Episiotomy use at operative vaginal delivery

Episiotomy, a component of operative vaginal delivery (OVD), aims to prevent anal sphincter tears and associated sequelae. Robust evidence suggests restrictive use should be adopted at vaginal delivery but poor quality contradictory evidence exists at OVD. This thesis concerns a series of studies conducted to address this gap in knowledge. Formative work established a priori views and current practice of all obstetricians in the UK and Ireland via a national survey. The majority of clinicians preferred routine use of episiotomy at forceps delivery and restrictive use at vacuum. Respondents indicated support for the planned pilot RCT. A feasibility study established the possibility of conducting a pilot RCT with its known complexities. Data collection tools were developed and found to be fit for purpose and acceptable to women. Shortcomings in the study design informed the proposed pilot RCT. Contemporaneous to the pilot RCT, we conducted a prospective cohort study (n=1360) of morbidity in relation to episiotomy use at OVD to contextualise its findings. Episiotomy was not found to be protective of anal sphincter tears, shoulder dystocia or neonatal trauma but was associated with an increased risk of postpartum haemorrhage [adjusted OR 1.72 (95%CI 1.21 – 2.45)], perineal infection [adjusted OR 4.04 (95%CI 1.44 – 11.37)] and analgesic use [adjusted OR 3.35 (95%CI 2.49 – 4.51)]. The two centred pilot RCT, while not powered to provide definitive evidence, suggested a restrictive approach to episiotomy use does not appear to reduce or greatly increase anal sphincter tears [8.1% vs 10.9%, adjusted OR 0.77, (95% CI 0.28 – 2.10)]. There may however be a difference in effect size and direction between vacuum and forceps use. Routine use was associated with an increase in PPH [36% vs 27%; adjusted OR 1.88, (95% CI 0.99 - 3.57)]. A longitudinal follow up of participants to one year postpartum suggested routine use of episiotomy may decrease rates of urinary morbidity, particularly stress incontinence; dyspareunia; and perineal pain compared to restrictive use. This pilot RCT supports current practice regarding approach to episiotomy use at OVD meantime, pending the results of a definitive study.EThOS - Electronic Theses Online ServiceTenovus (T03/23)GBUnited Kingdo

Awareness of lifestyle and colorectal cancer risk:findings from the BeWEL study

It is estimated that 47% of colorectal cancers (CRC) could be prevented by appropriate lifestyles. This study aimed to identify awareness of the causes of CRC in patients who had been diagnosed with a colorectal adenoma through the Scottish Bowel Screening Programme and subsequently enrolled in an intervention trial (using diet and physical activity education and behavioural change techniques) (BeWEL). At baseline and 12-month follow-up, participants answered an open-ended question on factors influencing CRC development. Of the 329 participants at baseline, 40 (12%) reported that they did not know any risk factors and 36 (11%) failed to identify specific factors related to diet and activity. From a potential knowledge score of 1 to 6, the mean score was 1.5 (SD 1.1, range 0 to 5) with no difference between intervention and control groups. At follow-up, the intervention group had a significantly greater knowledge score and better weight loss, diet, and physical activity measures than the control group. Awareness of relevant lifestyle factors for CRC remains low in people at increased risk of the disease. Opportunities within routine NHS screening to aid the capability (including knowledge of risk factors) of individuals to make behavioural changes to reduce CRC risk deserve exploration.Additional co-author: The BeWEL team. The BeWEL Team consists of Shaun Treweek, Fergus Daly, Jill Belch, Jackie Rodger, Alison Kirk, Anne Ludbrook, Petra Rauchhaus, Patricia Norwood, Joyce Thompson, and Jane Wardle

Study Protocol for "MOVEdiabetes":A Trial to Promote Physical Activity for Adults with Type 2 Diabetes in Primary Health Care in Oman

