Inequalities in birth before arrival at hospital in South West England: a multimethods study of neonatal hypothermia and emergency medical services call-handler advice.

OBJECTIVES: To examine inequalities in birth before arrival (BBA) at hospitals in South West England, understand which groups are most likely to experience BBA and how this relates to hypothermia and outcomes (phase A). To investigate opportunities to improve temperature management advice given by emergency medical services (EMS) call-handlers during emergency calls regarding BBA in the UK (phase B). DESIGN: A two-phase multimethod study. Phase A analysed anonymised data from hospital neonatal records between January 2018 and January 2021. Phase B analysed anonymised EMS call transcripts, followed by focus groups with National Health Service (NHS) staff and patients. SETTING: Six Hospital Trusts in South West England and two EMS providers (ambulance services) in South West and North East England. PARTICIPANTS: 18 multidisciplinary NHS staff and 22 members of the public who had experienced BBA in the UK. RESULTS: 35% (64/184) of babies conveyed to hospital were hypothermic on arrival. When compared with national data on all births in the South West, we found higher percentages of women with documented safeguarding concerns at booking, previous live births and 'late bookers' (booking their pregnancy >13 weeks gestation). These women may, therefore, be more likely to experience BBA. Preterm babies, babies to first-time mothers and babies born to mothers with disability or safeguarding concerns at booking were more likely to be hypothermic following BBA. Five main themes emerged from qualitative data on call-handler advice: (1) importance placed on neonatal temperature; (2) advice on where the baby should be placed following birth; (3) advice on how to keep the baby warm; (4) timing of temperature management advice and (5) clarity and priority of instructions. CONCLUSIONS: Findings identified factors associated with BBA and neonatal hypothermia following BBA. Improvements to EMS call-handler advice could reduce the number of babies arriving at hospital hypothermic.

Randomised trial of the clinical and cost effectiveness of a supraglottic airway device compared with tracheal intubation for in-hospital cardiac arrest (AIRWAYS-3): Protocol, design and implementation.

Survival from in-hospital cardiac arrest is approximately 18%, but for patients who require advanced airway management survival is lower. Those who do survive are often left with significant disability. Traditionally, resuscitation of cardiac arrest patients has included tracheal intubation, however insertion of a supraglottic airway has gained popularity as an alternative approach to advanced airway management. Evidence from out-of-hospital cardiac arrest suggests no significant differences in mortality or morbidity between these two approaches, but there is no randomised evidence for airway management during in-hospital cardiac arrest. The aim of the AIRWAYS-3 randomised trial, described in this protocol paper, is to determine the clinical and cost effectiveness of a supraglottic airway versus tracheal intubation during in-hospital cardiac arrest. Patients will be allocated randomly to receive either a supraglottic airway or tracheal intubation as the initial advanced airway management. We will also estimate the relative cost-effectiveness of these two approaches. The primary outcome is functional status, measured using the modified Rankin Scale at hospital discharge or 30 days post-randomisation, whichever occurs first. AIRWAYS-3 presents ethical challenges regarding patient consent and data collection. These include the enrolment of unconscious patients without prior consent in a way that avoids methodological bias. Other complexities include the requirement to randomise patients efficiently during a time-critical cardiac arrest. Many of these challenges are encountered in other emergency care research; we discuss our approaches to addressing them. Trial registration: ISRCTN17720457. Prospectively registered on 29/07/2022.

Prevalence of perceived discrimination and associations with mental health inequalities in the UK during 2019-2020: A cross-sectional study.

