Understanding Vaccine Hesitancy in Vietnamese Fish Farmers.

(1) Background: Antibiotic (AB) usage in food animals is a significant contributor to antimicrobial resistance (AMR). Vaccination can reduce the over-use of AB treatment. Little is known about farmers' attitudes and beliefs about AB and vaccine usage in developing countries, especially in aquaculture. (2) Methods: We used the necessity/concerns framework to guide our research, where vaccine hesitancy is viewed as a function of the perceived necessity versus the perceived concerns about treatment. We measured disease and treatment perceptions in 400 Vietnamese farmers of Pangasius catfish, specifically regarding (a) chemical treatment of water, (b) antibiotic usage, and (c) vaccination of fish. (3) Results: Although farmers' concerns about AB usage outweighed necessity beliefs, 86.5% reported having used ABs on their farm. Knowledge and attitudes towards vaccination were positive, with views of its necessity outweighing concerns. However, if available, only 67.6% said they would definitely use vaccines in the future. Farmers were more likely to use vaccines if they reported having fewer problems with fish disease, felt that any concerns about vaccines were outweighed by their perceived benefits, had less mistrust of vaccination, and had fewer concerns about commercial profiteering. (4) Conclusion: Interventions that highlight concerns about continued antibiotic use, reduce concerns, and mistrust and increase the perceived necessity of vaccines combined with greater availability of vaccines may be the most effective way of overcoming vaccine hesitancy and increase appropriate use of vaccines by Vietnamese fish farmers.

Healthcare costs and quality of life associated with the long-term outcome of anxiety disorders.

BACKGROUND AND OBJECTIVES: Anxiety disorders are costly; however, the relationship with treatment outcome has been neglected. This study examined healthcare costs and quality of life by diagnostic status (treatment outcome and the presence of comorbidity) at long-term follow-up. DESIGN AND METHODS: This cohort study comprized 317 patients entering treatment for at least one Axis I anxiety disorder. Four groups were identified based on diagnostic status at follow-up (recovered or disordered) and self-reported degree of interim treatment (high or low). A further grouping was established based on co-morbid diagnostic status at follow-up. Healthcare costs were calculated for the two years prior to treatment entry and the two years prior to follow-up using a repeated measures analysis of variance (ANOVA). Group differences in quality of life were assessed using a univariate ANOVA. RESULTS: Over two thirds of the sustained recovery group was treatment-free at follow-up whilst the remainder required adjuvant drug therapy. Over half of those remaining disordered at follow-up incurred substantial healthcare costs and presented with treatment-resistant symptoms and severely impaired quality of life. CONCLUSIONS: Despite substantial investment some patients were associated with a clinical anxiety diagnosis at follow-up, and multimorbidity was associated with considerably higher costs.

The impact of hypothetical PErsonalised Risk Information on informed choice and intention to undergo Colorectal Cancer screening colonoscopy in Scotland (PERICCS)-a randomised controlled trial.

BACKGROUND: There is currently no existing evidence on the effects of personalised risk information on uptake of colonoscopy following first line screening for colorectal cancer. This study aimed to measure the impact of providing risk information based on faecal haemoglobin concentration to allow a fully informed choice around whether or not to undergo colonoscopy. METHODS: Two thousand seven hundred sixty-seven participants from the Scottish Bowel Screening Programme (SBoSP) database, who had not recently been invited for screening, were randomised to receive one of three types of hypothetical risk information materials: (1) numerical risk information (risk categories of one in 40, one in 1600 and one in 3500), (2) categorical risk information (highest, moderate and lowest risk), or (3) positive screening result letter (control group). The primary outcome was the impact of the risk materials on intention to undergo colonoscopy, to allow comparison with the current colonoscopy uptake of 77% for those with a positive screening result in the SBoSP. Secondary outcomes were knowledge, attitudes and emotional responses to the materials. RESULTS: Four hundred thirty-four (15.7%) agreed to participate with 100 from the numerical risk group (69.0%), 104 from the categorical risk group (72.2%) and 104 from the control group (71.7%) returning completed materials. Intention to undergo colonoscopy was highest in the highest risk groups for the numerical and categorical study arms (96.8% and 95.3%, respectively), but even in the lowest risk groups was > 50% (58.1% and 60.7%, respectively). Adequate knowledge of colorectal screening and the risks and benefits of colonoscopy was found in ≥ 98% of participants in all three arms. All participants reported that they found the information easy-to-understand. 19.1%, 24.0% and 29.6% of those in the numerical, categorical and control group, respectively, reported that they found the information distressing (p > 0.05). CONCLUSIONS: Applying the risk categories to existing SBoSP data shows that if all participants were offered an informed choice to have colonoscopy, over two thirds of participants would intend to have the test. Equating to an increase in the number of screening colonoscopies from approx. 14,000 to 400,000 per annum, this would place an unmanageable demand on colonoscopy services, with a very small proportion of cancers and pre-cancers detected. However, the response to the materials were very positive, suggesting that providing risk information to those in lowest and moderate risk groups along with advice that colonoscopy is not currently recommended may be an option. Future research would be required to examine actual uptake. TRIAL REGISTRATION: Date applied 1 December 2017 ISRCTN number 14254582 .

