the design of real systems that cope with the 'knowledge environment' of the user. Every stage of the evaluation process is re-examined here, and considered as a framework to define goals and criteria about a step of design: (1) the impact of the system on the progress of health care provision (priorities, cost-benefit analysis, share of tasks among different media); (2) effectiveness in the end-user's environment and long-term effects on his behaviour (changes in people's role and responsibilities, improvements in the quality of data, acceptance of the system); (3) the intrinsic efficiency of the system apart from the operational context (correctness of the knowledge base, appropriateness of the reasoning). The need to differentiate the test sample into three classes (obvious, typical, atypical) is emphasized, discussing the influence on both evaluation and design. In particular the difficulty of having 'gold standards' on atypical cases, due to the disagreement among the experts, leads to the definition of two alternative attitudes: the 'standardization mode' and the 'brain-storming mode'.

Expert Systems↗

PubMed1999

[Smoking cessation and pregnancy].

OBJECTIVES: To assess the effectiveness of smoking cessation programs implemented during pregnancy and to assess the impact of these programs on the health of the fetus and infant, on the mother and on the family. SEARCH STRATEGY: Randomized and quasi-randomized controlled trials identified by the search strategy of the Cochrane Pregnancy and Childbirth Group, supplemented by the search strategy of the Cochrane Tobacco Group. SELECTION CRITERIA: Trials in which programs to increase smoking cessation were implemented during pregnancy. DATA COLLECTION AND ANALYSIS: Data were abstracted according to predetermined criteria by two observers (S Oliver + J Lumley or E Waters + J Lumley). A total of 40 trials, conducted between 1975 and 1997, comprising over 9,000 women were identified and included in the review. An additional study provided data on over 3,000 women in a cluster-randomized trial. Interventions commonly included in these programs were: the provision of information on the risks of smoking to the fetus and infant and the benefits of quitting; recommendations to quit; feedback about the fetus; teaching cognitive-behavioural strategies for quitting smoking. There was substantial variation in the intensity of the intervention and the extent of reminders and reinforcement through pregnancy. Participants were healthy pregnant women and the usual setting was a hospital or community antenatal clinic. The principal outcome measure was continued smoking in late pregnancy. Eight trials provided some information on fetal outcomes: mean birthweight, low birthweight, preterm birth and perinatal mortality. MAIN RESULTS: Pooled data from 30 trials revealed a significant reduction in the odds of continued smoking in late pregnancy in the intervention groups (odds ratio (OR) = 0.51, 95% confidence interval 0.45 to 0.58). This equates to an absolute difference in the proportion continuing to smoke of 6.6%. The findings were similar when analyses were restricted to the 17 trials with biochemical validated smoking cessation (OR = 0.49, 95% CI 0.42 to 0.58 and an absolute difference in continued smoking of 7.2%); to the 11 trials where the intervention intensity was high (OR = 0.50, 95% CI 0.42 to 0.59 and an absolute difference in continued smoking of 8.6%); and to the 12 trials with a high quality score for the intervention--rated on the theoretical basis, the intensity of the intervention, detailed description of the intervention, process evaluation, validated smoking cessation--(OR = 0.47, 95% CI 0.40 to 0.56 and an absolute difference in continued smoking of 8.9%). The six trials with validated smoking cessation, a high intensity intervention and a high quality score had a pooled OR = 0.47, 95% CI 0.38 to 0.57 and an absolute difference in continued smoking of 9.2%. The subset of trials with information on fetal outcome revealed a reduction in low birthweight (pooled OR = 0.80, 95% CI 0.67 to 0.97), a non-significant reduction in preterm birth (pooled OR = 0.82, 95% CI 0.66 to 1.01), and an increase in mean birthweight of 41 g (95% CI 16.6 to 65.5), but no differences in very low birthweight, stillbirths, neonatal deaths or total perinatal mortality. Three trials of smoking relapse prevention among women who had stopped smoking by the first antenatal visit had a pooled OR = 0.73, 95% CI 0.45 to 1.18, for smoking in late pregnancy, with an absolute difference of 5.5%. The single large cluster-randomized trial showed no evidence of a decrease in continued smoking: the adjusted OR for quitting smoking by late pregnancy was 1.0, 95% CI 0.69 to 1.6. There were no differences in adjusted mean birthweight in this trial by intervention or control clinic. Process evaluation identified some problems with the implementation of this trial. CONCLUSIONS: Smoking cessation programs implemented in pregnancy increase smoking cessation, lead to a small increase in mean birthweight and a small reduction in low birthweight and preterm birth. (ABSTRACT TRUN

Controlled Clinical Trials as Topic↗