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Objectives: Newborn infants exposed to lack of oxygen and blood flow to the brain around birth may develop brain dysfunction (hypoxic-ischaemic encephalopathy-HIE). These infants undergo 72 hours of cooling therapy and most are not held by their parents in the UK. We examined the implementation of 'CoolCuddle', identifying factors that impact embedding of this complex intervention in neonatal intensive care units (NICUs) across England., Design: Process evaluation and qualitative study using a standard questionnaire and interviews. Normalisation Process Theory (NPT) core constructs were used to assess relevant issues to staff embedding 'CoolCuddle', to discern change over time and different settings. Qualitative interviews provided valuable contextual exploration of implementation., Setting and Participants: Six tertiary NICUs in England. Thirty-seven families with a newborn baby undergoing cooling therapy for HIE were recruited from September 2022 to August 2023; 17 NICU staff Normalisation MeAsure Development (NoMADs) at six NICUs over 6 months were included; 14 neonatal/research nurses from three participating NICUs were interviewed., Intervention: The family-centred intervention 'CoolCuddle' was developed to enable parents to hold their infant during cooling, without affecting the cooling therapy or intensive care., Outcome Measures: NoMAD questionnaires at three timepoints over 6 months and NPT informed qualitative interviews., Results: NoMAD questionnaires at baseline showed more variation between units, for intervention acceptability, than those at 3 and 6 months. Qualitative data highlighted that staff understood the benefits of CoolCuddle but were apprehensive due to perceived risks involved in moving cooling babies. A rigorous standard operating procedure was flexible enough to incorporate the use of local processes and equipment and provided the relevant procedural knowledge to deliver CoolCuddle safely., Conclusions: The CoolCuddle intervention can be implemented safely under the supervision of standard neonatal teams as part of usual practice in diverse NICU settings in England. The importance of having a rigorous standard operating procedure, which can be adapted to support local settings, is highlighted., Trial Registration Number: ISRCTN10018542; Results: registered on 30 August 2022., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Lidocaine patches, applied over rib fractures, may reduce pulmonary complications in older patients. Known barriers to recruiting older patients in emergency settings necessitate a feasibility trial. We aimed to establish whether a definitive randomised controlled trial (RCT) evaluating lidocaine patches in older patients with rib fracture(s) was feasible., Methods: This was a multicentre, parallel-group, open-label, feasibility RCT in seven hospitals in England and Scotland. Patients aged ≥65 years, presenting to ED with traumatic rib fracture(s) requiring hospital admission were randomised to receive up to 3×700 mg lidocaine patches (Ralvo), first applied in ED and then once daily for 72 hours in addition to standard care, or standard care alone. Feasibility outcomes were recruitment, retention and adherence. Clinical end points (pulmonary complications, pain and frailty-specific outcomes) and patient questionnaires were collected to determine feasibility of data collection and inform health economic scoping. Interviews and focus groups with trial participants and clinicians/research staff explored the understanding and acceptability of trial processes., Results: Between October 23, 2021 and October 7, 2022, 206 patients were eligible, of whom 100 (median age 83 years; IQR 74-88) were randomised; 48 to lidocaine patches and 52 to standard care. Pulmonary complications at 30 days were determined in 86% of participants and 83% of expected 30-day questionnaires were returned. Pulmonary complications occurred in 48% of the lidocaine group and 59% in standard care. Pain and some frailty-specific outcomes were not feasible to collect. Staff reported challenges in patient compliance, unfamiliarity with research measures and overwhelming the patients with research procedures., Conclusion: Recruitment of older patients with rib fracture(s) in an emergency setting for the evaluation of lidocaine patches is feasible. Refinement of data collection, with a focus on the collection of pain, frailty-specific outcomes and intervention delivery are needed before progression to a definitive trial., Trial Registration Number: ISRCTN14813929., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Childhood respiratory tract infections (RTIs) are common and can lead to unnecessary antibiotic use and antimicrobial resistance. The CHIldren with COugh (CHICO) intervention incorporates a clinician-focused algorithm (STARWAVe) to predict future hospitalisation risk, elicitation of carer concerns, and a carer-focused personalised leaflet recording treatment decisions and safety-netting information., Aim: To examine the implementation of the CHICO intervention by primary care clinicians., Design and Setting: A qualitative study with primary care clinicians in England taking part in the CHICO randomised controlled trial., Method: Interviews explored the CHICO intervention's acceptability and use. Clinicians from a range of practices with high and low antibiotic dispensing rates were recruited. Normalisation process theory underpinned data collection and thematic analysis., Results: Most clinicians liked the intervention because it was quick and easy to use, it helped elicit carer concerns, and reassured clinicians and carers of the appropriateness of treatment decisions. However, clinicians used it as a supportive aid for treatment decisions rather than as a tool for behaviour change. The accompanying advice leaflet helped explain treatment decisions and support self-care. The intervention did not always align with clinicians' usual processes, which could affect use. Increased familiarisation with the algorithm led to reduced intervention use, which was further reduced during the COVID-19 pandemic as a result of changes to practice and remote consultations., Conclusion: Clinicians found the CHICO intervention useful to support decision making around antibiotic prescribing and it helped discussions with carers about concerns and treatment decisions. The intervention may need to be adapted to align more with clinicians' consultation flow and remote consultations., (© The Authors.)

