Lead Pipes and Child Mortality

Beginning around 1880, public health issues and engineering advances spurred the installation of city water and sewer systems. As part of this growth, many cities chose to use lead service pipes to connect residences to city water systems. This choice had negative consequences for child mortality, although the consequences were often hard to observe amid the overall falling death rates. This paper uses national data from the public use sample of the 1900 Census of Population and data on city use of lead pipes in 1897 to estimate the effect of lead pipes on child mortality. In 1900, 29 percent of the married women in the United States who had given birth to at least one child and were age forty-five or younger lived in locations where lead service pipes were used to deliver water. Because the effect of lead pipes depended on the acidity and hardness of the water, much of the negative effect was concentrated on the densely populated eastern seaboard. In the full sample, women who lived on the eastern seaboard in cities with lead pipes experienced increased child mortality of 9.3 percent relative to the sample average. These estimates suggest that the number of child deaths attributable to the use of lead pipes numbered in the tens of thousands. Many surviving children may have experienced substantial IQ impairment as a result of lead exposure. The tragedy is that lead problems were avoidable, particularly once data became available on the toxicity of lead. These findings have implications for current policy and events.

Transitioning to Motherhood After Trauma: Interacting With the Healthcare System

Little is known about the interactions with the healthcare system among women with past interpersonal trauma accessing maternal health care. The purpose of this study was to critically examine the experiences of women with past interpersonal trauma as they interacted with the healthcare system during the transition to motherhood. A critical feminist perspective informed by Relational-Cultural Theory was used to guide this secondary analysis of 29 interview transcripts from: (a) Aboriginal women, (b) refugees, and (c) survivors of childhood sexual abuse. Four themes emerged: 1. Birthing a healthy baby: the common relational thread; 2. Receiving physical care over the emotional needs of the mothers; 3.Moving beyond sharing information to meaningful relational interactions; and 4. Women\u27s past trauma: little choice over their needs then and now. Findings support the need for both a relational-cultural and trauma-informed approach in education and practice when caring for women transitioning to motherhood after trauma

Lead and Mortality

This paper examines the effect of water-borne lead exposure on infant mortality in American cities over the period 1900-1920. Infants are highly sensitive to lead, and more broadly are a marker for current environmental conditions. The effects of lead on infant mortality are identified by variation across cities in water acidity and the types of service pipes that the water ran through – lead, iron, or concrete – which together determined the extent of lead exposure. Estimates that restrict the sample to cities with lead pipes and panel estimates provide further support for the causal link between water-borne lead and infant mortality. The magnitudes of the effects were large. In 1900, a decline in exposure equivalent to an increase in pH from 6.675 (25th percentile) to 7.3 (50th percentile) in cities with lead-only pipes would have been associated with a decrease in infant mortality of 7 to 33 percent or at least 12 fewer infant deaths per 1,000 live births. This paper examines the effect of water-borne lead exposure on infant mortality in American cities over the period 1900-1920. Infants are highly sensitive to lead, and more broadly are a marker for current environmental conditions. The effects of lead on infant mortality are identified by variation across cities in water acidity and the types of service pipes that the water ran through – lead, iron, or concrete – which together determined the extent of lead exposure. Estimates that restrict the sample to cities with lead pipes and panel estimates provide further support for the causal link between water-borne lead and infant mortality. The magnitudes of the effects were large. In 1900, a decline in exposure equivalent to an increase in pH from 6.675 (25th percentile) to 7.3 (50th percentile) in cities with lead-only pipes would have been associated with a decrease in infant mortality of 7 to 33 percent or at least 12 fewer infant deaths per 1,000 live births.