Experiencing discrimination is associated with poorer mental health and the demographic patterning of discrimination may explain social inequalities in mental health. The present research examined prevalence of perceived discrimination in the UK and associations with social inequalities in mental health. Data were taken from the UK Household Longitudinal Study (n = 32,003). Population subgroups (sex, age, ethnicity, health, religiousness, income, education, and occupation), perceived personal discrimination (personal experience) and perceived belonging to a discriminated group (identified as belonging to a group discriminated against in this country), and probable mental health problems (GHQ-12 assessed, cut off 4+) were reported on in 2019/2020. Nineteen percent of participants perceived personal discrimination in the last year, 9% perceived belonging to a discriminated group, and 22% had probable mental health problems. There were significant inequalities in both perceived discrimination and mental health. Being a younger adult, of mixed ethnicity, having health problems, having a university degree, and being unemployed increased risk of mental health problems and these associations were partially explained by perceived discrimination being more common among these groups. Perceived discrimination is common among UK adults, but prevalence differs by population subgroup. Perceived discrimination may contribute to social inequalities in mental health.

Addressing social inequity through improving relational care: A social-ecological model based on the experiences of migrant women and midwives in South Wales.

BACKGROUND: Migrant and ethnic inequalities in maternal and perinatal mortality persist across high-income countries. Addressing social adversity and inequities across the childbirth trajectory cannot be left to chance and the good intentions of practitioners. Robust, evidence-based tools designed to address inequity by enhancing both the quality of provision and the experience of care are needed. METHODS: An inductive modelling approach was used to develop a new evidence-based conceptual model of woman-midwife relationships, drawing on data from an ethnographic study of relationships between migrant Pakistani women and midwives, conducted between 2013 and 2016 in South Wales, UK. Key analytic themes from early data were translated into social-ecological concepts, and a model was developed to represent how these key themes interacted to influence the woman-midwife relationship. RESULTS: Three key concepts influencing the woman-midwife relationship were developed from the three major themes of the underpinning research: (1) Healthcare System; (2) Culture and Religion; and (3) Family Relationships. Two additional weaving concepts appeared to act as a link between these three key concepts: (1) Authoritative Knowledge and (2) Communication of Information. Social and political factors were also considered as contextual factors within the model. A visual representation of this model was developed and presented. CONCLUSIONS: The model presented in this paper, along with future work to further test and refine it in other contexts, has the potential to impact on inequalities by facilitating future discussion on cultural issues, encouraging collaborative learning and knowledge production and providing a framework for future global midwifery practice, education and research. PATIENT OR PUBLIC CONTRIBUTION: At the outset of the underpinning research, a project involvement group was created to contribute to study design and conduct. This group consisted of the three authors, an Advocacy Officer at Race Equality First and an NHS Consultant Midwife. This group met regularly throughout the research process, and members were involved in discussions regarding ethical/cultural/social issues, recruitment methods, the creation of participant information materials, interpretation of data and the dissemination strategy. Ideas for the underpinning research were also discussed with members of the Pakistani community during community events and at meetings with staff from minority ethnic and migrant support charities (BAWSO, Race Equality First, The Mentor Ring). Local midwives contributed to study design through conversations during informal observations of antenatal appointments for asylum seekers and refugees.

Associations of alcohol use, mental health and socioeconomic status in England: Findings from a representative population survey.

BACKGROUND: Alcohol use and mental health problems often co-occur, however, little is known about how this varies by type of mental health problem and to what extent associations are explained by socioeconomic status (SES). Our study examined the prevalence and associations of non-drinking, hazardous use, and harmful/probable dependence in individuals who do and do not meet criteria for different mental health problems and whether associations remained after adjustment for SES. METHODS: A secondary analysis of an English dataset, 2014 Adult Psychiatric Morbidity Survey (N = 7,218), was conducted. The Alcohol Use Disorder Identification Test was used to categorise participants as non-drinking, low risk, hazardous use and harmful/probable dependence. Mental health problems were screened using a range of validated tools. Multinomial logistic regression analyses were used to address study aims. RESULTS: The prevalence of non-drinking, hazardous and harmful/probable dependence was higher among those meeting criteria for a mental health problem. After adjustment for SES, non-drinking was most common in those meeting criteria for probable psychotic disorder (MOR = 3.42, 95 %CI = 1.74-6.70), hazardous use in those meeting criteria for anti-social personality disorder (MOR = 2.66, 95 %CI = 1.69-4.20) and harmful/probable dependence in those meeting criteria for borderline personality disorder (MOR = 9.77, 95 % CI = 4.81-19.84). CONCLUSIONS: There were marked increases in the odds of reporting both non-drinking and harmful drinking among those meeting criteria for a mental health problem, particularly more severe problems. Our findings indicate that the relationship between alcohol and mental health is more complex and comorbid alcohol and mental health problems should be treated in parallel with access to both services.