Background: Vaccinations for seasonal influenza and pertussis have been recommended for pregnant women in England since 2010 and 2012, respectively. Uptake rates are suboptimal with large regional variations. To improve uptake, from 2016 onwards maternity trusts were commissioned to offer pertussis (and other) vaccinations in addition to these being available in primary care. Since 2021, Covid-19 vaccination has also been recommended for pregnant women. Overall maternal vaccination rates are routinely available, but not the relative provision by maternity trusts. We aimed to describe the national picture of maternity trust provision of maternal vaccinations, including how the maternity trust vaccination programme has progressed., Methods: Cross-sectional survey plus comparisons with 2017-18 figures for maternity trust provision of pertussis vaccination, and with UKHSA data for total pertussis vaccination., Results: Twelve NHS commissioners participated (from 13/06/22 to 31/03/23) providing data for 120 (of a total 124) maternity trusts across England. All 120 (100%) trusts were commissioned to deliver influenza, and 107 (89%) to deliver pertussis vaccinations, though not all actually administered the vaccines; 29% offered Covid-19 vaccinations. For 2021-22 we found a mean of 25% (range 0-81.3%) women were vaccinated for pertussis (a large increase compared with previous estimates for 2017-18); and 11% (range 0-74.2%) for influenza, via their maternity trust. Commissioners reported a negative impact of the pandemic on routine vaccination provision. There was indication of efficiency by vaccinating women attending for other appointments. There are diverse mechanisms for reporting pertussis and influenza vaccinations administered at maternity trusts back to primary care, which may be inefficient for maternity staff workload and accuracy of data transfer (especially for pertussis)., Conclusion: A high proportion of maternity trusts provide both pertussis and influenza vaccinations, despite a negative impact of the pandemic. Reasons for large between-trust variation in vaccination rates should be explored to improve uptake and equity., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Adam Finn reports a relationship with Joint Committee on Vaccination and Immunisation that includes: board membership. Adam Finn reports a relationship with WHO European Technical Advisory Group of Experts on Immunisation (until Dec 2022) that includes: board membership. Adam Finn reports a relationship with WHO Working Group on COVID19 vaccines that includes: board membership. Adam Finn reports a relationship with Bionet Asia, the Helmsley Charitable Trust, Hillevax, Imophoron, Janssen, RQ Bio and VB Vaccines. that includes: consulting or advisory. Adam Finn reports a relationship with AstraZeneca, Janssen, Valneva, Pfizer, Moderna, and Sanofi, and of other vaccines from these and other manufacturers, including GlaxoSmithKline that includes: funding grants and non-financial support. n/a., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Using the National Child Mortality Database, this work aims to investigate background characteristics and risk factors in the sleeping environment associated with sudden infant death syndrome (SIDS) and compare the prevalence with previous English SIDS case-control studies., Design: Cohort of SIDS in 2020 compared with a combined analysis of two case-control studies conducted in 1993-1996 and 2003-2006., Setting: England, UK PARTICIPANTS: 138 SIDS deaths in 2020 compared with 402 SIDS deaths and 1387 age-equivalent surviving controls, combined from previous studies., Results: The increased vulnerability of SIDS infants identified in previous studies has become more marked. The infants who died in 2020 were younger (median=66 days (IQR: 34-118) vs 86 days (IQR: 52-148), p=0.003) with an increased prevalence of low birth weight (30.5% vs 21.6%, p=0.04) and preterm births (29.6% vs 19.3%, p=0.012). The excess of socioeconomically deprived families, male infants and high levels of maternal smoking during pregnancy were still evident. Among recent deaths, fewer infants were put down or found on their side; however, there was no significant change in the proportion of infants who were put down (15.6% vs 14.6%, p=0.81) and found prone (40.4% vs 35.3%, p=0.37), despite population wide risk reduction advice over three decades. The proportional increase observed in 2003-2006 of half the deaths occurring while sleeping next to an adult was maintained in 2020, and for the vast majority (90%), this was in hazardous circumstances (adult had consumed alcohol, smoked, slept on a sofa, or the infant was premature or low birth weight and less than 3 months old). More deaths also occurred when there was a disruption in infant care routine compared with previous observations (52.6% vs 20.7%, p<0.001)., Conclusions: A more targeted approach is needed with vulnerable families emphasising the importance of sleeping infants on their back and proactive planning infant sleep when there are disruptions to the normal routine, in particular to avoid hazardous co-sleeping., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Guidance on foods to limit or avoid in pregnancy is provided on the NHS website for England. Advice on fish consumption is related to exposure to mercury, dioxins and polychlorinated biphenyls, which may have adverse