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Hasse Melbye,1 Salwan Al-ani,1 Mark Spigt1,2 1General Practice Research Unit, Department of Community Medicine, UIT The Arctic University of Norway, Tromsø, Norway; 2Department of Family Medicine, CAPHRI, Maastricht University, Maastricht, theNetherlands Background: When assessing patients with exacerbation of asthma or COPD, it may be useful to know the drop in forced expiratory volume in 1second (FEV1) compared with stable state, in particular when considering treatment with oral corticosteroids. The objective of the study was to identify indicators of drop in FEV1 during exacerbations. Methods: In this prospective multicenter study from primary care, patients diagnosed with asthma or COPD were examined at stable state and during exacerbations the following year. Symptoms, chest findings, and pulse oximetry were recorded, and spirometry was performed. A fixed drop in FEV1 (10% and ≥200 mL) and percentage change in FEV1 were outcomes when possible indicators were evaluated. Results: Three hundred and eighty patients attended baseline examination, and 88 with a subsequent exacerbation were included in the analysis. Thirty (34%) had a significant drop in FEV1 (10% and 200 mL). Increased wheezing was the only symptom associated with this drop with a likelihood ratio of 6.4 (95% confidence interval, 1.9–21.7). Crackles and any new ausculta­tion finding were also associated with a significant drop in FEV1, as was a ≥2% drop in oxygen saturation (SpO2) to ≤92% in the subgroup diagnosed with COPD. Very bothersome wheezing and severe decrease in SpO2 were also very strong predictors of change in FEV1 in linear regression adjusted for age, gender, and baseline FEV1% predicted. Conclusion: Increased wheezing, as experienced by the patient, and a decreased SpO2 value strongly indicated a drop in lung function during asthma and COPD exacerbations and should probably be taken into account when treatment with oral corticosteroids is considered. Keywords: bronchial obstruction, systemic corticosteroids, diagnostic tests, primary care

Johanna Laue,1 Hasse Melbye,1 Peder A Halvorsen,1 Elena A Andreeva,2 Maciek Godycki-Cwirko,3 Anja Wollny,4 Nick A Francis,5 Mark Spigt,6 Kenny Kung,7 Mette Bech Risør1 1Department of Community Medicine, General Practice Research Unit, University of Tromsø – The Arctic University of Norway, Tromsø, Norway; 2Department of Family Medicine, Northern State Medical University, Arkhangelsk, Russia; 3Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland; 4Institute of General Practice, University Medical Center Rostock, Rostock, Germany; 5Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK; 6CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, theNetherlands; 7The Jockey Club School of Public Health and Primary Care, The Chinese University of HongKong, Hong Kong Purpose: To explore the decision-making of general practitioners (GPs) concerning treatment with antibiotics and/or oral corticosteroids and hospitalization for COPD patients with exacerbations.Methods: Thematic analysis of seven focus groups with 53 GPs from urban and rural areas in Norway, Germany, Wales, Poland, Russia, the Netherlands, and Hong Kong.Results: Four main themes were identified. 1) Dealing with medical uncertainty: the GPs aimed to make clear medical decisions and avoid unnecessary prescriptions and hospitalizations, yet this was challenged by uncertainty regarding the severity of the exacerbations and concerns about overlooking comorbidities. 2) Knowing the patient: contextual knowledge about the individual patient provided a supplementary framework to biomedical knowledge, allowing for more differentiated decision-making. 3) Balancing the patients’ perspective: the GPs considered patients’ experiential knowledge about their own body and illness as valuable in assisting their decision-making, yet felt that dealing with disagreements between their own and their patients’ perceptions concerning the need for treatment or hospitalization could be difficult. 4) Outpatient support and collaboration: both formal and informal caregivers and organizational aspects of the health systems influenced the decision-making, particularly in terms of mitigating potentially severe consequences of “wrong decisions” and concerning the negotiation of responsibilities.Conclusion: Fear of overlooking severe comorbidity and of further deteriorating symptoms emerged as a main driver of GPs’ management decisions. GPs consider a holistic understanding of illness and the patients’ own judgment crucial to making reasonable decisions under medical uncertainty. Moreover, GPs’ decisions depend on the availability and reliability of other formal and informal carers, and the health care systems’ organizational and cultural code of conduct. Strengthening the collaboration between GPs, other outpatient care facilities and the patients’ social network can ensure ongoing monitoring and prompt intervention if necessary and may help to improve primary care for COPD patients with exacerbations. Keywords: COPD exacerbation, antibiotics, oral corticosteroids, hospitalization, primary care, decision-making