Abstract Background Benefits of physical activity in the management of diabetes are well documented. However, evidence on the effectiveness of interventions integrating physical activity in diabetes care is sparse especially in the countries of the Gulf Cooperation Council. The results from this study will increase our understanding of the use of multi-component interventions aimed at increasing physical activity levels in inactive adults with type 2 diabetes in primary health care in Oman. Methods/design The study is a one year 1:1 cluster randomized controlled trial of the MOVEdiabetes programme (intervention) versus usual care in eight primary health care centres in Oman. The MOVEdiabetes programme utilizes face to face physical activity consultations promoting 150 min of moderate to vigorous physical activity per week (≥600MET-mins/week), pedometers to self-monitor step counts and monthly telephone WhatsApp messages for follow up support. Inactive adults with type 2 diabetes and no contraindication to physical activity will be recruited over a two months period, and followed up for 12 months. To demonstrate a 50% between group difference in physical activity levels (MET-mins/week) over 12 months, (at a power of 80%, and significance level of 5%), 128 participants would be required to complete the study (64 in each arm). Based on a drop-out rate of 20%, 154 participants would require to be recruited (77 in each arm). Assuming a recruitment rate of 70%, 220 potential eligible participants would need to be approached. The primary outcome is change in levels of physical activity measured by the Global Physical Activity Questionnaire. In addition, accelerometers will be used in a sub group to objectively assess physical activity. Secondary outcomes include changes in metabolic and cardiovascular biomarkers, change in self-reported health, social support, self-efficacy for physical activity, and perceived acceptability of the program. All intervention delivery and support costs will be monitored. Discussion This study will contribute to the evidence on the feasibility, cultural acceptability and efficacy of interventional approaches for increasing physical activity in primary care for persons with type 2 diabetes in Oman. Trial registration International Standard Randomised Controlled Trials No: ISRCTN14425284 . Registered 12 April 2016

Breast cancer risk reduction:is it feasible to initiate a randomised controlled trial of a lifestyle intervention programme (ActWell) within a national breast screening programme?

BackgroundBreast cancer is the most commonly diagnosed cancer and the second cause of cancer deaths amongst women in the UK. The incidence of the disease is increasing and is highest in women from least deprived areas. It is estimated that around 42% of the disease in post-menopausal women could be prevented by increased physical activity and reductions in alcohol intake and body fatness. Breast cancer control endeavours focus on national screening programmes but these do not include communications or interventions for risk reductionThis study aimed to assess the feasibility of delivery, indicative effects and acceptability of a lifestyle intervention programme initiated within the NHS Scottish Breast Screening Programme (NHSSBSP).MethodsA 1:1 randomised controlled trial (RCT) of the 3 month ActWell programme (focussing on body weight, physical activity and alcohol) versus usual care conducted in two NHSSBSP sites between June 2013 and January 2014. Feasibility assessments included recruitment, retention, and fidelity to protocol. Indicative outcomes were measured at baseline and 3 month follow-up (body weight, waist circumference, eating and alcohol habits and physical activity. At study end, a questionnaire assessed participant satisfaction and qualitative interviews elicited women¿s, coaches and radiographers¿ experiences. Statistical analysis used Chi squared tests for comparisons in proportions and paired t tests for comparisons of means. Linear regression analyses were performed, adjusted for baseline values, with group allocation as a fixed effectResultsA pre-set recruitment target of 80 women was achieved within 12 weeks and 65 (81%) participants (29 intervention, 36 control) completed 3 month assessments. Mean age was 58¿±¿5.6 years, mean BMI was 29.2¿±¿7.0 kg/m2 and many (44%) reported a family history of breast cancer.The primary analysis (baseline body weight adjusted) showed a significant between group difference favouring the intervention group of 2.04 kg (95%CI ¿3.24 kg to ¿0.85 kg). Significant, favourable between group differences were also detected for BMI, waist circumference, physical activity and sitting time. Women rated the programme highly and 70% said they would recommend it to others.ConclusionsRecruitment, retention, indicative results and participant acceptability support the development of a definitive RCT to measure long term effects.Trial registrationThe trial was registered with Current Controlled Trials (ISRCTN56223933)

Feasibility study to assess the impact of a lifestyle intervention (‘LivingWELL’) in people having an assessment of their family history of colorectal or breast cancer

