Folic acid prescription in pregnancy.

We resolved to prescribe folic acid supplements for all women who attended this practice during the first twelve weeks of pregnancy. Six months after this decision a prescription was recorded in only 13% of cases: this compared with 18% during the two months immediately following the decision. It was resolved to improve this performance and observations six months later revealed a prescription recorded in 63% of cases. Subsequently a new form for recording an antenatal consultation was devised and six months after its implementation, 100% recording of folate prescription for appropriate cases was observed. It was concluded that these simple audit exercises prompted changes in practice which helped to improve standards of patient care

Do practitioners and friends support patients with coronary heart disease in lifestyle change? a qualitative study.

BACKGROUND: Healthy lifestyles help to prevent coronary heart disease (CHD) but outcomes from secondary prevention interventions which support lifestyle change have been disappointing. This study is a novel, in-depth exploration of patient factors affecting lifestyle behaviour change within an intervention designed to improve secondary prevention for patients with CHD in primary care using personalised tailored support. We aimed to explore patients\u27 perceptions of factors affecting lifestyle change within a trial of this intervention (the SPHERE Study), using semi-structured, one-to-one interviews, with patients in general practice. METHODS: Interviews (45) were conducted in purposively selected general practices (15) which had participated in the SPHERE Study. Individuals, with CHD, were selected to include those who succeeded in improving physical activity levels and dietary fibre intake and those who did not. We explored motivations, barriers to lifestyle change and information utilised by patients. Data collection and analysis, using a thematic framework and the constant comparative method, were iterative, continuing until data saturation was achieved. RESULTS: We identified novel barriers to lifestyle change: such disincentives included strong negative influences of social networks, linked to cultural norms which encouraged consumption of \u27delicious\u27 but unhealthy food and discouraged engagement in physical activity. Findings illustrated how personalised support within an ongoing trusted patient-professional relationship was valued. Previously known barriers and facilitators relating to support, beliefs and information were confirmed. CONCLUSIONS: Intervention development in supporting lifestyle change in secondary prevention needs to more effectively address patients\u27 difficulties in overcoming negative social influences and maintaining interest in living healthily

Systematic Review of the Effect of Diet and Exercise Lifestyle Interventions in the Secondary Prevention of Coronary Heart Disease

The effectiveness of lifestyle interventions within secondary prevention of coronary heart disease (CHD) remains unclear. This systematic review aimed to determine their effectiveness and included randomized controlled trials of lifestyle interventions, in primary care or community settings, with a minimum follow-up of three months, published since 1990. 21 trials with 10,799 patients were included; the interventions were multifactorial (10), educational (4), psychological (3), dietary (1), organisational (2), and exercise (1). The overall results for modifiable risk factors suggested improvements in dietary and exercise outcomes but no overall effect on smoking outcomes. In trials that examined mortality and morbidity, significant benefits were reported for total mortality (in 4 of 6 trials; overall risk ratio (RR) 0.75 (95% confidence intervals (CI) 0.65, 0.87)), cardiovascular mortality (3 of 8 trials; overall RR 0.63 (95% CI 0.47, 0.84)), and nonfatal cardiac events (5 of 9 trials; overall RR 0.68 (95% CI 0.55, 0.84)). The heterogeneity between trials and generally poor quality of trials make any concrete conclusions difficult. However, the beneficial effects observed in this review are encouraging and should stimulate further research

Motherhood in the teens and twenties: some surprises.

We report a study of the association of health and social support variables with motherhood in teenagers and older mothers. Both teenage and older mothers reported poorer physical and mental health and fewer and less frequent social contacts than their nulliparous peers. Contrary to expectation, however, older mothers reported less extensive and less adequate social support networks than did teenagers

The contribution of qualitative research in designing a complex intervention for secondary prevention of coronary heart disease in two different healthcare systems

BACKGROUND: Developing complex interventions for testing in randomised controlled trials is of increasing importance in healthcare planning. There is a need for careful design of interventions for secondary prevention of coronary heart disease (CHD). It has been suggested that integrating qualitative research in the development of a complex intervention may contribute to optimising its design but there is limited evidence of this in practice. This study aims to examine the contribution of qualitative research in developing a complex intervention to improve the provision and uptake of secondary prevention of CHD within primary care in two different healthcare systems. METHODS: In four general practices, one rural and one urban, in Northern Ireland and the Republic of Ireland, patients with CHD were purposively selected. Four focus groups with patients (N = 23) and four with staff (N = 29) informed the development of the intervention by exploring how it could be tailored and integrated with current secondary prevention activities for CHD in the two healthcare settings. Following an exploratory trial the acceptability and feasibility of the intervention were discussed in four focus groups (17 patients) and 10 interviews (staff). The data were analysed using thematic analysis. RESULTS: Integrating qualitative research into the development of the intervention provided depth of information about the varying impact, between the two healthcare systems, of different funding and administrative arrangements, on their provision of secondary prevention and identified similar barriers of time constraints, training needs and poor patient motivation. The findings also highlighted the importance to patients of stress management, the need for which had been underestimated by the researchers. The qualitative evaluation provided depth of detail not found in evaluation questionnaires. It highlighted how the intervention needed to be more practical by minimising administration, integrating role plays into behaviour change training, providing more practical information about stress management and removing self-monitoring of lifestyle change. CONCLUSION: Qualitative research is integral to developing the design detail of a complex intervention and tailoring its components to address individuals' needs in different healthcare systems. The findings highlight how qualitative research may be a valuable component of the preparation for complex interventions and their evaluation

Approaches to detect genetic effects that differ between two strata in genome-wide meta-analyses: Recommendations based on a systematic evaluation.

Genome-wide association meta-analyses (GWAMAs) conducted separately by two strata have identified differences in genetic effects between strata, such as sex-differences for body fat distribution. However, there are several approaches to identify such differences and an uncertainty which approach to use. Assuming the availability of stratified GWAMA results, we compare various approaches to identify between-strata differences in genetic effects. We evaluate type I error and power via simulations and analytical comparisons for different scenarios of strata designs and for different types of between-strata differences. For strata of equal size, we find that the genome-wide test for difference without any filtering is the best approach to detect stratum-specific genetic effects with opposite directions, while filtering for overall association followed by the difference test is best to identify effects that are predominant in one stratum. When there is no a priori hypothesis on the type of difference, a combination of both approaches can be recommended. Some approaches violate type I error control when conducted in the same data set. For strata of unequal size, the best approach depends on whether the genetic effect is predominant in the larger or in the smaller stratum. Based on real data from GIANT (>175 000 individuals), we exemplify the impact of the approaches on the detection of sex-differences for body fat distribution (identifying up to 10 loci). Our recommendations provide tangible guidelines for future GWAMAs that aim at identifying between-strata differences. A better understanding of such effects will help pinpoint the underlying mechanisms