Associations between interrelated dimensions of socio-economic status, higher risk drinking and mental health in South East London: A cross-sectional study.

AIM: To examine patterns of hazardous, harmful and dependent drinking across different socio-economic groups, and how this relationship may be explained by common mental disorder. METHODS AND FINDINGS: Between 2011-2013, 1,052 participants (age range 17-91, 53% female) were interviewed for Phase 2 of the South East London Community Health study. Latent class analysis was used to define six groups based on multiple indicators of socio-economic status in three domains. Alcohol use (low risk, hazardous, harmful/dependent) was measured using the Alcohol Use Disorders Identification Test and the presence of common mental disorder was measured using the revised Clinical Interview Schedule. Multinomial regression was used to explore associations with hazardous, harmful and dependent alcohol use, including after adjustment for common mental disorder. Harmful and dependent drinking was more common among people in Class 2 'economically inactive renters' (relative risk ratio (RRR) 3.05, 95% confidence interval (CI) 1.07-8.71), Class 3 'economically inactive homeowners' (RRR 4.11, 95% CI 1.19-14.20) and Class 6 'professional renters' (RRR 3.51, 95% CI 1.14-10.78) than in Class 1 'professional homeowners'. Prevalent common mental disorder explained some of the increased risk of harmful or dependent drinking in Class 2, but not Class 3 or 6. CONCLUSIONS: Across distinct socio-economic groups in a large inner-city sample, we found important differences in harmful and dependent drinking, only some of which were explained by common mental disorder. The increased risk of harmful or dependent drinking across classes which are very distinct from each other suggests differing underlying drivers of drinking across these groups. A nuanced understanding of alcohol use and problems is necessary to understand the inequalities in alcohol harms.

The midwife-woman relationship in a South Wales community: Experiences of midwives and migrant Pakistani women in early pregnancy.

BACKGROUND: In 2015, 27.5% of births in England and Wales were to mothers born outside of the UK. Compared to their White British peers, minority ethnic and migrant women are at a significantly higher risk of maternal and perinatal mortality, along with lower maternity care satisfaction. Existing literature highlights the importance of midwife-woman relationships in care satisfaction and pregnancy outcomes; however, little research has explored midwife-woman relationships for migrant and minority ethnic women in the UK. METHODS: A focused ethnography was conducted in South Wales, UK, including semi-structured interviews with 9 migrant Pakistani participants and 11 practising midwives, fieldwork in the local migrant Pakistani community and local maternity services, observations of antenatal appointments, and reviews of relevant media. Thematic data analysis was undertaken concurrently with data collection. FINDINGS: The midwife-woman relationship was important for participants' experiences of care. Numerous social and ecological factors influenced this relationship, including family relationships, culture and religion, differing health-care systems, authoritative knowledge and communication of information. Marked differences were seen between midwives and women in the perceived importance of these factors. CONCLUSIONS: Findings provide new theoretical insights into the complex factors contributing to the health-care expectations of pregnant migrant Pakistani women in the UK. These findings may be used to create meaningful dialogue between women and midwives, encourage women's involvement in decisions about their health care and facilitate future midwifery education and research. Conclusions are relevant to a broad international audience, as achieving better outcomes for migrant and ethnic minority communities is of global concern.

Challenges in the retrospective assessment of trauma: comparing a checklist approach to a single item trauma experience screening question.