Objectives To assess the feasibility of delivering and evaluating a weight management (WM) programme for overweight patients with a family history (FH) of breast cancer (BC) or colorectal cancer (CRC).  Study design A two-arm (intervention vs usual care) randomised controlled trial. Setting National Health Service (NHS) Tayside and NHS Grampian.  Participants People with a FH of BC or CRC aged≥18 years and body mass index of ≥25 kg/m2 referred to NHS genetic services.  Intervention Participants were randomised to a control (lifestyle booklet) or 12-week intervention arm where they were given one face-to-face counselling session, four telephone consultations and web-based support. A goal of 5% reduction in body weight was set, and a personalised diet and physical activity (PA) programme was provided. Behavioural change techniques (motivational interviewing, action and coping plans and implementation intentions) were used.  Primary outcome Feasibility measures: recruitment, programme implementation, fidelity measures, achieved measurements and retention, participant satisfaction assessed by questionnaire and qualitative interviews.  Secondary outcomes Measured changes in weight and PA and reported diet and psychosocial measures between baseline and 12-week follow-up. Results Of 480 patients approached, 196 (41%) expressed interest in the study, and of those, 78 (40%) patients were randomised. Implementation of the programme was challenging within the time allotted and fidelity to the intervention modest (62%). Qualitative findings indicated the programme was well received. Questionnaires and anthropometric data were completed by >98%. Accelerometer data were attained by 84% and 54% at baseline and follow-up, respectively. Retention at 12 weeks was 76%. Overall, 36% of the intervention group (vs 0% in control) achieved 5% weight loss. Favourable increases in PA and reduction in dietary fat were also reported.  Conclusions A lifestyle programme for people with a family history of cancer is feasible to conduct and acceptable to participants, and indicative results suggest favourable outcomes.  Trial registration number ISRCTN13123470; Pre-results

Feasibility study to assess the delivery of a lifestyle intervention (TreatWELL) for patients with colorectal cancer undergoing potentially curative treatment

Objectives To assess the feasibility of delivering and evaluating a lifestyle programme for patients with colorectal cancer undergoing potentially curative treatments.Study design Non-randomised feasibility trial.Setting National Health Service (NHS) Tayside.Participants Adults with stage I–III colorectal cancer.Intervention The programme targeted smoking, alcohol, physical activity, diet and weight management. It was delivered in three face-to-face counselling sessions (plus nine phone calls) by lifestyle coaches over three phases (1: presurgery, 2: surgical recovery and 3: post-treatment recovery).Primary outcome Feasibility measures (recruitment, retention, programme implementation, achieved measures, fidelity, factors affecting protocol adherence and acceptability).Secondary outcomes Measured changes in body weight, waist circumference, walking and self-reported physical activity, diet, smoking, alcohol intake, fatigue, bowel function and quality of life.Results Of 84 patients diagnosed, 22 (26%) were recruited and 15 (18%) completed the study. Median time for intervention delivery was 5.5 hours. Coaches reported covering most (>70%) of the intervention components but had difficulties during phase 2. Evaluation measures (except walk test) were achieved by all participants at baseline, and most

Simulation as a Key Training Method for Inculcating Public Health Leadership Skills: A Mixed Methods Study

BACKGROUND: Successful management of public health challenges requires developing and nurturing leadership competencies. We aimed to evaluate the effectiveness of training simulations to assess public health leadership and decision-making competencies during emergencies as an effective learning and training method. METHODS: We examined the effects of two simulation scenarios on public health school students in terms of their experience (compared to face-to-face learning) and new skills acquired for dealing with similar emergent situations in the future. A mixed-methods design included developing a validated and pre-tested questionnaire with open-and closed-ended questions that examined the simulation impact and the degree of student satisfaction with the conditions in which it was conducted. Semi-structured in-depth interviews were conducted with the students after going through the simulations. The questionnaire results were evaluated using descriptive analytics. The interviews were analyzed using thematic analyses. All data were collected during June 2022. RESULTS: The questionnaire results indicate that students strengthened their interpersonal communication skills and learned about the importance of listening to the opinions of others before formulating their positions. Four themes emerged from 16 in-depth interviews, according to Kolb\u27s experimental learning cycle. Students emphasized the effectiveness of experiential learning versus traditional classroom learning. The simulation scenarios were felt to realistically convey critical issues regarding leadership, decision-making, and teamwork challenges. They effectively conveyed the importance of building a culture of conducting substantive and respectful discussions. CONCLUSION: Simulation is a powerful pedagogical training tool for public health leadership competencies. Simulations were seen to be advantageous over face-to-face learning in imparting a range of leadership skills and hands-on practice. We recommend integrating simulations in all public health leadership training programs

