Factors associated with informal human milk sharing among donors and recipients: A mixed-methods systematic review.

BACKGROUND: The multiple benefits associated with the provision of human milk exceed individual health outcomes, engendering substantial economic, societal and environmental domains. Human milk is the absolute, unparalleled source of nutrition for infants. Informal human milk sharing is a modernistic and rapidly progressing practice. No systematic review of the factors associated with this contemporary practice among donors and recipients of informal human milk sharing exists. AIM: The aim of this review was to identify, evaluate, synthesize and integrate the evidence on the factors associated with informal human milk sharing among donors and recipients. METHODS: A mixed methods systematic review was conducted according to the Joanna Briggs Institute methodological guidance utilizing a convergent integrated approach. The following databases were systematically searched: CINAHL, Scopus, Medline and Embase and Web of Science between inception to August 2023. A grey literature search was conducted using multiple techniques. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Twenty-four studies were included in this review. Ten integrated findings relating to the factors associated with informal human milk sharing among donors and recipients were identified. The four integrated findings pertaining to donors included: altruistic motivation and value, resistance to commercialization and overcoming inaccessibility, uniting digital and personal connectedness and lack of awareness and acceptance of informal human milk sharing in healthcare settings. The six integrated findings relating to recipients included: maternal or infant factors, superiority and advantageous impact of breastmilk, human milk bank influences, digital connections and transparency, healthcare professional facilitation of informal human milk sharing, and professional and logistical implications. CONCLUSION: This review highlighted a multitude of factors that motivate, facilitate and impede the practice of informal human milk sharing. Future research is required to explore these factors further within broader geographical locations to enhance the generalizability and rigor of the body of knowledge. Further studies should consider the exploration of the experiences and psychological impact of informal human milk sharing on donors and recipients. The provision of human milk to all infants is an imperative public health endeavor and thus positioning this as a key benchmark for research and practice is crucial.

Perspectives and factors associated with informal human milk sharing: a mixed-methods systematic review protocol.

Background: The practice of informal human milk sharing is a relatively new phenomenon and poses significant questions in the domain of infant feeding. Informal human milk sharing is a means of donating human milk from another lactating individual who is not the child's biological parent, in a casual manner, that is, without the involvement of health professionals or agencies. The advent of digital technology has facilitated the donation and receipt of human milk through digital online platforms and thus has amplified this modern practice. This research aims to comprehensively examine and synthesize evidence about the motivations, barriers, facilitators and experiences of individuals who both donate (donors) and the primary care givers of the infants who receive (recipients) human milk informally to provide to infants. Methods: A mixed-methods systematic review will be undertaken. This review will consider qualitative, quantitative and primary mixed-methods studies which report on the factors associated with informal milk sharing, and on donors' and recipients' experiences of the practice. Primary mixed-method studies will be included if the individual qualitative and quantitative components can be extracted. Five databases will be searched for studies on informal human milk sharing published from inception of the database. Study quality will be evaluated using the standardized JBI critical appraisal tools, selected based on the methodology in each individual study. Data extraction will be conducted using the JBI mixed methods data extraction form followed by data transformation, synthesis and integration. This mixed-methods systematic review will follow a convergent integrated approach in accordance with JBI guidance. Discussion: Informal human milk sharing is a novel practice in the domain of infant feeding. This review will enable a thorough understanding of this practice from both the donors and recipients' perspective and will have implications for healthcare professionals, policy and future clinical decision-making. Protocol registration number: PROSPERO CRD42023405653.

Colliding worlds: Family carers' experiences of balancing work and care in Ireland during the COVID-19 pandemic.