effects on fetal neurodevelopment. Our aim was to provide evidence on the effectiveness of the guidance in minimising exposure to toxins while maximising nutrient intake in a mixed-methods study. An online questionnaire on fish consumption before/during pregnancy was completed by postpartum women (≤12 months) in England (n = 598). A subsample of participants was invited to take part in an interview (n = 14). Women who ate fish before pregnancy reduced their intakes of both oily and white fish during pregnancy, with some avoiding it altogether. Women did not exceed the limit on tinned tuna, but there was evidence of mis-recall on the suggested limit. Overall intakes of fish were below that recommended during pregnancy (36% compliance for pre-pregnancy consumers). Barriers to fish consumption included risk aversion, confusion over specific details of the guidance, cost, availability, family preferences and smell/taste. Clarity and simplicity of the NHS guidance, with an overall message on the number of portions of fish a week advised prominently shown, would help pregnant women to benefit from the nutrients in fish while minimising exposure to toxins. The guidance on the number of cans of tuna advised per week is poorly recalled and needs to be disseminated accurately. The guidance on shark/marlin/swordfish could receive less prominence as it is rarely eaten by pregnant women in England.

Background: The National Health Service (NHS) website gives guidance for pregnant women in England on foods/drinks to avoid or limit because of microbiological, toxicological or teratogenic hazards. These include, for example, some types of soft cheeses, fish/seafood and meat products. This website and midwives are trusted sources of information for pregnant women, but the ways in which midwives can be supported to provide clear and accurate information are unknown., Aims: The aims were to: (1) determine midwives' accuracy of recall of information and confidence in delivering the guidance to women; (2) identify barriers to provision; (3) identify the ways in which midwives provide this information to women., Methods: Registered Midwives practicing in England completed an online questionnaire. Questions included those on what information they provided and their confidence in delivering it, the ways they provided information on foods to avoid/limit, their recall of some of the guidance, and what resources they used. Ethics approval was given by the University of Bristol., Results: More than 10% of midwives (n = 122) were 'Not at all confident/Don't know' in providing advice about ten items, including game meat/gamebirds (42% and 43%, respectively), herbal teas (14%) and cured meats (12%). Only 32% correctly recalled overall advice on eating fish, and only 38% the advice on tinned tuna. The main barriers to provision were lack of time in appointments and lack of training. The most usual methods of disseminating information were verbal (79%) and signposting to websites (55%)., Conclusion: Midwives were often unconfident about their ability to provide accurate guidance, and recall on items tested was frequently mistaken. Delivery of guidance by midwives on foods to avoid or limit needs to be supported by appropriate training and access to resources, and sufficient time in appointments. Further research on barriers to the delivery and implementation of the NHS guidance is needed., (© 2023. The Author(s).)

Objectives: Conducting randomised controlled trials (RCTs) in primary care is challenging; recruiting patients during time-limited or remote consultations can increase selection bias and physical access to patients' notes is costly and time-consuming. We investigated barriers and facilitators to running a more efficient design., Design: An RCT aiming to reduce antibiotic prescribing among children presenting with acute cough and a respiratory tract infection (RTI) with a clinician-focused intervention, embedded at the practice level. By using aggregate level, routinely collected data for the coprimary outcomes, we removed the need to recruit individual participants., Setting: Primary care., Participants: Baseline data from general practitioner practices and interviews with individuals from Clinical Research Networks (CRNs) in England who helped recruit practices and Clinical Commission Groups (CCGs) who collected outcome data., Intervention: The intervention included: (1) explicit elicitation of parental concerns, (2) a prognostic algorithm to identify children at low risk of hospitalisation and (3) provision of a printout for carers including safety-netting advice., Coprimary Outcomes: For 0-9 years old-(1) Dispensing data for amoxicillin and macrolide antibiotics and (2) hospital admission rate for RTI., Results: We recruited 294 of the intended 310 practices (95%) representing 336 496 registered 0-9 years old (5% of all 0-9 years old children). Included practices were slightly larger, had slightly lower baseline prescribing rates and were located in more deprived areas reflecting the national distribution. Engagement with CCGs and their understanding of their role in this research was variable. Engagement with CRNs and installation of the intervention was straight-forward although the impact of updates to practice IT systems and lack of familiarity required extended support in some practices. Data on the coprimary outcomes were almost 100%., Conclusions: The infrastructure for trials at the practice level using routinely collected data for primary outcomes is viable in England and should be promoted for primary care research where appropriate., Trial Registration Number: ISRCTN11405239., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Treating depression early in pregnancy can improve health outcomes for women and their children. Current low-intensity psychological therapy for perinatal depression is a supported self-help approach informed by cognitive behavioural therapy (CBT) principles. Interpersonal counselling (IPC) may be a more appropriate low-intensity talking therapy for addressing the problems experienced by pregnant women with depression. A randomised feasibility trial (ADAGIO) has compared the acceptability of offering IPC for mild-moderate antenatal depression in routine NHS services compared to low-intensity CBT. This paper reports on a nested qualitative study which explored women's views and expectations of therapy, experiences of receiving IPC, and Psychological Wellbeing Practitioners (PWPs - junior mental health workers) views of delivering the low-intensity therapy., Methods: A qualitative study design using in-depth semi-structured interviews and focus groups. Thirty-two pregnant women received talking therapy within the ADAGIO trial; 19 contributed to the interview study from July 2019 to January 2020; 12 who had IPC and seven who had CBT. All six PWPs trained in IPC took part in a focus group or interview. Interviews and focus groups were recorded, transcribed, anonymised, and analysed using thematic methods., Results: Pregnant women welcomed being asked about their mental health in pregnancy and having the chance to have support in accessing therapy. The IPC approach helped women to identify triggers for depression and explored relationships using strategies such as 'promoting self-awareness through mood timelines', 'identifying their circles of support', 'developing communication skills and reciprocity in relationships', and 'asking for help'. PWPs compared how IPC differed from their prior experiences of delivering low-intensity CBT. They reported that IPC included a useful additional emotional component which was relevant to the perinatal period., Conclusions: Identifying and treating depression in pregnancy is important for the future health of both mother and child. Low-intensity perinatal-specific talking therapies delivered by psychological wellbeing practitioners in routine NHS primary care services in England are acceptable to pregnant women with mild-moderate depression. The strategies used in IPC to manage depression, including identifying triggers for low mood, and communicating the need for help, may be particularly appropriate for the perinatal period., Trial Registration: ISRCTN 11513120. 02/05/2019., (© 2021. The Author(s).)

Background: Advice to families to sleep infants on their backs, avoid smoke exposure, reduce excess bedcovering and avoid specific risks associated with cosleeping has greatly reduced sudden unexpected death in infancy (SUDI) rates worldwide. The fall in rates has not been equal across all groups, and this advice has been less effective for more socially deprived families. Understanding decision-making processes of families with infants at risk would support the development of more effective interventions., Aim: To synthesise the qualitative evidence on parental decision-making for the infant sleep environment among families with children considered to be at increased risk of SUDI., Methods: This study was one of three related reviews of the literature for the Child Safeguarding Practice Review Panel's National Review in England into SUDI in families where the children are considered at risk of harm. A systematic search of eight online databases was carried out in December 2019. Metasynthesis was conducted, with themes extracted from each paper, starting with the earliest publication first., Results: The wider review returned 3367 papers, with 16 papers (across 13 studies) specifically referring to parental decision-making. Six overall themes were identified from the synthesis: (1) knowledge as different from action; (2) external advice must be credible; (3) comfort, convenience and disruption to the routine; (4) plausibility and mechanisms of protection; (5) meanings of safety and risk mitigation using alternative strategies; and (6) parents' own expertise, experience and instincts., Conclusion: Interventions that are intended to improve the uptake of safer sleep advice in families with infants at risk of sleep-related SUDI need to be based on credible advice with mechanisms of protection that are understandable, consistent with other sources, widened to all carers of the infant and fit within the complex practice of caring for infants., Competing Interests: Competing interests: AP, DW, PSB, JJG, PJF and CE received a grant from the Department for Education to conduct the literature review as part of the National Safeguarding Practice Review. AP and CE were authors on two of the studies, which met the inclusion criteria of the review. These studies were extracted and synthesised by members of the team not involved in those studies., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Rapid discharge strategies for patients with low-risk chest pain using high-sensitivity troponin assays have been