Health behaviors and their relationship with disease control in people attending genetic clinics with a family history of breast or colorectal cancer

The current work aimed to assess health behaviors, perceived risk and control over breast/colorectal cancer risk and views on lifestyle advice amongst attendees at cancer family history clinics. Participants attending the East of Scotland Genetics Service were invited to complete a questionnaire (demographic data, weight and height, health behaviors and psycho-social measures of risk and perceived control) and to participate in an in-depth interview. The questionnaire was completed by 237 (49%) of attendees, ranging from 18 to 77years (mean age 46 (±10) years). Reported smoking rates (11%) were modest, most (54%) had a BMI>25kg/m2, 55% had low levels of physical activity, 58% reported inappropriate alcohol intakes and 90% had fiber intakes indicative of a low plant diet. Regression analysis indicated that belief in health professional control was associated with higher, and belief in fatalism with poorer health behavior. Qualitative findings highlighted doubts about the link between lifestyle and cancer, and few were familiar with the current evidence. Whilst lifestyle advice was considered interesting in general there was little appetite for non-tailored guidance. In conclusion, current health behaviors are incongruent with cancer risk reduction guidance amongst patients who have actively sought advice on disease risk. There are some indications that lifestyle advice would be welcomed but endorsement requires a sensitive and flexible approach, and the acceptability of lifestyle interventions remains to be explored

Talking story : using narrative analysis to explore identity in middle school technology innovation

Ph.D. University of Hawaii at Manoa 2011.Includes bibliographical references.This dissertation examines the influence of professional identity on educators' understanding of technology innovation. The study draws on research on narrative sensemaking (Bruner 1990; Czarniawska 1997), storytelling (Boje 1991a; Brown et. al. 2009; Clandinin and Connelly 1996), communities of practice (Wenger 1999) and identity (Ashforth et. al. 1989; Wenger 1999). Interviews were conducted with teachers, administrators and technology specialists in the middle school (grades 6-8) at an independent school, chosen because of its recent investment in and commitment to transformational technology innovation. Building on Mishler's (1986) and Riessman's (1993) narrative analysis methods, 20 indepth interviews were analyzed using a whole story narrative analysis method. Story themes were identified that highlighted how educators made sense of the school's efforts to promote technology innovation in the classroom and their own experiences with it. Four distinct identity perspectives ("identity lenses") were identified. This analysis illustrated how an identity lens draws together aspects of professional work, interactions with colleagues, perceptions of organizational events and perspectives about technology in the classroom, as individuals make sense of technology innovation in their professional lives. Professional identity is transitional and negotiated constantly (Wenger 1999), particularly during periods of technology innovation (Barrett and Walsham 1999; Lamb and Davidson 2005). Four organizational values were identified as significant organizational exchanges through which individuals negotiated their professional identity related to the school's technology initiatives. This study contributes to our understanding of how professional identity influences individuals' interpretations of and participation with technology innovations. It demonstrates how narrative analysis of stories of technology innovation can be employed to understand how individuals make sense of technology changes in their professional lives. Implications for practice include the recognition of diverse perspectives ("identity lenses") related to technology innovation, which influence how individuals interpreted and related to technology innovation projects. Studying participants' stories highlighted how opportunities for "low-risk" experimentation allowed educators to find success with technology innovation. The support of knowledgeable technology professionals, who have teaching experience themselves, also emerged as an important enabler for such experimentation