Antimicrobial Resistance in Humans and Animals: Rapid Review of Psychological and Behavioral Determinants.

A rapid review of current evidence examining psychological issues regarding the use of antibiotics and antimicrobials and resistance to these in both human and animal populations was conducted. Specific areas of interest were studies examining psychological determinants of AMR and interventions which attempt to change behavior with regard to AMR in the general population; animals; and fish, in particular. Although there is some evidence of the effectiveness of behavior change in general human populations, there is limited evidence in farmed animals, with a particular dearth in fish farming. We conclude there is an urgent need for more psychological research to identify major barriers and facilitators to change and evaluate the effectiveness of theory-based interventions aimed at reducing AM use in food production animals, including the promotion of alternatives to AMs, such as vaccination.

The impact of personalised risk information compared to a positive/negative result on informed choice and intention to undergo colonoscopy following colorectal Cancer screening in Scotland (PERICCS) - a randomised controlled trial: study protocol.

BACKGROUND: In Scotland a new, easier to complete bowel screening test, the Faecal Immunochemical Test (FIT), has been introduced. This test gives more accurate information about an individual's risk of having colorectal cancer (CRC), based on their age and gender, and could lead to fewer missed cancers compared to the current screening test. However, there is no evidence of the effect on colonoscopy uptake of providing individuals with personalised risk information following a positive FIT test. The objectives of the study are: 1) To develop novel methods of presenting personalised risk information in an easy-to-understand format using infographics with involvement of members of the public 2) To assess the impact of different presentations of risk information on informed choice and intention to take up an offer of colonoscopy after FIT 3) To assess participants' responses to receiving personal risk information (knowledge, attitudes to screening/risk, emotional responses including anxiety). METHODS: Adults (age range 50-74) registered on the Scottish Bowel Screening database will be invited by letter to take part. Consenting participants will be randomised to one of three groups to receive hypothetical information about their risk of cancer, based on age, gender and faecal haemoglobin concentration: 1) personalised risk information in numeric form (e.g. 1 in 100) with use of infographics, 2) personalised information described as 'highest', 'moderate' or 'lowest' risk with use of infographics, and 3) as a 'positive' test result, as is current practice. Groups will be compared on informed choice, intention to have a colonoscopy, and satisfaction with their decision. Follow-up semi-structured qualitative interviews will be conducted, by telephone, with a small number of consenting participants (n = 10 per group) to explore the acceptability/readability and any potential negative impact of the risk information, participants' understanding of risk factors, attitudes to the different scenarios, and reasons for reported intentions. DISCUSSION: Proving personalised risk information and allowing patient choice could lead to improved detection of CRC and increase patient satisfaction by facilitating informed choice over when/whether to undergo further invasive screening. However, we need to determine whether/how informed choice can be achieved and assess the potential impact on the colonoscopy service. TRIAL REGISTRATION: The trial is registered on www.isrctn.com on 08/12/2017. Registration no: ISRCTN14254582.

Attitudes towards the Faecal Occult Blood Test (FOBT) versus the Faecal Immunochemical Test (FIT) for colorectal cancer screening: perceived ease of completion and disgust.