extensively evaluated. The adherence to, and acceptability of such strategies, has largely been explored using quantitative data. The aims of this integrated qualitative study were to explore the acceptability of the limit of detection and ECG discharge strategy (LoDED) to patients and health professionals, and to refine a discharge information leaflet for patients with low-risk chest pain., Methods: Patients with low-risk chest pain who consented to a semi-structured interview were purposively sampled for maximum variation from four of the participating National Health Service sites between October 2018 and May 2019. Two focus groups with ED health professionals at two of the participating sites were completed in April and June 2019., Results: A discharge strategy based on a single undetectable hs-cTn test (LoDED) was acceptable to patients. They trusted the health professionals who were treating them and felt reassured by other tests, (ECG) alongside blood test(s), even when the clinical assessment did not provide a firm diagnosis. In contrast, health professionals had reservations about the LoDED strategy, including concern about identifying low-risk patients and a shortened patient observation period. Findings from 11 patient interviews and 2 staff focus groups (with 20 clinicians) centred around three overarching themes: acceptability of the LoDED strategy, perceptions of symptom severity and uncertainty, and patient discharge information., Conclusion: Rapid discharge for low-risk chest pain is acceptable to patients, but clinicians reported some reticence in implementing the LoDED strategy. Further work is required to optimise discharge discussions and information provision for patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In 2008, new statutory national procedures for responding to unexpected child deaths were introduced throughout England. There has, to date, been no national audit of these procedures., Study Design: Families bereaved by the unexpected death of a child under 4 years of age since 2008 were invited to participate. Factors contributing to the death and investigations after the death were explored. Telephone interviews were conducted, and coroners' documents were obtained. The nature and quality of investigations was compared with the required procedures; information on each case was reviewed by a multiagency panel; and the death was categorised using the Avon clinicopathological classification., Results: Data were obtained from 91 bereaved families (64 infant deaths and 27 children aged 1-3 years); 85 remained unexplained after postmortem examination. Documentation of multiagency assessments was poorly recorded. Most (88%) families received a home visit from the police, but few (37%) received joint visits by police and healthcare professionals. Postmortem examinations closely followed national guidance; 94% involved paediatric pathologists; 61% of families had a final meeting with a paediatrician to explain the investigation outcome. There was no improvement in frequency of home visits by health professionals or final meetings with paediatricians between 2008-2013 and 2014-2017 and no improvement in parental satisfaction with the process., Conclusions: Statutory procedures need to be followed more closely. The implementation of a national child mortality database from 2019 will allow continuing audit of the quality of investigations after unexpected child deaths. An important area amenable to improvement is increased involvement by paediatricians., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Acute respiratory tract infections (RTI) in children are a common reason for antibiotic prescribing. Clinicians' prescribing decisions are influenced by perceived parental expectations for antibiotics, however there is evidence that parents actually prefer to avoid antibiotics. This study aimed to investigate the influence of parent-clinician communication on antibiotic prescribing for RTI in children in England., Methods: A mixed methods analysis of videoed primary care consultations for children (under 12 years) with acute cough and RTI. Consultations were video-recorded in six general practices in southern England, selected for socio-economic diversity. 56 recordings were transcribed in detail and a subset of recordings and transcripts used to develop a comprehensive interaction-based coding scheme. The scheme was used to examine communication practices between parents and clinicians and how these related to antibiotic or non-antibiotic treatment strategies., Results: Parents' communication rarely implied an expectation for antibiotics, some explicitly offering a possible viral diagnosis. Clinicians mostly gave, or implied, a viral diagnosis and mainly recommended non-antibiotic treatment strategies. In the minority of cases where parents' communication behaviours implied they may be seeking antibiotic treatment, antibiotics were not usually prescribed. Where clinicians did prescribe antibiotics, they voiced concern about symptoms or signs, including chest pain, discoloured phlegm, prolonged fever, abnormal chest sounds, or pink /bulging ear drums., Conclusions: We found little evidence of a relationship between parents' communication behaviours and antibiotic prescribing. Rather, where antibiotics were prescribed, this was associated with clinicians' expressed concerns regarding symptoms and signs.

