Simple Educational Interventions Research Articles

COVID-19 vaccine hesitancy and response to a simple educational intervention in patients attending an outpatient dialysis unit in Johannesburg, South Africa

Background: Patients living with kidney failure are at risk of severe COVID-19 disease. However, vaccination reduces transmission and severity of disease. The uptake of COVID-19 vaccination in South Africa remains poor, suggesting a requirement for novel recruitment strategies. We examined COVID-19 vaccine hesitancy in an urban dialysis population in Johannesburg, South Africa, and investigated the efficacy of an educational intervention on vaccination intention. Methods: One hundred and four participants were recruited from outpatient haemo- and peritoneal dialysis units at the Helen Joseph Hospital. Participants completed anonymous, self-administered questionnaires analysing their acceptance of and concerns regarding COVID-19 vaccination before and after dissemination of the South African Nephrology Society SARS-CoV-2 vaccine information brochure. Results: Seventy-two participants (69%) were unvaccinated against SARS-CoV-2; 23 (22%) indicated unwillingness to undergo vaccination. Vaccine side effects, safety and perceived risk of SARS-CoV-2 transmission by vaccination were important factors in hesitancy. A small proportion believed that COVID-19 was not a serious threat to personal health. News media was an important information source for vaccine-hesitant respondents; prior healthcare worker counselling reduced hesitancy (OR 0.175, 95% CI 0.039–0.784; P = 0.023). The information brochure reduced concerns about vaccine side effects (P = 0.028), increasing vaccination intention to 84%. In-centre vaccination was additionally identified as a strategy to reduce hesitancy (OR 0.053, 95% CI 0.012–0.221; P < 0.001). Conclusions: This first analysis in an urban dialysis population in South Africa highlights factors contributing to vaccine hesitancy. Simple educational interventions capitalising on trust in healthcare workers and improved vaccine accessibility may increase vaccine uptake. Keywords: COVID-19, vaccine hesitancy, dialysis

168 Emergency Medicine Clinicians’ Confidence in Managing Epistaxis Is Improved by A Simple Intervention: A Closed-Loop Quality Improvement Study

Abstract Aim Epistaxis is a common, potentially life-threatening presentation in the Emergency Department (ED) with an incidence of 108/100 000 population per year. 85% of all patients presenting with epistaxis are managed by ED clinicians without specialist input or admission. Guidelines exist from ENT UK on epistaxis management, however awareness of these guidelines, nuances in techniques and levels of confidence by ED clinicians is not known. This quality improvement study aims to assess the confidence of ED clinicians in managing epistaxis, and investigate whether this could be improved through educational intervention. Method A single-centre, prospective, baseline audit was conducted following local approval. An initial questionnaire assessed knowledge of appropriate Hippocratic first aid method for epistaxis, alongside individual confidence in providing epistaxis prevention advice. The educational intervention included a 30 minute interactive tutorial on epistaxis during the local department teaching for ED clinicians. The audit loop was then closed by repeating the questionnaire. Results Pre- (n = 20) and post- (n = 8) intervention questions were completed by ED clinicians. Knowledge scores of appropriate epistaxis first aid provision increased from 53% pre-intervention to 88% post-intervention. Reported confidence in providing epistaxis prevention advice also increased from a mean score of 2.7 pre-intervention to 4.1 post-intervention on a 5-point Likert scale. Conclusions ED clinicians generally lack knowledge on appropriate first aid techniques on managing epistaxis and confidence in providing epistaxis prevention advice. Both of these parameters may be improved by simple educational interventions which may be implemented nationally.

BReATHE interventions (Beating Regional Asthma Through Health Education)—an innovative approach to children’s asthma care in the North East and North Cumbria, UK: an interventional study

To objective of this project was to reduce unplanned hospital admission rates in children related to asthma to the Newcastle upon Tyne Hospitals National Health Service Trust (NUTH).Multiple educational interventions...

