Reflections on the UK's approach to the 2009 swine flu pandemic: conflicts between national government and the local management of the public health response.

The first cases of swine flu in the UK were detected on 27th April 2009. Two weeks later Birmingham became a "hotspot" for the HIN1 pandemic in England. This paper describes the experiences of local public health agencies during the pandemic and the problems encountered when trying to work within a hierarchical and hermetic system of national policy making. We argue that over reliance on the speculative logic of modellers, together with a failure to adapt swiftly the nation's preparedness plans and public health apparatus created in readiness for a serious and fatal disease, led to an institutional void of policy making during the pandemic, where new rules and concepts emerged about what constituted scientifically acceptable and politically legitimate interventions. The imposition of a single national approach to managing the pandemic and a disregard for the role of local authorities seriously impaired the ability of local agencies to respond in a flexible, timely and pragmatic way to the rapidly emerging situation. Future planning for pandemics must recognise that global epidemics are curbed at the local level, and ensure that any response is proportionate, flexible and effective.

Evaluation of Lay Support in Pregnant women with Social risk (ELSIPS): a randomised controlled trial.

BACKGROUND: Maternal, neonatal and child health outcomes are worse in families from black and ethnic minority groups and disadvantaged backgrounds. There is little evidence on whether lay support improves maternal and infant outcomes among women with complex social needs within a disadvantaged multi-ethnic population in the United Kingdom (UK). METHOD/DESIGN: The aim of this study is to evaluate a lay Pregnancy Outreach Worker (POW) service for nulliparous women identified as having social risk within a maternity service that is systematically assessing social risks alongside the usual obstetric and medical risks. The study design is a randomised controlled trial (RCT) in nulliparous women assessed as having social risk comparing standard maternity care with the addition of referral to the POW support service. The POWs work alongside community midwifery teams and offer individualised support to women to encourage engagement with services (health and social care) from randomisation (before 28 weeks gestation) until 6 weeks after birth. The primary outcomes have been chosen on the basis that they are linked to maternal and infant health. The two primary outcomes are engagement with antenatal care, assessed by the number of antenatal visits; and maternal depression, assessed using the Edinburgh Postnatal Depression Scale at 8-12 weeks after birth. Secondary outcomes include maternal and neonatal morbidity and mortality, routine child health assessments, including immunisation uptake and breastfeeding at 6 weeks. Other psychological outcomes (self efficacy) and mother-to-infant bonding will also be collected using validated tools.A sample size of 1316 will provide 90% power (at the 5% significance level) to detect increased engagement with antenatal services of 1.5 visits and a reduction of 1.5 in the average EPDS score for women with two or more social risk factors, with power in excess of this for women with any social risk factor. Analysis will be by intention to treat. Qualitative research will explore the POWs' daily work in context. This will complement the findings of the RCT through a triangulation of quantitative and qualitative data on the process of the intervention, and identify other contextual factors that affect the implementation of the intervention. DISCUSSION: The trial will provide high quality evidence as to whether or not lay support (POW) offered to women identified with social risk factors improves engagement with maternity services and reduces numbers of women with depression. MREC NUMBER: 10/H1207/23 TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN35027323.

Effect of a peer support service on breast-feeding continuation in the UK: a randomised controlled trial.

OBJECTIVE: to assess the effectiveness of a peer support worker (PSW) service on breast-feeding continuation. DESIGN: cluster randomised controlled trial (ISRCTN16126175). SETTING: Primary Care Trust, UK serving a multi-ethnic, socio-economically disadvantaged population. PARTICIPANTS: 2,724 women giving birth following antenatal care from 66 clinics: 33 clinics (1,267 women) randomised to the PSW service and 33 clinics (1,457 women) to usual care. 848 women consented to additional follow-up by questionnaire at 6 months. INTERVENTION: PSW service provided in the antenatal and postnatal period. MEASUREMENTS: any and exclusive breast feeding at 10-14 days obtained from routine computerised records and at 6 weeks and 6 months from a questionnaire. FINDINGS: follow-up: 94% at 10-14 days, 67.5% at 6 months. There was no difference in any breast feeding at 10-14 days between intervention and usual care, odds ratio (OR) 1.07 (95% CI 0.87-1.31, p=0.54). Proportion of women reporting any breast feeding in the intervention group at 6 weeks was 62.7% and 64.5% in the usual care group OR 0.93 (95% CI 0.64-1.35); and at 6 months was 34.3% and 38.9%, respectively, OR 1.06 (95% CI 0.71-1.58). KEY CONCLUSIONS: universal antenatal peer support and postnatal peer support for women who initiated breast feeding did not improve breast-feeding rates up to 6 months in this UK population. IMPLICATIONS FOR PRACTICE: with high levels of professional support part of usual maternity care it may not be possible for low intensity peer support to produce additional benefit. More intensive or targeted programmes might be effective, but should have concurrent high quality evaluation.

Perceptions of the health effects of stoves in Mongolia.

PURPOSE: The purpose of this paper is to evaluate the views of stove users in Ulaanbaatar, Mongolia on how stoves affect their health. DESIGN/METHODOLOGY/APPROACH: In this paper focus groups were conducted with improved stove users; traditional stove users; and a mix of traditional and improved stove users. Individual interviews were also held with various types of stove users. A translator moderated all discussions with a questioning route. All discussions were fully transcribed and translated. The transcripts were analysed by identifying common themes in responses to form an emerging theory. FINDINGS: The findings in the paper are that all stove users recognised respiratory symptoms caused by stove smoke and other health effects such as warmth, dirt and workload, which they perceived to be important. Stove users had a lack of knowledge about the diseases caused by the smoke. Public health was a key driver for the improved stove project, yet has been neglected in improved stove marketing. RESEARCH LIMITATIONS/IMPLICATIONS: The study used in this paper was limited by the language barrier. Some of the meanings of participants' responses may have been lost in translation. PRACTICAL IMPLICATIONS: This paper has highlighted the importance of the health effects of stove smoke to stove users. Uptake of the improved stoves has been low. Public health should be included in marketing strategies for improved stoves to increase their uptake. ORIGINALITY/VALUE: The paper shows that acute respiratory infections are a major cause of mortality world-wide. Indoor air pollution from burning biomass fuels in household stoves causes a significant proportion of respiratory infections. No qualitative research has been published exploring stove users' views on the health effects of stoves. This paper provides an insight into stove users' perceptions for those interested in people-centred approaches to tackling international health issues.