Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability.

AIM: To explore the factor structure, reliability, and potential usefulness of a patient safety climate questionnaire in UK health care. SETTING: Four acute hospital trusts and nine primary care trusts in England. METHODS: The questionnaire used was the 27 item Teamwork and Safety Climate Survey. Thirty three healthcare staff commented on the wording and relevance. The questionnaire was then sent to 3650 staff within the 13 NHS trusts, seeking to achieve at least 600 responses as the basis for the factor analysis. 1307 questionnaires were returned (36% response). Factor analyses and reliability analyses were carried out on 897 responses from staff involved in direct patient care, to explore how consistently the questions measured the underlying constructs of safety climate and teamwork. RESULTS: Some questionnaire items related to multiple factors or did not relate strongly to any factor. Five items were discarded. Two teamwork factors were derived from the remaining 11 teamwork items and three safety climate factors were derived from the remaining 11 safety items. Internal consistency reliabilities were satisfactory to good (Cronbach's alpha > or =0.69 for all five factors). CONCLUSIONS: This is one of the few studies to undertake a detailed evaluation of a patient safety climate questionnaire in UK health care and possibly the first to do so in primary as well as secondary care. The results indicate that a 22 item version of this safety climate questionnaire is useable as a research instrument in both settings, but also demonstrates a more general need for thorough validation of safety climate questionnaires before widespread usage.

A study of risk factors for pneumococcal disease among children in a rural area of west Africa.

BACKGROUND: Pneumoccal infection is one of the leading causes of pneumonia, meningitis and septicaemia in developing countries. We have investigated possible risk factors for pneumococcal disease among children living in a rural area of The Gambia. METHODS: A prospective case-control study was conducted in which children with pneumococcal infection were identified from among children attending out-patient and under-fives clinics and matched according to age with healthy children selected randomly from the local community. A questionnaire was used to investigate possible nutritional, medical, socioeconomic and environmental risk factors for pneumococcal disease. RESULTS: An increased risk of pneumococcal disease was associated with poor weight gain, a history of serious illness in the previous 6 months, exposure to cigarette smoke or being carried on mother's back while cooking. The risk of pneumococcal disease was reduced among children whose mothers had a personal source of income. CONCLUSIONS: The incidence of pneumococcal disease could be reduced by improving nutrition and taking steps to identify and rehabilitate those children whose weight is faltering or falling. Encouraging mothers to develop greater financial independence may also be beneficial. Reduced exposure to smoke should be promoted by improving ventilation in kitchens, introducing more efficient and less polluting stoves, keeping children away from smoky environments and discouraging parental smoking.

PIP: Pneumococcal infection is a leading cause of pneumonia, meningitis, and septicemia in developing countries. The authors investigated possible risk factors for pneumococcal disease during 1989-91 among children living in the rural Upper River Division of The Gambia. A prospective case-control study approach was used in which 80 children with pneumococcal infection were matched according to age with 159 healthy children randomly selected from the local community. The subjects were of mean age 14.0-14.2 months. A questionnaire was used to identify possible nutritional, medical, socioeconomic, and environmental risk factors for pneumococcal disease. The study found an increased risk of pneumococcal disease to be associated with poor weight gain, a history of serious illness during the previous 6 months, exposure to cigarette smoke, or being carried upon a mother's back while she cooks. The risk of pneumococcal disease was reduced among children whose mothers had a personal source of income. The authors suggest reducing the incidence of pneumococcal disease by improving nutrition and growth monitoring, encouraging mothers to develop greater financial independence, and reducing children's exposure to smoke.

Importance of enteric bacteria as a cause of pneumonia, meningitis and septicemia among children in a rural community in The Gambia, West Africa.

Two thousand eight hundred ninety-eight children younger than 5 years old were investigated during a 2-year period in a rural area of The Gambia for possible pneumonia, meningitis or septicemia. After clinical examination and appropriate investigations, 1014 children were diagnosed as having pneumonia, 31 as having meningitis and 100 as having septicemia. Nine hundred seven children had a final diagnosis of malaria including 702 who satisfied the World Health Organization criteria for a diagnosis of pneumonia. A bacterial etiology was established in 115 (11%) patients with a final diagnosis of pneumonia, in 25 (81%) with meningitis and in 29 (29%) with suspected septicemia. Overall the pneumococcus was the leading pathogen identified among children with pneumonia and meningitis and ranked third among those with septicemia. However, during the wet season, when malaria transmission was highest, 50% of blood culture isolates obtained from children satisfying the World Health Organization criteria for a diagnosis of pneumonia were Salmonella or coliform species, and the pneumococcus and Haemophilus influenzae type b accounted for only 43% of isolates. Thus enteric bacteria may be as important as those bacteria more usually associated with respiratory disease among children presenting with a clinical picture of pneumonia during the wet season. This finding has important implications for case management and surveillance for antibiotic resistance.