The Coronavirus disease 2019 (COVID-19) pandemic public health and social protective measures imposed globally resulted in partial or full closure of key services and supports for services and supports for people with a disability, chronic illness or age-related dependency. This caused huge disruption to care provision and family carers were relied upon to assume this care at home. Many family carers, including those in employment, found themselves navigating additional care responsibilities without 'usual levels' of support from family, friends, work, school, day care services, homecare and community services. The purpose of this study was to examine the impact of the COVID-19 pandemic on family carers, their employment and care-giving responsibilities, through the lens of the Conservation of Resources (COR) theory (Hobfoll, 1989). Adopting a qualitative research approach, 16 family carers (14 females, 2 males) who were in employment prior to the onset of or during the pandemic, participated in an in-depth, semi-structured telephone or online video interview between June and September 2020. Interviews lasted between 45 and 100 min, were audio-recorded and transcribed verbatim. A thematic analysis of the interview data identified four main themes: colliding worlds; navigating unchartered waters alone; opportunity despite adversity and the relentless unknowing. Findings indicate that the onset of the pandemic resulted in the sudden loss of valued resources, which disrupted routines and caused care and work life domains to become intrinsically intertwined. Consistent with the main principles of the COR theory, adapting and transitioning to different ways of working and caring with depleted resources and supports, generated considerable stress for family carers and impacted their well-being. The implications for employers, healthcare providers, policy makers and other key stakeholders are considered, to enable family carers to successfully reconcile work with care and protect their well-being, as the pandemic continues to unfold and in the event of future societal crises.

The invisible workforce during the COVID-19 pandemic: Family carers at the frontline.

This is an open letter to acknowledge the essential and increasingly challenging role unpaid family carers are playing in the COVID-19 pandemic. The letter is written by members of the CAREWELL team, a HRB-funded project that aims to promote health and self-care behaviours among working family carers. Family carers provide care to family and friends in the community who need support due to old-age, disability and chronic illness. In many cases, family carers are supporting those who are considered most at risk in this pandemic meaning carers must reduce their own risk of infection in order to protect their dependent family members. The temporary reduction of some home care services, as well as school and creche closures, means that family carers are providing increased levels of care with little or no support. At a time when both worlds of work and care have been dramatically transformed, we wish to shed light on those who are currently balancing paid employment with a family caregiving role. We argue that there is much to be learned from the recent work restrictions that could benefit employees, including working family carers, beyond this pandemic. We also wish to build on the potential positives of a transformed society and encourage policy makers and employers to focus on what is currently being implemented, and to identify which measures could be used to create a bedrock of policies and practices that would offer robust and effective support to family carers. It is hoped that family carers will receive greater recognition for the significant role they play in society, providing essential care and alleviating the strain on health and social care systems, both during and post the COVID-19 pandemic.

Conceptualising a model to guide nursing and midwifery in the community guided by an evidence review.

BACKGROUND: Successful models of nursing and midwifery in the community delivering healthcare throughout the lifespan and across a health and illness continuum are limited, yet necessary to guide global health services. Primary and community health services are the typical points of access for most people and the location where most care is delivered. The scope of primary healthcare is complex and multifaceted and therefore requires a practice framework with sound conceptual and theoretical underpinnings. The aim of this paper is to present a conceptual model informed by a scoping evidence review of the literature. METHODS: A scoping evidence review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Databases included CINAHL, MEDLINE, PsycINFO and SocINDEX using the EBSCO platform and the Cochrane Library using the keywords: model, nursing, midwifery, community, primary care. Grey literature for selected countries was searched using the Google 'advanced' search interface. Data extraction and quality appraisal for both empirical and grey literature were conducted independently by two reviewers. From 127 empirical and 24 non-empirical papers, data extraction parameters, in addition to the usual methodological features, included: the nature of nursing and midwifery; the population group; interventions and main outcomes; components of effective nursing and midwifery outcomes. RESULTS: The evidence was categorised into six broad areas and subsequently synthesised into four themes. These were not mutually exclusive: (1) Integrated and Collaborative Care; (2) Organisation and Delivery of Nursing and Midwifery Care in the Community; (3) Adjuncts to Nursing Care and (4) Overarching Conceptual Model. It is the latter theme that is the focus of this paper. In essence, the model depicts a person/client on a lifespan and preventative-curative trajectory. The health related needs of the client, commensurate with their point position, relative to both trajectories, determines the nurse or midwife intervention. Consequently, it is this need, that determines the discipline or speciality of the nurse or midwife with the most appropriate competencies. CONCLUSION: Use of a conceptual model of nursing and midwifery to inform decision-making in primary/community based care ensures clinical outcomes are meaningful and more sustainable. Operationalising this model for nursing and midwifery in the community demands strong leadership and effective clinical governance.

Implementing a peer-support intervention for people with type 2 diabetes: a qualitative study.