Social marketing is a commonly used strategy in global health. Social marketing programmes may sell subsidized products through commercial sector outlets, distribute appropriately priced products, deliver health services through social franchises and promote behaviours not dependent upon a product or service. We aimed to review evidence of the effectiveness of social marketing in low- and middle-income countries, focusing on major areas of investment in global health: HIV, reproductive health, child survival, malaria and tuberculosis. We searched PubMed, PsycInfo and ProQuest, using search terms linking social marketing and health outcomes for studies published from 1995 to 2013. Eligible studies used experimental or quasi-experimental designs to measure outcomes of behavioural factors, health behaviours and/or health outcomes in each health area. Studies were analysed by effect estimates and for application of social marketing benchmark criteria. After reviewing 18 974 records, 125 studies met inclusion criteria. Across health areas, 81 studies reported on changes in behavioural factors, 97 studies reported on changes in behaviour and 42 studies reported on health outcomes. The greatest number of studies focused on HIV outcomes (n = 45) and took place in sub-Saharan Africa (n = 67). Most studies used quasi-experimental designs and reported mixed results. Child survival had proportionately the greatest number of studies using experimental designs, reporting health outcomes, and reporting positive, statistically significant results. Most programmes used a range of methods to promote behaviour change. Programmes with positive, statistically significant findings were more likely to apply audience insights and cost-benefit analyses to motivate behaviour change. Key evidence gaps were found in voluntary medical male circumcision and childhood pneumonia. Social marketing can influence health behaviours and health outcomes in global health; however evaluations assessing health outcomes remain comparatively limited. Global health investments are needed to (i) fill evidence gaps, (ii) strengthen evaluation rigour and (iii) expand effective social marketing approaches.

Hintergrund: Zur Rauchentwöhnung empfehlen klinische Richtlinien die Kombination aus verhaltenstherapeutischer Unterstützung und Pharmakotherapie. Intensivere Unterstützung führt laut einiger Studien zu höheren Abstinenzraten, so dass intensivierte verhaltenstherapeutische Maßnahmen[zum vollständigen Text gelangen Sie über die oben angegebene URL], 50. Kongress für Allgemeinmedizin und Familienmedizin

Infant and young child feeding has been recognised as an essential element to improve growth of children, especially in developing countries where malnutrition among children and its dire consequences are very prevalent. However, little attention has been paid on the influence of fathers on child feeding practices, although fathers are very important in raising well-adjusted, happy and successful children. Therefore, this study aimed to assess the influence of fathers' child feeding knowledge and practice on children's dietary diversity. A community-based comparative cross-sectional study was conducted among 850 eligible urban and rural house-holds with children of 6-23 months. The father and mother of the child were interviewed on children's dietary diversity and fathers' knowledge and practice of child feeding. Nearly half (46%) of the children in the rural district did not meet the minimum dietary diversity, and in the urban district, the rate was even worse (72%). Grains were the common food group given to the children in both districts, whereas flesh food was the least commonly consumed food group. Additionally, low vitamin A-rich food and other fruit and vegetable consumption seem to be a problem in both districts. Almost all dimensions of fathers' knowledge and practice were significantly related to children's minimum dietary diversity; especially, fathers' knowledge of food groups was an important predictor (P-value

The use of growth monitoring and promotion (GMP) has become widespread. It is a potential contributor towards achieving the Millennium Development Goals of halving hunger and reducing child mortality by two-thirds within 2015. Yet, GMP appears to be a prerequisite for good child health but several studies have shown that there is a discrepancy between the purpose and the practice of GMP. The high prevalence of malnutrition in many developing countries seems to confirm this fact. A descriptive qualitative study was carried out from April to September 2011. Focus group discussions and in-depth interviews were conducted amongst mothers and health workers. Data were analyzed using a qualitative content analysis technique, with the support of ATLAS.ti 5.0 software. The results suggest that most mothers were aware of the need for regular weight monitoring while health workers also seemed to be well-aware and to practise GMP according to the international guidelines. However, there was a deficit in maternal knowledge with regard to child-feeding and a lack of basic resources to keep and/or to buy healthful and nutritionally-rich food. Furthermore, the role of the husband was not always supportive of proper child-feeding. In general, GMP is unlikely to succeed if mothers lack awareness of proper child-feeding practices, and if they are not supported by their husbands.

Aim Little is known about the reasons why tuberculosis (TB) service providers do not follow TB treatment guidelines. A better understanding of their real-world experiences associated with non-compliance with guideline may highlight opportunities for enhanced TB care. Whether the problem is actual or perceived may also affect the type of intervention needed to overcome the barrier. This study aimed to explore TB service providers' reasons for not complying with TB treatment guidelines. MethodA descriptive qualitative design was used. Focus group discussions were held with 39 service providers involved in TB care. The study was carried out in the Tigray region of Ethiopia, in four of the six zonal hospitals. Data were analysed using content analysis. ResultsThe main reasons for non-compliance with TB treatment guidelines were: (1) insufficient diagnostic modalities, limiting the capacity to correctly diagnose TB and provide the right regimen; (2) ambiguity in guideline recommendations especially for specific subgroups of patients, making it difficult to prioritize them to the right regimen; and (3) poor documentation concerning referred patients, with no appropriate examination and difficulty obtaining information from previously treated patients. ConclusionNon-compliance may reflect valid questions about the applicability of guideline recommendations in the local context of health care. Special consideration should be given to previously treated patients, as an important factor influencing guideline compliance. Guideline compliance may also be improved by a better strategy to retest those patients whose initial tests are negative in health care contexts where TB is frequently missed.