Objectives: To investigate whether decreased otoacoustic emission (OAE) signal recordings in the right ear are associated with an increased risk of sudden infant death syndrome (SIDS) and to monitor any temporal changes in risk factors., Design: Retrospective case-control study., Setting: Telephone interviews with families recruited in England between July 2016 and October 2017 who experienced the unexpected death of a child <4 years old since 2008 and control families recruited from maternity wards in Bristol and Birmingham., Participants: We recruited 91 (89%) of the 102 bereaved families who made initial contact, 64 deaths were under 1 year (sudden unexpected death in infancy) of which 60 remained unexplained (SIDS). Of the 220 control families, 194 (88%) follow-up interviews were conducted. We had analysable hearing data for 24 SIDS infants (40%) and 98 controls (51%)., Results: OAE signals were marginally increased rather than decreased among SIDS infants for the right ear, especially at lower frequencies, but not significantly so. The strongest predictors of SIDS were bed-sharing in hazardous (infant sleeping next to a carer who smoked, drank alcohol or slept on a sofa) circumstances (35% vs 3% controls, p<0.0001), infants found prone (33% vs 3% controls, p<0.0001) and infants whose health in the final week was 'not good' (53% vs 9% controls, p<0.0001). The prevalence of maternal smoking during pregnancy among both SIDS mothers (20%) and controls (10%) was much lower than previous studies., Conclusions: Hearing data were difficult to obtain; larger numbers would be needed to determine if asymmetrical differences between the right and left ear were a marker for SIDS. A national prospective registry for monitoring and a renewed campaign to a new generation of parents needs to be considered underlining the initial message to place infants on their backs for sleep and the more recent message to avoid bed-sharing in hazardous circumstances., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: While most respiratory tract infections (RTIs) will resolve without treatment, many children will receive antibiotics and some will develop severe symptoms requiring hospitalisation. There have been calls for evidence to reduce uncertainty regarding the identification of children who will and will not benefit from antibiotics. The aim of this feasibility trial is to test recruitment and the acceptance of a complex behavioural intervention designed to reduce antibiotic prescribing, and to inform how best to conduct a larger trial., Methods and Analysis: The CHICO (Children's Cough) trial is a single-centre feasibility cluster randomised controlled trial (RCT) comparing a web-based, within-consultation, behavioural intervention with usual care for children presenting to general practitioner practices with RTI and acute cough. The trial aims to recruit at least 300 children between October 2014 and April 2015, in a single area in South West England. Following informed consent, demographic information will be recorded, and symptoms and signs measured. Parents/carers of recruited children will be followed up on a weekly basis to establish symptom duration, resource use and cost of the illness to the parent until the child's cough has resolved or up to 8 weeks, whichever occurs earlier. A review of medical notes, including clinical history, primary care reconsultations and hospitalisations will be undertaken 2 months after recruitment. The trial feasibility will be assessed by: determining acceptability of the intervention to clinicians and parent/carers; quantifying differential recruitment and follow-up; determining intervention fidelity; the success in gathering the data necessary to conduct a cost-effectiveness analysis; and collecting data about antibiotic prescribing rates to inform the sample size needed for a fully powered RCT., Ethics and Dissemination: The study was approved by the North West-Haydock Research Ethics Committee, UK (reference number: 14/NW/1034). The findings from this feasibility trial will be disseminated through research conferences and peer-reviewed journals., Trial Registration Number: ISRCTN23547970., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Opioid substitution treatment (OST) has multiple benefits for heroin injectors and is an evidence-based major component of international treatment. The current qualitative study sought to explore participants' attitudes to and reasons for participating in a feasibility randomised trial in primary care offering 'same day' OST (methadone) for injecting heroin users compared to usual care., Methods: Twenty injecting heroin users (8 intervention and 12 controls; 16 males and 4 females) were interviewed; purposive sampling was used to select a maximum variation sample from those who agreed; and analysis used thematic methods., Results: Motivation to join the trial included the need to secure treatment set against some ambivalence due to previous negative experiences of trying to obtain OST. Positive effects of securing methadone via the trial, included self-reported improvements in health and self-care; reduction in crime, stress and drug use. Completing the baseline questionnaires at recruitment appeared to enhance motivation for treatment for all participants. For some control participants, this motivation seemed to increase a sense of self-efficacy and cognitive dissonance generated was resolved by seeking treatment from their GP. Self-determination theory suggests that behaviour change may have been initiated during the recruitment appointment, resulting in an increased determination to seek treatment amongst control participants., Conclusions: Taking part in the 'script in a day' trial enabled participants in the intervention arm to gain same-day access to methadone and reduce their drug use. For those in the control arm, completing the baseline questionnaires at recruitment appeared to create cognitive dissonance between their current health state and own aspirations, so increasing motivation for treatment. Over 50% obtained and were still in receipt of OST (methadone or buprenorphine) at the 3 month follow-up. We suggest that a regular 'health evaluation' for injecting heroin users not in treatment, paired with low-barrier access to treatment, may be a way of exploring this and encouraging more into obtaining OST more quickly and at the best time for them. This intervention should be delivered without pressure for change., Clinical Trial Registration: This trial is registered with International Standard Randomised Controlled Trial Number Register: SCript In a Day for injecting drug users: feasibility trial: ISRCTN16846554.