OBJECTIVE: This qualitative study aimed to explore participants', peer supporters' and practice nurses' experience of the implementation of a peer-support intervention for people with type 2 diabetes. METHODS: The study was conducted in family practice in Ireland. Participants were selected from the patients, peer supporters and practice nurses who participated in a 2-year randomized controlled trial of peer support in type 2 diabetes. The sample consisted of 6 practice nurses, 15 peer supporters and 33 intervention participants. Data were collected using focus groups and semi-structured interviews and transcribed verbatim. Key themes and concepts were identified using framework analysis. RESULTS: The following themes emerged: who gets invited to be a peer supporter?; training and support for peer supporters; and peer-support meetings and challenges of delivering a peer-support programme. Recruiting peer supporters via the general practices was successful. Although some peer supporters were hesitant to participate initially, they were satisfied in their role and felt well trained and supported. Participants were overwhelmingly positive about the peer-support meetings. They welcomed the fact that the meetings were led by a peer; however, some participants reported that they would have liked occasional input from health professionals. The 'Frequently Asked Questions' element of the intervention was very popular with both participants and peer supporters. CONCLUSIONS: This study revealed that it was feasible to implement a peer-support intervention in the general practice setting. Challenges of delivering such an intervention were identified, particularly in relation to meeting attendance, and should be considered in further research in the area.

Multimorbidity in a cohort of patients with type 2 diabetes.

BACKGROUND: People with type 2 diabetes frequently have a variety of related and unrelated chronic conditions. These additional conditions have implications for patient education, treatment burden and disease management. OBJECTIVES: The aim of this study was to examine the nature of multimorbidity, and its impact on GP visits, polypharmacy and glycaemic control as measured by HbA1c, in a cohort of patients with type 2 diabetes attending general practice in Ireland. METHODS: A cohort of 424 patients with type 2 diabetes enrolled in a cluster randomized controlled trial based in Irish general practice was examined. Patient data included: medical conditions, HbA1c, health service utilization, socio-economic status and number of prescribed medications. RESULTS: 90% of patients had at least one additional chronic condition and a quarter had four or more additional chronic conditions. 66% of patients had hypertension; 25% had heart disease; and 16% had arthritis. General practitioner visits and polypharmacy increased significantly with increasing numbers of chronic conditions. When comparing patient self-report with medical records, patients who reported a higher proportion of their conditions had better glycaemic control with a significantly lower HbA1c score. CONCLUSION: There was a high prevalence of multimorbidity in these patients with type 2 diabetes and the results suggest that glycaemic control is related to patients' awareness of their chronic conditions. The variety of conditions emphasizes the complexity of illness management in this group and the importance of maintaining a generalist and multidisciplinary approach to their clinical care.

Patient generated "frequently asked questions": identifying informational needs in a RCT of peer support in type 2 diabetes.

AIMS: The purpose of this study is to discuss the use of a system of patient generated "frequently asked questions" (FAQs) in order to gain insight into the information needs of participants. METHODS: FAQs generated during group meetings taking place in a randomized controlled trial of peer support in type 2 diabetes are described in terms of their frequencies and topic areas. Data from focus groups and semi-structured interviews concerning the FAQs was subjected to content analysis. RESULTS: 59/182 (33%) of the FAQs were directly related to the topic area of the scheduled peer support meeting with foot care, eyes and kidneys generating the most specific questions. The FAQs addressed mainly knowledge and concerns. The FAQs appeared to enhance peer support and also enabled participants to ask questions to experts that they may not have asked in a clinic situation. CONCLUSIONS: The use of FAQs to support peer supporters proved beneficial in a randomized controlled trial and may be usefully added to the tools used within a peer support framework. The use of FAQs provided valuable insight into the informal information needs of people with diabetes. Means of providing a similar structure in routine clinical care should be explored.

Cost effectiveness of peer support for type 2 diabetes.