BACKGROUND: Colorectal cancer screening is key to early detection and thus to early treatment, but uptake is often sub-optimal, particularly amongst lower income groups. It is proposed that the imminent introduction of the single-sample Faecal Immunochemical Test (FIT) in Scotland may lead to increased uptake as compared to the current Faecal Occult Blood Test (FOBT), but underlying reasons are yet to be determined. The aim was to evaluate attitudes and intentions towards completing the FIT compared to the current FOBT for colorectal cancer screening. METHODS: A convenience sample of 200 adults (mean age 56.5, range 40-89; 59% female) living in Scotland rated both the FOBT and the FIT with regard to ease of completion, perceived disgust and intention to complete and return (all measured on Likert-type 1-7 scale). Participants were randomised to be presented (via a face-to-face contact) with either the FIT or FOBT first. RESULTS: Participants reported higher intention to complete and return the FIT versus the FOBT (mean difference 0.62, 95% CI (0.44, 0.79)). Overall, 85.0% (n = 170) of participants agreed or strongly agreed that they would intend to complete and return the FIT compared to 65.5% (n = 131) for the FOBT (χ(2) = 20.4, p < .001). The FIT was also perceived to be easier to complete (mean difference 0.85, 95% CI (0.70, 1.01) and much less disgusting (mean difference 1.11, 95% CI (0.94, 1.27)). Lower perceived disgust, higher socio-economic status and previous participation in any cancer screening were significant predictors of intention to complete the FOBT, whilst only higher perceived ease of completion predicted intention to complete the FIT. CONCLUSIONS: People reported higher intentions to complete and return a FIT than a FOBT test for colorectal cancer screening, largely due to a perception that it is easier and less disgusting to complete. The findings suggest that the introduction of the FIT as standard in the UK could result in a notable increase in screening uptake.

A pilot randomized controlled trial of telephone intervention to increase Breast Cancer Screening uptake in socially deprived areas in Scotland (TELBRECS).

OBJECTIVES: To determine whether a brief telephone support intervention could increase breast cancer screening uptake among lower socio-demographic women in Scotland, via eliciting and addressing barriers to screening attendance. METHODS: In a pilot randomized controlled trial, participants receiving a reminder letter for a missed screening appointment (February-June 2014) were randomized to four arms: No telephone call (control), Simple telephone reminder (TEL), Telephone support (TEL-SUPP), or Telephone support plus anticipated regret (TEL-SUPP-AR). Primary outcomes were making an appointment and attending breast screening. RESULTS: Of 856 women randomized and analysed on intention-to-treat basis, compared with controls, more women in the telephone intervention groups made an appointment (control: 8.8%, TEL: 20.3%, TEL-SUPP: 14.1%; TEL-SUPP-AR: 16.8%, χ(2)(3) = 12.0, p = .007) and attended breast screening (control: 6.9%, TEL: 16.5%, TEL-SUPP: 11.3%; TEL-SUPP-AR: 13.1%, χ(2)(3) = 9.8, p = .020). Of 559 women randomized to the three telephone groups, 404 were successfully contacted and 247 participated in the intervention. Intervention participants (ie. per protocol analysis) were more likely to make (17% versus 10%, χ(2)(1) = 7.0, p = .008) and attend (13% versus 7%, χ(2)(1) = 5.5, p = .019) an appointment than non-participants, but there were no differences in attendance between the three telephone groups. CONCLUSIONS: A simple telephone reminder doubled attendance at breast screening in women from lower socio-demographic areas who had not attended their initial appointment, compared with a reminder letter only (odds ratio 2.12, 95% CI (1.2, 3.8)). However, contacting women proved problematic and there was no additional effect of telephone support or anticipated regret.

Anticipated regret to increase uptake of colorectal cancer screening (ARTICS): A randomised controlled trial.

Screening is important for early detection of colorectal cancer. Our aim was to determine whether a simple anticipated regret (AR) intervention could increase uptake of colorectal cancer screening. A randomised controlled trial of a simple, questionnaire-based AR intervention, delivered alongside existing pre-notification letters, was conducted. A total of 60,000 adults aged 50-74 years from the Scottish National Screening programme were randomised into the following groups: (1) no questionnaire (control), (2) Health Locus of Control questionnaire (HLOC) or (3) HLOC plus AR questionnaire. The primary outcome was return of the guaiac faecal occult blood test (FOBT). The secondary outcomes included intention to return test kit and perceived disgust (ICK). A total of 59,366 people were analysed as allocated (intention-to-treat (ITT)); no overall differences were seen between the treatment groups on FOBT uptake (control: 57.3%, HLOC: 56.9%, AR: 57.4%). In total, 13,645 (34.2%) individuals returned the questionnaires. Analysis of the secondary questionnaire measures showed that AR indirectly affected FOBT uptake via intention, whilst ICK directly affected FOBT uptake over and above intention. The effect of AR on FOBT uptake was also moderated by intention strength: for less-than-strong intenders only, uptake was 4.2% higher in the AR (84.6%) versus the HLOC group (80.4%) (95% CI for difference (2.0, 6.5)). The findings show that psychological concepts including AR and perceived disgust (ICK) are important factors in determining FOBT uptake. However, the AR intervention had no simple effect in the ITT analysis. It can be concluded that, in those with low intentions, exposure to AR may be required to increase FOBT uptake. The current controlled trials are presented at the website www.controlled-trials.com (number: ISRCTN74986452).