Recent decades have seen the emergence and increasing prominence of a range of public and private sector providers of agricultural information and advice, owing to state transition away from direct provision of agricultural advisory services. In this paper, we evaluate the establishment of trust in agri-environmental agricultural advisory services in England. Qualitative field research was undertaken with farmers, advisors and promoters engaged in four contrasting agri-environmental advisory initiatives. Findings suggest that longevity and expertise in service provision are more important than the public, private or charitable status of specific advisory service in engendering trust. Consistent funding allocated to well-known agencies or their affiliates is thus more likely influence farmer behaviour in the short term than 'contract' advisory projects awarded to novice service providers. Study participants also put their trust in services that were perceived as 'impartial' or actively 'pro-agriculture'. However, we suggest this 'pro-farmer' orientation can negatively impact on environmental outcomes: advisors may be incentivised to provide information on the easiest access to agri-environmental grants, rather than the actions with the most environmental benefit., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Britain has one of the lowest breastfeeding rates in Europe, with particularly low rates among White British families living in disadvantaged communities. As breastfeeding has important long-term health benefits for babies and their mothers, this represents a serious inequality in health. It is part of the remit of Sure Start Children's Centres which serve disadvantaged areas to offer child and family health services, including breastfeeding support. This study utilised an action research strategy to involve stakeholders in developing and extending breastfeeding promotion and support within three Children's Centres in Bristol. A total of 10 focus groups were conducted with Children's Centre staff and local parents between July 2008 and May 2009. Stakeholders' views were explored on current breastfeeding promotion and how Children's Centres could better support breastfeeding to meet local needs. Barriers to breastfeeding promotion were identified as latent hostility in the local community towards breastfeeding, and lack of knowledge about infant feeding among staff. Following implementation of the proposed changes, staff, parents and researchers shared their views on what had been achieved and on possible future initiatives. While there was variation in the extent to which Children's Centres engaged with the action research process, and in the extent to which change was made, all Centres did develop their breastfeeding promotion practice. Initiatives put into practice included strengthening links with health professionals, actively seeking to involve fathers, increasing the breastfeeding peer support offered locally and adopting a clear 'Breastfeeding Welcome' policy. This study has demonstrated that a collaborative action research approach can effectively stimulate the development of breastfeeding promotion and support within Children's Centres, leading to prompt and sustainable changes in practice., (© 2011 Blackwell Publishing Ltd.)

Refugees and asylum-seekers have many health needs, and access to health services is often complicated by language barriers and a lack of properly trained interpreters and health advocates. This study aimed to identify the health needs of the Somali community in Bristol by conducting 10 semistructured interviews with community representatives and healthcare professionals, and two focus groups with Somali residents.The findings were validated and discussed at a workshop with local residents, teachers, primary healthcare team members and stakeholders. Priorities were agreed and translated into action. Three interrelated themes were identified--access to health promotion information, communication needs and service provision. Suggestions were made to establish groups, drop-in sessions and health awareness days. The findings for the Bristol Somali community could apply to most newly arrived refugee communities in the UK. Understanding where people have come from, their healthcare needs and the social factors that characterise exile will help healthcare professionals to improve the services offered to these communities.

Background: Few studies have examined the effect on patients and staff of the physical environment in primary care facilities., Aim: To explore changes in patient and staff satisfaction, patient anxiety, and patient-doctor communication when a GP surgery moves from old premises to enhanced purpose-built accommodation., Design of Study: Questionnaire surveys, interviews, and focus groups pre- and post move., Setting: An urban general practice in Bristol., Method: Patient questionnaires assessed anxiety (Spielberger State-Trait Anxiety Inventory; STAI), satisfaction with the environment, and communication during the consultation. Staff questionnaires assessed satisfaction with the environment and job satisfaction. Qualitative methods explored patient and staff views in more depth., Results: A total of 1118 pre-move and 954 post-move patient questionnaires showed significant increases in satisfaction scores for reception/waiting areas (mean 6.46, 95% confidence interval [CI]=5.97 to 6.95) and consulting rooms (mean 3.80, 95% CI=3.44 to 4.15) in the new premises. Patients' satisfaction with patient-doctor communication also increased (mean 0.88, 95% CI=0.30 to 1.46) and anxiety scores were significantly reduced before and after the consultation in the new premises compared with the old (STAI mean difference before consultation 0.72, 95% CI=0.37 to 1.08; mean after consultation 0.37, 95% CI=0.03 to 0.72). Patients highlighted the increased space and light, more modern appearance, greater comfort, and novel works of art in the new surgery. Staff workplace satisfaction increased significantly after moving and remained higher than in the old building., Conclusion: This large-scale study examining the effects of a UK primary care environment on patients and staff shows that an enhanced environment is associated with improvements in patients' perception of patient-doctor communication, reduction in anxiety, and increases in patient and staff satisfaction.