OBJECTIVES: The aim of this study is to examine the cost-effectiveness of a group-based peer support intervention in general practice for patients with type 2 diabetes. METHODS: Incremental cost utility analysis combining within trial and beyond trial components to compare the lifetime costs and benefits of alternative strategies: CONTROL: standardized diabetes care; INTERVENTION: group-based peer support in addition to standardized diabetes care. Within trial analysis was based on a cluster randomized controlled trial of 395 patients with type 2 diabetes in the east of Ireland. Beyond trial analysis was conducted using the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model. Uncertainty was explored using a range of sensitivity analyses and cost-effectiveness acceptability curves were generated. RESULTS: Compared with the control strategy, the intervention was associated with an increase of 0.09 (95 percent confidence interval [CI], -0.05 to 0.25) in mean quality-adjusted life-years per patient and savings of €637.43 (95 percent CI, -2455.19 to 1125.45) in mean healthcare cost per patient and €623.39 (95 percent CI, -2507.98 to 1298.49) in mean total cost per patient respectively. The likelihood of the intervention being cost-effective was appreciably higher than 80 percent for a range of potential willingness-to-pay cost-effectiveness thresholds. CONCLUSIONS: Our results suggest that while a group-based peer support intervention shows a trend toward improved risk factor management, we found no significant differences in final cost or effectiveness endpoints between intervention and control. The probabilistic results suggest that the intervention was more cost-effective, with probability values of higher than 80 percent across a range of potential cost-effectiveness threshold values.

'The real deal': a feasibility study of peer-led sex education for early school leavers.

OBJECTIVES: To explore female early school leaver's experience of sexual activity and sex education, and to assess the feasibility and potential impact of a peer-led sex education intervention. METHODS: Forty five young female early school leavers and ten peer educators participated in the study. The ten peer educators, early school leavers who were teenage mothers, were trained to deliver the peer-led education intervention. Both quantitative (self-completed questionnaire) and qualitative (focus groups) research methods were used to evaluate the intervention. RESULTS: The average age of participants was 17.5 years. The average age at leaving school was 15 years. Many participants were smokers and took alcohol on a regular basis. Over three quarters of the young women were sexually active. Although most used contraception in the past, over 30% had not the last time they had sex. While participants' knowledge around sexual issues showed some improvement following the pilot intervention, there was little change in attitudes to sexual behaviour. CONCLUSIONS: This feasibility study was very well received by both peer educators and participants. To assess the effectiveness of the intervention we recommend that a larger randomised control trial be conducted.

The effect of the Irish smoke-free workplace legislation on smoking among bar workers.

BACKGROUND: On 29 March 2004, the Republic of Ireland (ROI) became the first EU country to introduce a nationwide ban on workplace smoking. While the focus of this measure was to protect worker health by reducing exposure to second-hand smoke, other effects such as a greater reduction in smoking prevalence and consumption were likely among bar workers. METHODS: A random sample of bar workers from Cork city were surveyed before (n = 129) and after (n = 107; 82.9% follow-up rate) implementation of the smoke-free legislation. Self report and combined self report and cotinine concentration were used to determine smoking status. For comparison a cross-sectional random telephone survey of the general population (ROI) was conducted before and 1 year after the smoke-free legislation. There were 1240 pre- and 1221 participants post-ban in the equivalent age and occupational subset of the general population. RESULTS: There was a non-significant decline in smoking prevalence among bar workers 1 year post-ban (self report: -2.8% from 51.4% to 48.6%, P = 0.51; combined self report and cotinine: -4.7% from 56.1% to 51.4%, P = 0.13), but a significant decline in consumption of four cigarettes (95% CI 2.21-6.36) per day. Within the occupationally equivalent general population sub-sample there was a significant drop (3.5%, P = 0.06) in smoking prevalence but no significant change in consumption. CONCLUSIONS: Ireland's smoke-free workplace legislation was accompanied by a drop in smoking prevalence in both bar workers and the general population sub-sample.

Development of a complex intervention to test the effectiveness of peer support in type 2 diabetes.