BACKGROUND: Research on trauma and its impact on mental health typically relies on self-reports which can be influenced by recall bias and an individual's subjective interpretation of events. This study aims to compare responses on a checklist of life events with a trauma experience screening question, both of which assessed trauma experience retrospectively. METHODS: A community sample of adults were asked about life events from a checklist before asking them whether they ever had a trauma experience, i.e. "an event that either puts them or someone close to them at risk of serious harm or death". RESULTS: Less than half of the sample who reported at least one life event on the checklist that qualified as a trauma reported a trauma experience that they perceived put them or close others at risk of serious harm. Women responders, those reporting early life traumas, and a greater number of lifetime trauma events were more likely to report a trauma experience. Current symptoms of Common Mental Disorder did not account for differences in reporting of trauma experiences. CONCLUSIONS: Epidemiological approaches which require participants to make subjective judgement on the severity of the trauma experience will capture individual differences that we have shown are influenced by gender and previous trauma experience.

Exploring evidence for a prospective relationship between common mental disorder and meeting residential mobility preferences.

This study investigates evidence of a selective influence of mental health in meeting residential mobility preferences. Data from two waves of Understanding Society (the UK Household Longitudinal Study) were used to identify four preference-mobility groups ('desired stayers', 'entrapped', 'desired movers', 'displaced'). Associations between mental health (symptoms of common mental disorder, CMD) and preference-mobility groups were measured both before and after residential moves. Those identified with CMD at baseline were at greater risk of being both in the 'entrapped' and the 'desired mover' groups, relative to the 'desired stayer' group in the following year. The association between preference-mobility group and subsequent poorer mental health was found among both groups that failed to meet their mobility preferences ('entrapped' and 'displaced'). This study finds evidence for a selective influence of mental health - such that those with poorer mental health are less likely to achieve a desired residential move, and highlights the importance of considering a bidirectional relationship between residential mobility and mental health.

A cognitive-perceptual model of symptom perception in males and females: the roles of negative affect, selective attention, health anxiety and psychological job demands.

Kolk et al.'s model of symptom perception underlines the effects of trait negative affect, selective attention and external stressors. The current study tested this model in 263 males and 498 females from an occupational sample. Trait negative affect was associated with symptom reporting in females only, and selective attention and psychological job demands were associated with symptom reporting in both genders. Health anxiety was associated with symptom reporting in males only. Future studies might consider the inclusion of selective attention, which was more strongly associated with symptom reporting than negative affect. Psychological job demands appear to influence symptom reporting in both males and females.

Family social support, community "social capital" and adolescents' mental health and educational outcomes: a longitudinal study in England.

PURPOSE: To examine the associations between family social support, community "social capital" and mental health and educational outcomes. METHODS: The data come from the Longitudinal Study of Young People in England, a multi-stage stratified nationally representative random sample. Family social support (parental relationships, evening meal with family, parental surveillance) and community social capital (parental involvement at school, sociability, involvement in activities outside the home) were measured at baseline (age 13-14), using a variety of instruments. Mental health was measured at age 14-15 (GHQ-12). Educational achievement was measured at age 15-16 by achievement at the General Certificate of Secondary Education. RESULTS: After adjustments, good paternal (OR = 0.70, 95% CI 0.56-0.86) and maternal (OR = 0.65, 95% CI 0.53-0.81) relationships, high parental surveillance (OR = 0.81, 95% CI 0.69-0.94) and frequency of evening meal with family (6 or 7 times a week: OR = 0.77, 95% CI 0.61-0.96) were associated with lower odds of poor mental health. A good paternal relationship (OR = 1.27, 95% CI 1.06-1.51), high parental surveillance (OR = 1.37, 95% CI 1.20-1.58), high frequency of evening meal with family (OR = 1.64, 95% CI 1.33-2.03) high involvement in extra-curricular activities (OR = 2.57, 95% CI 2.11-3.13) and parental involvement at school (OR = 1.60, 95% CI 1.37-1.87) were associated with higher odds of reaching the educational benchmark. Participating in non-directed activities was associated with lower odds of reaching the benchmark (OR = 0.79, 95% CI 0.70-0.89). CONCLUSIONS: Building social capital in deprived communities may be one way in which both mental health and educational outcomes could be improved. In particular, there is a need to focus on the family as a provider of support.