A pilot telephone intervention to increase uptake of breast cancer screening in socially deprived areas in Scotland (TELBRECS): study protocol for a randomised controlled trial.

BACKGROUND: Breast cancer accounts for almost 30% of all cancers and is the second leading cause of cancer deaths in women in Scotland. Screening is key to early detection. The Scottish Breast Screening Programme is a nationwide, free at point of delivery screening service, to which all women aged between 50 and 70 years are invited to attend every 3 years. Currently over three-quarters of invited women regularly attend screening. However, women from more deprived areas are much less likely to attend: for example in the 3 years from 2010-2012 only 63% of women in the most deprived area attended the East of Scotland Breast Screening programme versus 81% in the least deprived. Research has suggested that reminders (telephone or letter) and brief, personalised interventions addressing barriers to attendance may be helpful in increasing uptake in low-income women. METHODS/DESIGN: We will employ a brief telephone reminder and support intervention, whose purpose is to elicit and address any mistaken beliefs women have about breast screening, with the aim that the perceived benefits of screening come to outweigh any perceived barriers for individuals. We will test whether this intervention, plus a simple anticipated regret manipulation, will lead to an increase in the uptake of breast cancer screening amongst low-income women who have failed to attend a first appointment, in a randomised controlled trial with 600 women. Participants will be randomly allocated to one of four treatment arms i.e. 1) Letter reminder (i.e. Treatment as usual: CONTROL); 2) Telephone reminder (TEL), 3) Telephone reminder plus telephone support (TEL-SUPP) and 4) Telephone reminder plus support plus AR (TEL-SUPP-AR). The primary outcome will be attendance at breast screening within 3 months of the reminder letter. DISCUSSION: If this simple telephone support intervention (with or without AR intervention) leads to a significant increase in breast screening attendance, this would represent a rare example of a theoretically-driven, relatively simple psychological intervention that could result in earlier detection of breast cancer amongst an under-served group of lower socio-economic women. TRIAL REGISTRATION: Current Controlled trials: ISRCTN06039270. Registered 16th January 2014.

Improving medication adherence in stroke survivors: mediators and moderators of treatment effects.

OBJECTIVE: The purpose of the current study was to test theory-based predictions of mediators and moderators of treatment effects of a pilot randomized controlled trial, which aimed to increase adherence to preventive medication in stroke survivors via addressing both automatic (i.e., habitual responses) and reflective (i.e., beliefs and value systems) aspects of medication-taking behavior. METHOD: Sixty-two stroke survivors were randomly allocated to either an intervention or control group. Intervention participants received a brief 2-session intervention aimed at increasing adherence via (a) helping patients establish better medication-taking routines using implementation intentions plans (automatic), and (b) eliciting and modifying any mistaken patient beliefs regarding medication and/or stroke (reflective). The control group received similar levels of non-medication-related contact. Primary outcome was adherence to antihypertensive medicine measured objectively over 3 months using an electronic pill bottle. Secondary outcome measures included self-reported adherence (including forgetting) and beliefs about medication. RESULTS: Intervention participants had 10% greater adherence on doses taken on schedule (intervention, 97%; control, 87%; 95% CI [0.2, 16.2], p = .048), as well as significantly greater increases in self-reported adherence and reductions in concerns about medication. Treatment effects were mediated by reductions in both forgetting and concerns about medication, and moderated by the presence of preexisting medication-taking routines. CONCLUSIONS: Addressing both automatic and reflective aspects of behavior via helping stroke survivors develop planned regular routines for medication-taking, and addressing any concerns or misconceptions about their medication, can improve adherence and thus potentially patient outcomes.

"My doctor has changed my pills without telling me": impact of generic medication switches in stroke survivors.