Objective: to assess fathers' and grandmothers' knowledge of breast feeding and their ability to support successful breast feeding. To design a suitable intervention for fathers and grandmothers to support breast-feeding mothers, to assess the acceptability and feasibility of the intervention and monitor its likely effects on breast-feeding rates., Design: qualitative focus groups and interviews. Evaluation of the feasibility of an antenatal intervention., Setting: Community Health Centre and family homes in an area of relative social and economic deprivation in South Bristol, UK, from November 2001 to May 2003., Participants: 10 grandmothers and five fathers in focus groups and interviews. Twenty-nine families in the intervention., Intervention: an antenatal intervention for grandmothers or partners to support breast feeding, which combined the benefits and mechanics of breast feeding with ways of providing support for breast feeding., Findings: using an antenatal session based around a leaflet, specifically written for grandmothers and partners, and including a demonstration of good breast-feeding positioning and attachment in addition to the discussion of specific issues around the health benefits and mechanics of breast feeding was found to be acceptable, useful and enjoyable by all participants, particularly for first-time parents. The importance of fathers and grandmothers in providing emotional and practical support for breast-feeding mothers is highlighted, since those who were still breast feeding at eight weeks all felt that they were receiving similar or better support postnatally than they were antenatally. Significantly more intervention mothers were breast feeding their babies at eight weeks than in the wider practice population of mothers outside the study who intended to breast feed. Fathers' attitudes to breast feeding postnatally were fairly similar to those before the baby was born with breast feeding in public and knowing how much milk the baby was getting having the most influence on whether they felt that their partner should continue to breast feed., Implications for Practice: this type of intervention could be part of a multi-faceted approach towards improving breast-feeding initiation and continuation, particularly in areas of low prevalence. Health professionals should be opportunistic about involving other family members in discussions about breast feeding whenever possible, both antenatally and postnatally.

Objectives: to determine whether a specific 'hands-off' breastfeeding technique, based on the physiology of suckling and clinical experience, if taught to mothers in the immediate postnatal period, improves their chances of breastfeeding successfully and reduces the incidence of problems. To investigate the factors associated with breastfeeding at two and six weeks postpartum using logistic regression analysis., Design: a non-randomised prospective cohort phased intervention study., Setting: subjects recruited from one postnatal ward in St. Michael's Hospital, Bristol from October 1996 to November 1998., Participants: 1400 South Bristol mothers who were breastfeeding on discharge from hospital. Three hundred and ninety-five of these mothers were scored for efficiency of using the breastfeeding technique., Intervention: a 'hands-off' breastfeeding technique was taught to midwives in hospital who subsequently taught mothers in their care., Measurements: frequencies of exclusive and 'any breastfeeding' at two and six weeks from questionnaires sent to mothers at home, and incidence of breastfeeding problems., Findings: significant increases were observed in the proportion of mothers exclusively breastfeeding at two weeks (P < 0.001) and six weeks (P=0.02) and in 'any breastfeeding' rates (P=0.005) at two weeks after the technique intervention. The incidence of mothers feeling that they did 'not have enough milk' (perceived milk insufficiency) decreased significantly after the breastfeeding technique had been taught (P=0.02). Logistic regression analysis produced a model which showed that mothers with high scores for the 'hands-off' technique were significantly more likely to be breastfeeding at six weeks compared with those who did not use all the elements of the technique (OR 2.4; CI 1.3, 4.3). Factors associated with continuing to breastfeed at two and six weeks postpartum were also investigated using logistic regression. At two weeks, the significant factors associated with breastfeeding included mothers feeling that they had a 'plentiful milk supply' (OR 3.3; CI 2.1, 5.3), not using a dummy (OR 2.6; CI 1.6, 4.0), not giving the baby any other fluid in hospital (OR 2.4; CI 1.5, 3.8) and receiving enough support for breastfeeding from hospital staff (OR 2.1; CI 1.3, 3.5). By six weeks, in addition to these factors, the encouragement from a supportive partner, other family members and health professionals in enabling women to continue to breastfeed was found to show the largest associations with the maintenance of breastfeeding [(OR 37.2; CI 17.3, 80.2) for all three encouraging (327/817; 40% of breastfeeders) compared with no encouragement (67/817; 8% of breastfeeders)]., Conclusions: in the immediate postnatal period, if mothers are taught good breastfeeding technique by midwives in a 'hands-off' style, which enables mothers to position and attach their babies for themselves, and which is based on a physiological approach, breastfeeding rates are increased and the incidence of perceived milk insufficiency decreases. Successful breastfeeding in the early weeks was associated both with practices and support in hospital and with factors at home including not using dummies and having a supportive partner, family and health professionals who are encouraging breastfeeding., Implications for Practice: teaching mothers how to breastfeed in a 'hands-off' way is important in empowering mothers to 'do it for themselves' and in improving breastfeeding rates. Widespread adoption of consistent good practice is achievable following a brief workshop teaching session. Using the 'breastfeeding score checklist' may help midwives to assess a breastfeed more accurately and determine which aspects need improving. Health professionals should aim to educate all key family members, whenever an opportunity arises both during pregnancy and postnatally, in the benefits of breast milk for babies in the first few months of life and how to encourage and support a mother in the early weeks of breastfeeding., (Copyright 2002 Elsevier Science Ltd.)