Medicines prescribed by non-medical independent prescribers in primary care in Wales: a 10-year longitudinal study April 2011–March 2021

OBJECTIVES: The therapeutic classes of medicines prescribed by non-medical independent prescribers (NMIPs) working in primary care in Wales has not been studied in detail. The aim of this study was to conduct a 10-year longitudinal analysis of NMIP prescribing in Wales from April 2011 to March 2021. The study examined the British National Formulary (BNF) chapters from which medicines were prescribed by NMIPs, whether this changed over time, and whether there was variation in prescribing across the geographic regions of Wales. DESIGN: Retrospective secondary data analysis of primary care prescribing data. Monthly prescribing data for the 10 National Health Service financial years (April to March) from April 2011 to March 2021 were obtained from the Comparative Analysis System for Prescribing Audit software. Data were analysed according to BNF chapter, to identify in which therapeutic areas NMIPs were prescribing, and whether this changed over the study period. RESULTS: The number of items prescribed by NMIPs increased during the study period. From April 2011 to March 2021 prescribing in seven BNF chapters equated to approximately 80% of total items, with cardiovascular system medicines most prescribed. In the financial year 2011–2012 the BNF chapters with the greatest proportion of items prescribed were infection (18%) and respiratory system (13%), while in 2020–2021, these had changed to cardiovascular (23%) and nervous system (19%). The number of items prescribed in each health board in Wales varied, however, the BNF chapters contributing the largest percentages of items to the health board totals were broadly comparable. CONCLUSIONS: The BNF chapter with the most prescribed items changed from infection to cardiovascular during the study period, suggesting an increase in chronic disease management by NMIPs. The impact of this on the delivery of primary care services and patient outcomes is a focus for future work

Social Support for Changing Multiple Behaviors: Factors Associated With Seeking Support and the Impact of Offered Support

Introduction. Social support is important for behavior change, and it may be particularly important for the complexities of changing multiple risk behaviors (MRB). Research is needed to determine if participants in an MRB intervention can be encouraged to activate their social network to aid their change efforts. Methods. Healthy Directions 2, a cluster-randomized controlled trial of an intervention conducted in two urban health centers, targeted five behaviors (physical activity, fruit and vegetable intake, red meat consumption, multivitamin use, and smoking). The self-guided intervention emphasized changing MRB simultaneously, focused on self-monitoring and action planning, and encouraged participants to seek support from social network members. An MRB score was calculated for each participant, with one point being assigned for each behavioral recommendation that was not met. Analyses were conducted to identify demographic and social contextual factors (e.g., interpersonal, neighborhood, and organizational resources) associated with seeking support and to determine if type and frequency of offered support were associated with changes in MRB score. Results. Half (49.6%) of participants identified a support person. Interpersonal resources were the only contextual factor that predicted engagement of a support person. Compared to individuals who did not seek support, those who identified one support person had 61% greater reduction in MRB score, and participants identifying multiple support persons had 100% greater reduction. Conclusion. Engagement of one’s social network leads to significantly greater change across multiple risk behaviors. Future research should explore strategies to address support need for individuals with limited interpersonal resources

Prescribing trends over time by non-medical independent prescribers (NMIPs) in primary care settings across Wales (2011-2018): a secondary database analysis

Introduction: As of 2015, as part of the implementation of the Welsh Government primary care plan and primary care clusters, the Welsh Government has encouraged non-medical healthcare professionals working in primary care to train as independent prescribers (IPs). Objectives: This research aimed to identify the number of NMIPs in primary care in Wales and describe their prescribing trend of items between 2011 and 2018, in order to compare their prescribing pattern before and after the implementation of primary care clusters for Wales. Design: Retrospective secondary data analysis and interrupted time series analysis in order to compare prescribing by non-medical independent prescribers (NMIPs) preimplementation and postimplementation of primary care clusters across Wales. Results: Over the study period, 600 NMIPs (nurses n=474 and pharmacists n=104) had prescribed at least one item. The number of nurse IPs increased by 108% and pharmacists by 325% (pharmacists had the largest increase between July 2015 and March 2018). The number of items prescribed by NMIPs increased over time by an average of 1380 per month (95% CI 904 to 1855, p<0.001) after the implementation of primary care clusters compared with 496 (95% CI 445 to 548, p<0.001) prior its implementation. Approximately one-third of the items prescribed by NMIPs was within Betsi Cadwaladr University Health Board (HB) with only 4% in Powys Teaching HB. Conclusion: The number of NMIPs and their volume of prescribing in primary care in Wales has increased following the implementation of primary care clusters in 2015. This suggests that the Government’s recommendations of using NMIPs in primary care have been implemented. Future studies should focus on efficiency and quality of prescribing by NMIPs in primary care