Gaming the System: Creative, Simple, and Effectives Educational Interventions to Enhance Hospice IDT Learning on Key Clinical and Regulatory Topics (FR454)

•Describe novel educational interventions for three common regulatory, quality, or clinical issues based on simple well-known games that may enhance knowledge retention for members of the hospice interdisciplinary team.•Describe one additional regulatory, quality, or clinical issue they would like to see addressed and propose a fun, novel educational intervention which will be recorded by the group leader. Hospice regulatory burden has increased dramatically over the past decade. Keeping physicians, nurses, social workers, chaplains, and other key team members informed and engaged on regulatory, quality, and clinical updates requires creative and innovative solutions. Three topics that have received increased emphasis as as a result of recent regulatory changes include prognostication in the last week of life, medication reconciliation, and interdisciplinary communication. Our team that created novel educational interventions on these topics consisted of two hospice chief medical officers, a leading nurse educator from NHPCO, a clinical nurse specialist, and a pharmacist all actively involved in regulatory and clinical education with groups including AAHPM, HPNA, and NHPCO. The first educational intervention, “Prognostication Charades,” was developed from work conducted at MD Anderson with the goal to help the interdisciplinary team prospectively identify patients who are transitioning to the last week of life. The second will be “Med Rec Bingo” where common medications are matched against their side effects in the hospice setting. One challenge many hospice nurses and physicians face is explaining the rationale for medication discontinuation to patients and families during the initial hospice admission visit. The last game, “Family Feud Communication,” will match effective responses to a variety of common scenarios in the care of serious and terminally ill individuals and their families. Hospice teams face many communication challenges, including individualizing the plan of care, anticipating needs through IDT meeting discussions, and facilitating family meetings. After the didactic presentations, we will break into small groups and allow the audience to interact with the various formats and offer valuable feedback while selecting one future issue they would like to see addressed. Following the presentation, all educational interventions will be provided to those interested in adapting them to their own interdisciplinary teams.

Educational Programs for Neurodegenerative Diseases

As we cannot stop disease progression of neurodegenerative diseases, we have to consider neurodegenerative diseases as life-threatening illnesses and the objects of palliative care. Neurodegenerative disease patients and their families usually did not have much information about their diseases and often could not choose their treatment and care options on their own. Before applying the principles of palliative care to the patients and their families, we had to give appropriate information about their disease to them. But there were few educational interventions for neurodegenerative disease patients and their families and also few studies investigating the knowledge of them. Moreover all but one was the educational interventions for demented patients. All reports about the educational interventions for neurodegenerative diseases showed that the simple educational interventions might not reduce the burdens on the families, and moreover one report for extrapyramidal diseases and cerebellar degenerations showed that the simple educational interventions could not change the course of natural degradation of the diseases and might produce depressive reaction to the patients. In order to reduce the burdens of the families we have to support the families with physically, and in order to encourage the patients to accept their disease we have to control their depression and approach to them with the principles of palliative care.

Improving quality of care for patients with iron deficiency anemia presenting to the emergency department.

Patients presenting to the emergency department (ED) with iron deficiency anemia (IDA) are underrecognized, undertreated with iron, and overtransfused. A 3-month audit of red blood cell (RBC) transfusions at the Sunnybrook Health Sciences Centre ED in 2013 showed that only 53% of transfusions for IDA were appropriate. The aim of this quality improvement project was to increase the rate of appropriate transfusion to greater than 80%. Since November 2013, several quality improvement interventions have been implemented, including educational presentations, development of an algorithm on IDA management in the ED, and development of an ED IDA toolkit. The primary outcome was appropriateness of RBC transfusions per month. The process measure was monthly intravenous (IV) iron use in IDA patients managed exclusively by ED staff. Balancing measures included IV iron use according to the algorithm and undertransfusion. Over a 24-month period beginning January 2014, assessment of 193 units transfused in the ED showed an improvement of RBC appropriateness to 91% (range 50%-100%). IV iron use increased from one dose in the 3-month audit to an average of 2.6 and 4.7 per month in 2014 and 2015, respectively. IV iron use did not follow the algorithm in 19% (18 of 93) of cases: 12 were given to patients with less severe iron deficiency or bleeding. Improved RBC transfusion appropriateness for IDA in the ED can be achieved and maintained with the implementation of simple educational and practical interventions.

The Relationship between Health Literacy, Self-Efficacy, and Self-Care Behaviors in Diabetic Patients