BACKGROUND: Diabetes is a chronic illness which requires the individual to assume responsibility for their own care with the aim of maintaining glucose and blood pressure levels as close to normal as possible. Traditionally self management training for diabetes has been delivered in a didactic setting. In recent times alternatives to the traditional delivery of diabetes care have been investigated, for example, the concept of peer support which emphasises patient rather than professional domination. The aim of this paper is to describe the development of a complex intervention of peer support in type 2 diabetes for a randomised control trial in a primary care setting. METHODS: The Medical Research Council (MRC) framework for the development and evaluation of complex interventions for randomised control trials (RCT) was used as a theoretical guide to designing the intervention. The first three phases (Preclinical Phase, Phase 1, Phase 2) of this framework were examined in depth. The Preclinical Phase included a review of the literature relating to type 2 diabetes and peer support. In Phase 1 the theoretical background and qualitative data from 4 focus groups were combined to define the main components of the intervention. The preliminary intervention was conducted in Phase 2. This was a pilot study conducted in two general practices and amongst 24 patients and 4 peer supporters. Focus groups and semi structured interviews were conducted to collect additional qualitative data to inform the development of the intervention. RESULTS: The four components of the intervention were identified from the Preclinical Phase and Phase 1. They are: 1. Peer supporters; 2. Peer supporter training; 3. Retention and support for peer supporters; 4. Peer support meetings. The preliminary intervention was implemented in the Phase 2. Findings from this phase allowed further modeling of the intervention, to produce the definitive intervention. CONCLUSION: The MRC framework was instrumental in the development of a robust intervention of peer support of type 2 diabetes in primary care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN42541690.

Peer support in type 2 diabetes: a randomised controlled trial in primary care with parallel economic and qualitative analyses: pilot study and protocol.

BACKGROUND: Diabetes is a chronic illness, which requires the individual to assume responsibility for their own care with the aim of maintaining glucose and blood pressure levels as close to normal as possible. Traditionally self-management training for diabetes has been delivered in a didactic manner. In recent times alternatives to the traditional delivery of diabetes care have been investigated, for example, the concept of peer support which emphasises patient rather than professional domination. This paper describes the pilot study and protocol for a study that aims to evaluate the effectiveness of a peer support intervention for people with type 2 diabetes in a primary care setting. METHODS/DESIGN: A pilot study was conducted to access the feasibility of a randomized controlled trial of a peer support intervention. We used the MRC Framework for the evaluation of complex interventions. Elements of the intervention were defined and the study protocol was finalized. In this cluster randomised controlled trial twenty general practices are assigned to control and intervention groups. Each practice compiles a diabetes register and randomly selects 21 patients. All practices implement a standardised diabetes care system. In the intervention group all practices recruit three peer supporters. The peer supporters are trained to conduct nine group meetings in their general practice over a period of two years. Each meeting has a structured component. The primary outcomes are blood pressure, total cholesterol, HBA1c and the Diabetes Well-being score. In addition to biophysical, psychosocial, economic and health service utilization data peer supporter activity and qualitative data are collected. DISCUSSION: Peer support is a complex intervention and evaluating such an intervention presents challenges to researchers. This study will evaluate whether a peer support programme for patients with type 2 diabetes improves biophysical and psychosocial outcomes and whether it is an acceptable, cost effective intervention in the primary care setting. TRIAL REGISTRATION: Current Controlled Trials ISRCTN42541690.

Before and after study of bar workers' perceptions of the impact of smoke-free workplace legislation in the Republic of Ireland.

OBJECTIVES: To compare support for, and perceptions of, the impacts of smoke-free workplace legislation among bar workers in the Republic of Ireland (ROI) pre- and post-implementation, and to identify predictors of support for the legislation. SETTING: Public houses (pubs) in three areas of the ROI. DESIGN: Comparisons pre- and post-implementation of smoke-free workplace legislation. PARTICIPANTS: From a largely non-random selection, 288 bar workers volunteered for the baseline survey; 220 were followed up one year later (76.4%). OUTCOME MEASURES: Level of support for the legislation, attitude statements concerning potential impacts of the law and modelled predictors of support for the legislation. RESULTS: Pre-implementation 59.5% of participants supported the legislation, increasing to 76.8% post-implementation. Support increased among smokers by 27.3 percentage points from 39.4% to 66.7% (p < 0.001) and among non-smokers by 12.4% percentage points from 68.8% to 81.2% (p = 0.003).Pre-legislation three-quarters of participants agreed that the legislation would make bars more comfortable and was needed to protect workers' health. Post-legislation these proportions increased to over 90% (p < 0.001). However, negative perceptions also increased, particularly for perceptions that the legislation has a negative impact on business (from 50.9% to 62.7%, p = 0.008) and that fewer people would visit pubs (41.8% to 62.7%, p < 0.001). After adjusting for relevant covariates, including responses to the attitude statements, support for the ban increased two to three-fold post-implementation. Regardless of their views on the economic impact, most participants agreed, both pre- and post-implementation, that the legislation was needed to protect bar workers' health. CONCLUSION: Smoke-free legislation had the support of three-quarters of a large sample of bar workers in the ROI. However, this group holds complex sets of both positive and negative perspectives on the legislation. Of particular importance is that negative economic perceptions did not diminish the widely held perception that the ban is needed to protect workers' health.