A randomized comparative effectiveness study of Healthy Directions 2—A multiple risk behavior intervention for primary care

Objective: To evaluate the effectiveness of the Healthy Directions 2 (HD2) intervention in the primary care setting. Methods: HD2 was a cluster randomized trial (conducted 3/09–11/11). The primary sampling unit was provider (n = 33), with secondary sampling of patients within provider (n = 2440). Study arms included: 1) usual care (UC); 2) HD2—a patient self-guided intervention targeting 5 risk behaviors; and 3) HD2 plus 2 brief telephone coaching calls (HD2 + CC). The outcome measure was the proportion of participants with a lower multiple risk behavior (MRB) score by follow-up. Results: At baseline, only 4% of the participants met all behavioral recommendations. Both HD2 and HD2 + CC led to improvements in MRB score, relative to UC, with no differences between the two HD2 conditions. Twenty-eight percent of the UC participants had improved MRB scores at 6 months, vs. 39% and 43% in HD2 and HD2 + CC, respectively (ps ≤ .001); results were similar at 18 months (p ≤ .05). The incremental cost of one risk factor reduction in MRB score was $310 for HD2 and$450 for HD2 + CC. Conclusions: Self-guided and coached intervention conditions had equivalent levels of effect in reducing multiple chronic disease risk factors, were relatively low cost, and thus are potentially useful for routine implementation in similar health settings

Changes in suspected adverse drug reaction reporting via the Yellow Card scheme in Wales following the introduction of a National Reporting Indicator

AIMS: This study aimed to assess the impact of a National Reporting Indicator (NRI) on rates of reporting of suspected adverse drug reactions using the Yellow Card scheme following the introduction of the NRI in Wales (UK) in April 2014. METHODS: Yellow Card reporting data for general practitioners and other reporting groups in Wales and England for the financial years 2014–15 (study period 1) and 2015–16 (study period 2) were obtained from the Medicines and Healthcare Products Regulatory Agency and compared with those for 2013–14 (pre‐NRI control period). RESULTS: The numbers of Yellow Cards submitted by general practitioners in Wales were 271, 665 and 870 in the control period, study period 1 and study period 2, respectively. This is equivalent to an increase of 145% in study period 1 and 221% in study period 2 compared with the 12‐month control period (2013–14). Corresponding increases in England were 17% and 37%, respectively (P < .001 chi–squared test). The numbers of Yellow Cards submitted by other groups in Wales were 906, 795 and 947 in each of the study periods. CONCLUSIONS: Introduction of the NRI corresponded with a significant increase in the number of Yellow Cards submitted by general practitioners in Wales. General practitioner reporting rates continued to increase year on year through to 2018–19 with the NRI still in place. No concomitant change was found in reporting rates by other groups in the health boards in Wales

The All Wales Medicines Strategy Group: 18 years' experience of a national medicines optimisation committee

Aims To review the medicines optimisation activities of the All Wales Medicines Strategy Group (AWMSG), a committee established in 2002 to advise the Welsh Government on “all matters related to prescribing”. Although AWMSG conducts other activities (e.g., health technology appraisal for medicines), we focus here on its role in advising on medicines optimisation. Methods Prescribing indicators have been used in Wales to measure change, together with data on volumes and costs of medicines dispensed. A range of improvement strategies have been categorised under the “four Es”, namely educational initiatives, economic incentives, “engineering” and “enforcement”. Results AWMSG has helped health professionals in NHS Wales to reduce harm and waste, and to reduce inappropriate local or regional duplication and variation. Specific initiatives include the achievement of major cost savings by supporting increased generic prescribing and an “invest to save” approach related to prescribing of hypnotics and tranquillisers, non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitors. AWMSG also successfully commissioned the introduction of a single national in-patient medication chart for Wales in 2004. Ongoing priorities include a focus on reducing prescribing of certain medicines deemed “low value for prescribing” and on optimising the use of biosimilar medicines. Conclusions Since 2002, AWMSG has acted as a national medicines optimisation committee in Wales. From the outset, pharmacists and clinical pharmacologists have collaborated closely and shared their complementary expertise to make a much greater contribution to the safe, effective and cost-effective use of medicines than either group could have achieved by working separately