Background: Neglecting self-care behaviors is considered an important factor contributing to mortality among diabetic patients. According to Bandura’s Social-Cognitive Theory, there is a close relationship between individual performance and self-efficacy. Moreover, access to health-related information or health literacy can affect health status. Aim: To investigate the relationship between health literacy, self-efficacy, and self-care behaviors in diabetic patients. Method: This descriptive correlational study was conducted on 400 patients with diabetes referred to a diabetes clinic during 2015. The participants were selected through convenience sampling. The data collection tools included Short Test of Functional Health Literacy in Adults, Diabetes Management Self-Efficacy Scale, and the Summary of Diabetes Self-Care Activities. To analyze the data, Pearson’s correlation coefficient, independent t-test, and one-way analysis of variance were run in SPSS, version 19. Results: The mean age of the participants was 55.1±10.1 years and 74.75% of them were male. The mean scores of self-care behaviors, health literacy, and self-efficacy were 61.94±14.35, 63.6±20.7, and 146.3±22.9, respectively. Moreover, the results of Pearson’s correlation coefficient showed a significant direct correlation between health literacy and self-efficacy (P=0.03, r=0.1), as well as health literacy and self-care behaviors (P=0.04, r=0.1). Furthermore, self-efficacy had a significant direct correlation with self-care behaviors (P<0.001, r=0.5). Implications for Practice: Health literacy and self-efficacy can affect self-care behaviors in diabetic patients; thus, nurses are recommended to develop and implement simple educational interventions to enhance self-efficacy and health literacy, and in turn, promote self-care behaviors.

Phishing suspiciousness in older and younger adults: The role of executive functioning.

Phishing is the spoofing of Internet websites or emails aimed at tricking users into entering sensitive information, with such goals as financial or identity theft. The current study sought to determine whether age is associated with increased susceptibility to phishing and whether tests of executive functioning can predict phishing susceptibility. A total of 193 cognitively intact participants, 91 younger adults and 102 older adults, were primarily recruited through a Psychology department undergraduate subject pool and a gerontology research registry, respectively. The Executive Functions Module from the Neuropsychological Assessment Battery and the Iowa Gambling Task were the primary cognitive predictors of reported phishing suspiciousness. Other predictors included age group (older vs. younger), sex, education, race, ethnicity, prior knowledge of phishing, prior susceptibility to phishing, and whether or not browsing behaviors were reportedly different in the laboratory setting versus at home. A logistic regression, which accounted for a 22.7% reduction in error variance compared to the null model and predicted phishing suspiciousness with 73.1% (95% CI [66.0, 80.3]) accuracy, revealed three statistically significant predictors: the main effect of education (b = 0.58, SE = 0.27) and the interactions of age group with prior awareness of phishing (b = 2.31, SE = 1.12) and performance on the Neuropsychological Assessment Battery Mazes test (b = 0.16, SE = 0.07). Whether or not older adults reported being suspicious of the phishing attacks used in this study was partially explained by educational history and prior phishing knowledge. This suggests that simple educational interventions may be effective in reducing phishing vulnerability. Although one test of executive functioning was found useful for identifying those at risk of phishing susceptibility, four tests were not found to be useful; these results speak to the need for more ecologically valid tools in clinical neuropsychology.

Educational Intervention Improves Compliance With AAN Guidelines for Return Epilepsy Visits: A Quality Improvement Project.

In 2011, the American Academy of Neurology (AAN) released guidelines for return seizure visits detailing 8 points that should be addressed during such visits. These guidelines are designed to improve routine follow-up care for epilepsy patients. The authors performed a quality improvement project aimed at increasing compliance with these guidelines after educating providers about them. The authors performed a chart review before and after an intervention which included: education regarding the guidelines, providing materials to remind providers of the guidelines, and templates to facilitate compliance. The authors reviewed charts at 2 and 6 months after the intervention. Significant improvement in documentation of 4 of the 8 measures was observed after this educational intervention. This suggests that simple educational interventions may help providers change practice and can improve compliance with new guidelines while requiring minimal time and resources to implement.

Trauma team utilization of universal precautions: if you see something, say something.

The risks deriving from the lack of compliance with universal safety precautions (USPs) are unequivocal. However, the adoption of these prophylactic precautions by healthcare providers remains unacceptably low. We hypothesized that trauma teams are not routinely adhering to USPs and that a brief educational intervention, followed by real-time peer feedback, would substantially improve compliance rates. This before-and-after interventional study took place in the resuscitation bay of a Level I Trauma Center during trauma team activations. Six USPs were examined: hand washing (before and after patient contact), use of gloves, gowns, eye protection, and masks. Surgery and Emergency Medicine attending physicians, residents, and nurses, who had direct patient contact, were included. Following 162 baseline observations, an educational intervention in the form of brief lectures was conducted, emphasizing the danger to self from dereliction of USPs. Subsequently, 167 post-intervention observations were made after a one-month period of knowledge decay. Finally, real-time feedback was provided by trauma team leaders and study staff. Adherence to prophylactic measures was recorded again. Baseline compliance rates were dismal. Only hand washing prior to patient interaction, the use of eye protection, and the use of masks improved significantly (p<0.05) after the educational initiative. However, compliance rates remained suboptimal. No difference was noted regarding the three other USPs. Impressively, following real-time behavioral corrections, compliance improved to nearly 90% for all USPs (p<0.05). Compliance with OSHA-required USPs during trauma team activations is unacceptably low, but can be dramatically improved through simple educational interventions, combined with real-time peer feedback.