Effects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin pubs.

BACKGROUND: Environmental tobacco smoke (ETS) causes disease in nonsmokers. Workplace bans on smoking are interventions to reduce exposure to ETS to try to prevent harmful health effects. On March 29, 2004, the Irish government introduced the first national comprehensive legislation banning smoking in all workplaces, including bars and restaurants. This study examines the impact of this legislation on air quality in pubs and on respiratory health effects in bar workers in Dublin. METHODS: Exposure study. Concentrations of particulate matter 2.5 microm or smaller (PM(2.5)) and particulate matter 10 microm or smaller (PM(10)) in 42 pubs were measured and compared before and after the ban. Benzene concentrations were also measured in 26 of the pubs. Health effects study. Eighty-one barmen volunteered to have full pulmonary function studies, exhaled breath carbon monoxide, and salivary cotinine levels performed before the ban and repeated 1 year after the ban. They also completed questionnaires on exposure to ETS and respiratory symptoms on both occasions. FINDINGS: Exposure study. There was an 83% reduction in PM(2.5) and an 80.2% reduction in benzene concentration in the bars. Health effects study. There was a 79% reduction in exhaled breath carbon monoxide and an 81% reduction in salivary cotinine. There were statistically significant improvements in measured pulmonary function tests and significant reductions in self-reported symptoms and exposure levels in nonsmoking barmen volunteers after the ban. CONCLUSIONS: A total workplace smoking ban results in a significant reduction in air pollution in pubs and an improvement in respiratory health in barmen.

Experience of intimate partner violence among women and men attending general practices in Dublin, Ireland: a cross-sectional survey.

UNLABELLED: This cross-sectional study examined women's and men's reported experience of intimate partner violence in general practice in the greater Dublin region. A high prevalence of reported experience of controlling behaviour and violent incidents was found. Although the reported prevalence of both was higher in men, women were more likely to have reported fear of a partner and a severe level of violence. CONCLUSION: The findings demonstrate that intimate partner violence is a major problem among the men and women surveyed.

Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study.

OBJECTIVES: To compare exposure to secondhand smoke and respiratory health in bar staff in the Republic of Ireland and Northern Ireland before and after the introduction of legislation for smoke-free workplaces in the Republic. DESIGN: Comparisons before and after the legislation in intervention and control regions. SETTING: Public houses in three areas in the Republic (intervention) and one area in Northern Ireland (control). PARTICIPANTS: 329 bar staff enrolled in baseline survey; 249 (76%) followed up one year later. Of these, 158 were non-smokers both at baseline and follow-up. MAIN OUTCOME MEASURES: Salivary cotinine concentration, self reported exposure to secondhand smoke, and respiratory and sensory irritation symptoms. RESULTS: In bar staff in the Republic who did not themselves smoke, salivary cotinine concentrations dropped by 80% after the smoke-free law (from median 29.0 nmol/l (95% confidence interval 18.2 to 43.2 nmol/l)) to 5.1 nmol/l (2.8 to 13.1 nmol/l) in contrast with a 20% decline in Northern Ireland over the same period (from median 25.3 nmol/l (10.4 to 59.2 nmol/l) to 20.4 nmol/l (13.2 to 33.8 nmol/l)). Changes in self reported exposure to secondhand smoke were consistent with the changes in cotinine concentrations. Reporting any respiratory symptom declined significantly in the Republic (down 16.7%, -26.1% to -7.3%) but not in Northern Ireland (0% difference, -32.7% to 32.7%). After adjustment for confounding, respiratory symptoms declined significantly more in the Republic than in Northern Ireland and the decline in cotinine concentration was twice as great. CONCLUSION: The smoke-free law in the Republic of Ireland protects non-smoking bar workers from exposure to secondhand smoke.