Overlap in the clinical features of pneumonia and malaria in African children.

Pneumonia and malaria are common causes of childhood morbidity and mortality in many developing countries and simple guidelines have been proposed to facilitate their diagnosis by relatively unskilled health workers. We have studied children in The Gambia attending out-patient and under-five clinics with clinically suspected pneumonia (cough or difficulty in breathing and a raised respiratory rate) during periods of high or low malaria transmission. During a period of high malaria transmission, 33% of these children had radiological evidence of pneumonia (with or without malaria parasitaemia) compared to 38% who had malaria parasitaemia, no radiological evidence of pneumonia and no other obvious cause of fever. Corresponding figures during a period of low malaria transmission were 48% and 6% respectively. The clinical overlap between pneumonia and malaria has important implications for case management strategies and evaluation of disease-specific interventions in regions in which both pneumonia and malaria are prevalent.

The effect of temperature reduction on respiratory rate in febrile illnesses.

A raised respiratory rate is a useful sign in the diagnosis of pneumonia in children. It was observed that children with malaria and other febrile illnesses may also present with a raised respiratory rate. To determine the extent to which increased body temperature contributes to the raised respiratory rate observed in these children the effect of change in body temperature on respiratory rate was measured in 186 sick Gambian children with a raised respiratory rate, including those with pneumonia or malaria. A temperature dependent effect on respiratory rate of 3.7 breaths per minute per degree centigrade was demonstrated for the whole study cohort, with no significant difference between children with pneumonia or malaria. Twenty three per cent of children with pneumonia whose temperature fell had a final respiratory rate below that currently recommended by the World Health Organisation for the diagnosis of pneumonia. It is concluded that respiratory rate is to some extent dependent on body temperature in children with febrile illnesses such as pneumonia and malaria, but that this does not alone account for the raised respiratory rate seen in these children. The effect of reduction in body temperature on respiratory rate does not help to distinguish children with pneumonia from those with malaria. A history of recent use of an antipyretic or other measures to control fever is important when evaluating children for possible pneumonia.

Antidepressant treatments: effects in rodents on dose-response curves of 5-hydroxytryptamine- and dopamine-mediated behaviours and 5-HT2 receptor number in frontal cortex.

The effects of repeated electroconvulsive shock (ECS) administration, repeated desmethylimipramine injection (5 mg kg-1, twice daily for 14 days) and acute administration of the beta-adrenoceptor, clenbuterol, on 5-hydroxytryptamine (5-HT)- and dopamine-mediated behaviours in mice have been examined. All three treatments enhanced the carbidopa/5-hydroxytryptophan (5-HTP)-induced head-twitch response at all doses of 5-HTP examined, producing a parallel shift in the dose-response curve. A single ECS administration or single dose of desmethylimipramine had no effect. Only repeated ECS enhanced the locomotor response to injection of apomorphine. The dose-response curve shift was not parallel. A single ECS had no effect. A 6-hydroxydopamine lesion of brain dopamine terminals also enhanced the apomorphine response, but again did not produce a parallel shift in the dose-response curve. Both repeated ECS and repeated desmethylimipramine administration to rats increased the number of 5-HT2 receptor sites in rat brain. Clenbuterol had no effect. The enhancing effects of repeated ECS and clenbuterol administration on the 5-HTP-induced head-twitch response were additive. Enhanced 5-HT-mediated behavioural responses are seen in both mice and rats after these treatments. If it is assumed, therefore, that similar receptor changes occur in both species it appears that there is no relationship in either behavioural system between the ability of the treatment to alter receptor number and the change in the dose-response curve (parallel or non-parallel). All three antidepressant treatments (ECS, a tricyclic and a beta-adrenoceptor agonist) increase 5-HT-mediated behavioural responses although clenbuterol did not increase 5-HT2 receptor number. Only ECS increased dopamine-mediated responses.