Stability of increased adenoma detection at colonoscopy. Follow-up of an endoscopic quality improvement program-EQUIP-II.

We recently completed a randomized controlled trial of an endoscopic quality improvement program (EQUIP) that demonstrated an improved adenoma detection rate (ADR) through simple educational interventions. The aim of this study (phase III) is to examine whether the improvement in ADR in the trained endoscopists remained stable with further follow-up. We prospectively followed up 15 staff endoscopists who had previously been randomized to a quality improvement intervention. In the current study, we examined an additional 1,200 colonoscopy procedures conducted over a 5-month time period following the original study, referred to as phase III. During this time, all physicians received quarterly ADR and other quality metric feedback, and the previous control group was offered the educational intervention voluntarily. ADRs and adenoma per patient (APP) rates were estimated in the endoscopists who were and were not randomized to EQUIP training and compared with those obtained in phases I and II of the original study. The study was conducted in a tertiary care Academic Medical Center. The study sample comprised 1200 patients undergoing routine colonoscopy. The main outcome measurement was adenoma detection rate. The previously observed increase in ADR in the trained group from 36% in phase I to 47% in phase II was maintained into phase III (46%). The ADR of the untrained group remained unchanged from phase I (36%) to phase II (35%); it was increased only marginally in phase III to 39%, which was still lower than the 46% ADR in the trained group. The trained group had an increase in APP, from 0.72 in Phase I to 0.87 in Phase II and 0.98 in Phase III. For the previously untrained group, there was no change in APP from phase I (0.68) to phase II (0.68), but there was possibly a small increase (to 0.74) in Phase III. This study provides evidence that improvements in ADR obtained through the endoscopic quality-training program can persist for at least 5 months after completion of the program. It further suggests that a focus on ADR does not lead to a "one and done" phenomenon. The limitations of this study were as follows: single-center setting, and lack of sessile polyp information/standardization.

All for one and one for all: understanding health professionals' experience in individual versus collaborative online learning.

Computer-supported collaborative learning (CSCL) may facilitate continuing interprofessional education while overcoming barriers of time and place for busy health care professionals. The purpose of this study was to understand the experiences, advantages, and challenges of group versus individual online learning. Fifteen multidisciplinary health professionals participated in a 12-week online course on either diabetes or traumatic brain injury. This consisted of background e-modules and a longitudinal build-a-case exercise, done either individually or as a group. Focus group sessions exploring participants' experiences after course completion and at 4 months were conducted, transcribed, and analyzed for recurring themes. Participant reflection homework and video-recorded group sessions were used for triangulation of results. Individual learners appreciated the flexibility and control, but experienced decreased motivation. Group learners appreciated the immediate feedback from their co-learners and felt social pressure to come to the weekly sessions prepared but expressed challenges in determining group goal-setting for the session. Both groups felt they learned about interprofessional roles; however, group learners described a richer learning experience and understanding of interprofessional roles through the online collaboration exercise. The intense resources necessary for interprofessional CSCL, including time, faculty development, and technological issues, are described. CSCL is a valuable educational strategy in online learning. While individual online learning may be better suited for short and simple educational interventions such as knowledge acquisition, CSCL seems to allow for richer and deeper learning in complex and interprofessional educational experiences. However, strategies, resources, and faculty development required to enhance CSCL need to be addressed carefully.

The relationship between functional health literacy and health promoting behaviors among older adults.

Background:Health literacy is a measure of individual's ability to read, comprehend, and act on medical instructions. Older adults are one of the most important at risk groups affected by the impact of inadequate health literacy. Health promoting behaviors in older adults have potential impact on their health and quality of life and reduce the costs incurred to health care. Given the paucity of information health literacy and health promoting behavior, the purpose of this study was to examine health literacy level in older adults and the relationship between health literacy and health promoting behaviors.Materials and Method:A cross-sectional survey of 354 older adults was conducted in Isfahan. The method of sampling was clustering. Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA). Data were collected via home interviewing. Health promoting behaviors were measured based on self-reported smoking status, exercise, and consumption of fruit and vegetables. The collected data were analyzed using descriptive statistics and one-way ANOVA and χ2 tests under SPSS 18 software.Results:The sample group averaged 67 ± 6.97 years in age. Approximately 79.6% of adults were found to have inadequate health literacy. They tended to be older, have fewer years of schooling, lower household income, and being female Individuals with inadequate health literacy were more likely to report limitations in activity and lower consumption of fruit and vegetables (P < 0.001). No significant association was found between health literacy and smoking status.Conclusion:Considering high prevalence of inadequate health literacy among older adults, and its inverse relationship with some health promoting behaviors. Simple educational materials and effective interventions for low health literacy people can improve health promotion in society and mitigate the adverse health effects of low health literacy.

Educational and supportive interventions for improving adherence to inhalation therapy in people with chronic respiratory diseases: A systematic review protocol

Review question/objective The objective of this systematic review is to identify the best available research evidence related to the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy in people with chronic respiratory diseases, focusing on measures of adherence and health outcomes. The specific review questions to be addressed are: 1. What is the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy in terms of inhalation regimens and inhalation techniques in people with chronic respiratory diseases? 2. What is the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy on health service utilization and patient outcomes including symptoms, pulmonary function, and quality of life? 3. What is the effectiveness of various designs, in terms of components, modes and intensities, of educational and supportive interventions for improving adherence to inhalation therapy? Inclusion criteria Types of participants This review will consider studies that include adults aged 18 or above, with a clinical diagnosis of chronic respiratory disease and prescribed self-administered inhalation therapy as a long term regular treatment, irrespective of the type of inhaler used. For the purposes of this review, "chronic respiratory diseases" is defined by WHO in 2007 as "the chronic diseases of the airways and other structures of the lung" (p.5). 1 Inhalation therapy is defined as "a treatment in which a substance is administered to the respiratory tract with inspired air". 6 This review will focus on inhalation of drugs. Those studies with prescribed administration of oxygen and water will be excluded. There is no universal standard for how long a treatment is undertaken to be defined as a "long term treatment". Acute episodic drug treatments, such as a course of antibiotics, will be excluded. Types of interventions of interest All educational interventions, with or without supportive programs, designed to improve the chronic respiratory disease sufferers inhalation technique and adherence to their prescribed inhalation therapy will be considered. Those studies that involve comparison of different types of inhalation medications, inhaler devices or inhalation methods to improve the adherence to inhalation therapy will be excluded. For the TRUNCATED AT 350 WORDS

Relationship between health literacy, health status, and healthy behaviors among older adults in Isfahan, Iran

Background:Health literacy is a measure of an individual's ability to read, comprehend, and act on medical instructions. Limited health literacy can reduce the adults’ ability to comprehend and use basic health-related materials, such as prescription, food labels, health education pamphlets, articles, appointment slips, and health insurance plans, which can affect their ability to take appropriate and timely health care action. Nowadays, low health literacy is considered a worldwide health threat. So, the purpose of this study was to assess health literacy level in older adults and to investigate the relationships between health literacy and health status, health care utilization, and health preventive behaviors.Materials and Methods:A cross-sectional survey of 354 older adults was conducted in Isfahan. The method of sampling was clustering. Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA). Data were collected using home interviewing. Health status was measured based on self-rated general health. Health care utilization was measured based on self-reported outpatient clinic visits, emergency room visits, and hospitalizations, and health preventive behaviors were measured based on self-reported preventive health services use.Results:Approximately 79.6% of adults were found to have inadequate health literacy. They tended to be older, had fewer years of schooling, lower household income, and were females. Inadequate health literacy was associated with poorer general health (P < 0.001). Health literacy level was negatively associated with outpatient visits (P = 0.003) and hospitalization (P = 0.01). No significant association was found between health literacy level and emergency room utilization. Self-reported lack of PSA (Prostate-Specific Antigen) test (P < 0.001) and fecal occult blood test (FOBT; P = 0.003) was higher among individuals with inadequate health literacy than those with adequate health literacy. No significant association was found between health literacy level and mammogram in the last 2 years.Conclusion:Low health literacy is more prevalent in older adults. It indicates the importance of health literacy issue in health promotion. So, with simple educational materials and effective interventions for low health literacy group, we can improve health promotion in the society and mitigate the adverse health effects of low health literacy.

Epinephrine auto‐injector use in adolescents at risk of anaphylaxis: a qualitative study in Scotland, UK

Adolescents with severe allergies are at particular risk of severe and fatal anaphylactic reactions. Epinephrine (adrenaline) is known to be under-utilized by teenagers. We sought to gain knowledge of adolescents' attitudes towards and experience of epinephrine auto-injectors in order to inform improvements in patient education. A qualitative study of adolescents in Scotland, UK with a history of anaphylaxis and their parents. In-depth interviews explored adolescents' accounts of anaphylactic reactions, including issues related to using epinephrine auto-injectors. Focus groups with adolescents and parents were used to discuss interventions to improve adolescent self-management of anaphylaxis. Twenty-six adolescents and 28 parents were interviewed. Eight adolescents and 10 parents participated in separate focus groups. Most adolescents had not used the auto-injector in an anaphylactic emergency. We identified multi-faceted barriers to use, including: failure to recognize anaphylaxis; uncertainty about auto-injector technique and when to administer it; fear of using the auto-injector. Most adolescents reported carrying auto-injectors some of the time, though several found this inconvenient due to the size; only one reported non-use of an auto-injector because it had not been carried. Adolescents and parents reported under-use of epinephrine auto-injectors. Carriage is insufficient to ensure that auto-injectors are used. Barriers to use are multiple and complex, and unlikely to be overcome using simple educational interventions. Auto-injector training currently offered is often inadequate preparation for an emergency. A more comprehensive approach is needed, addressing the psychosocial dimensions of anaphylactic emergencies as well as treatment. Training should ideally be provided by specialist allergists or nurses, but can also be provided and reinforced in primary care.

Multidisciplinary Education Improves Prescription of Balanced Crystalloids: A Pilot Study

To assess the use of balanced and unbalanced crystalloids in adult surgical patients. Prospective study of 65 adult emergency general surgical admissions in a UK acute district general hospital, with a further 45 patients studied following educational interventions. 36.4% of patients studied were prescribed inappropriate saline for resuscitation/replacement before the intervention. This compared with no inappropriate prescriptions (0%) after educational intervention (p = 0.0137). Simple multidisciplinary educational interventions can improve intravenous fluid prescription.

Optimizing Antimicrobial Use in Nursing Homes: No Longer Optional

Optimizing Antimicrobial Use in Nursing Homes: No Longer Optional

Simple Antenatal Preparation to Improve Breastfeeding Practice

To address the impact of simple antenatal educational interventions on breastfeeding practice. A randomized controlled trial was carried out in a tertiary referral center from May 2002 to December 2004. A random sample of eligible low-risk antenatal patients was recruited from clinics in the National University Hospital, Singapore. Group A received breastfeeding educational material and individual coaching from a lactation counselor. Group B received breastfeeding educational material with no counseling. Group C received routine antenatal care only. A total of 401 women were recruited. Mothers receiving individual counseling and educational material practiced exclusive and predominant breastfeeding more often than mothers receiving routine care alone at 3 months (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.2-5.4) and 6 months (OR 2.4, 95% CI 1.0-5.7) postpartum. More mothers practiced exclusive and predominant breastfeeding at 6 months among women receiving individual counseling compared with women exposed to educational material alone (OR 2.5, 95% CI 1.0-6.3). Where breastfeeding practices are suboptimal, simple one-encounter antenatal education and counseling significantly improve breastfeeding practice up to 3 months after delivery. Provision of printed or audiovisual educational material is not enough. Health care workers should make every effort to have one face-to-face encounter to discuss breastfeeding with expectant mothers before they deliver. (www.ClinicalTrials.gov), NCT002770192 I.

Predicting antepartum stillbirth

Rates of stillbirth in the developed world have been static or rising in recent years. Clinical prediction of stillbirth risk may allow interventional studies. The most prevalent independent risk factors are nulliparity, advanced age and obesity. These are increasingly prevalent in the developed world. Obesity is particularly associated with stillbirth at term and after term. Pregestational diabetes is a major risk factor for stillbirth and these women are usually offered intensive surveillance during pregnancy. Despite this, a recent national study in the UK demonstrated a fourfold excess of stillbirth, with 80% unrelated to congenital abnormality. Studies of association between previous caesarean section and subsequent stillbirth risk are inconsistent, although in data sources with detailed information, the association has been confirmed. Global analyses of stillbirth risk demonstrate that 98% occur in the developing world and that many are due to potentially preventable causes. A randomized controlled trial of very simple educational interventions was associated with a 30% lower risk of stillbirth. Relatively simple interventions may be successful in reducing the global burden of stillbirth. Further biological understanding of the causes of stillbirth is required to reduce the burden of the disease in the developed world.