Generic (i.e. non-branded medicine) and therapeutic (i.e. a less expensive drug from the same class) substitution of medication provides considerable financial savings, but may negatively impact on patients. We report secondary qualitative/quantitative analysis of stroke survivors from a pilot randomised controlled brief intervention to increase adherence to medication. Patients' experiences of medication changes were examined in conjunction with electronically-recorded medication adherence. Twenty-eight patients reported frequent medication changes (e.g. size/shape/colour/packaging) and two-thirds of these reported negative effects, resulting in, at least, confusion and, at worst, mistakes in medication-taking. Patients reporting a direct effect on their medication-taking (n = 6) demonstrated poorer objectively-measured adherence (i.e. % doses taken on schedule) than those reporting confusion [mean difference = 19.9, 95% CI (2.0, 37.8)] or no problems [mean difference = 20.6, 95% CI (1.6, 40.0)]. Changes to medication resulting from switching between generic brands can be associated with notable problems, including poorer medication adherence, for a significant minority.

Anticipated regret to increase uptake of colorectal cancer screening in Scotland (ARTICS): study protocol for a randomised controlled trial.

BACKGROUND: Colorectal cancer is the second leading cause of cancer deaths in the UK. Screening is key to early detection. The Scottish programme of colorectal cancer screening is running successfully, and involves all adults aged between 50 and 74 years being invited to post back a faecal sample for testing every 2 years. However, screening uptake is sub-optimal: for example rates for the period November 2009 to October 2011 ranged from just 39% for males living in the most deprived areas to 67% for least deprived females. Recent research has shown that asking people to consider the emotional consequences of not participating in screening (anticipated regret) can lead to a significant increase in screening uptake. METHODS/DESIGN: We will test a simple anticipated regret manipulation, in a large randomised controlled trial with 60,000 members of the general public. They will be randomly allocated to one of 3 arms, no questionnaire, control questionnaire or anticipated regret questionnaire. The primary outcome will be screening test kit return. Results will also be examined by demographic variables (age, gender, deprivation) as these are currently related to screening kit return. DISCUSSION: If this anticipated regret intervention leads to a significant increase in colorectal cancer screening kit returns, this would represent a rare example of a theoretically-driven, simple intervention that could result in earlier detection of colorectal cancer and many more lives saved. TRIAL REGISTRATION: Current Controlled trials: ISRCTN74986452.

Improving adherence to medication in stroke survivors: a pilot randomised controlled trial.

BACKGROUND: Adherence to preventive medication is often poor, and current interventions have had limited success. PURPOSE: This study was conducted to pilot a randomised controlled trial aimed at increasing adherence to preventive medication in stroke survivors using a brief, personalised intervention. METHODS: Sixty-two stroke survivors were randomly allocated to either a two-session intervention aimed at increasing adherence via (a) introducing a plan linked to environmental cues (implementation intentions) to help establish a better medication-taking routine (habit) and (b) eliciting and modifying any mistaken patient beliefs regarding medication/stroke or a control group. Primary outcome was adherence to antihypertensive medication measured objectively over 3 months using an electronic pill bottle. RESULTS: Fifty-eight people used the pill bottle and were analysed as allocated; 54 completed treatment. The intervention resulted in 10 % more doses taken on schedule (intervention, 97 %; control, 87 %; 95 % CI for difference (0.2, 16.2); p = 0.048). CONCLUSIONS: A simple, brief intervention increased medication adherence in stroke survivors, over and above any effect of increased patient contact or mere measurement.

Long-term outcome of eight clinical trials of CBT for anxiety disorders: symptom profile of sustained recovery and treatment-resistant groups.

BACKGROUND: Few clinical trials of cognitive behaviour therapy (CBT) for anxiety disorders have conducted follow-up beyond one year post-treatment. This paper summarises the long-term outcome of eight clinical trials of CBT for anxiety disorders in terms of diagnostic status, healthcare usage and symptom severity and compares the symptom profile of participants with the best and worst outcomes relative to chronic depression and the normal population. METHODS: Follow-up at 2-14years with 396 patients (51% of those available to contact) employed structured diagnostic interview, assessment of healthcare usage and self-report measures of symptom severity. This paper concerns 336 participants who had either no disorder or at least one anxiety disorder and information on healthcare usage over the follow-up period. RESULTS: Only 38% recovered with little or no treatment over the follow-up period while 30% had a very poor outcome despite extensive treatment for anxiety over many years. The symptom profile of this 'treatment-resistant' group was comparable to 76 patients with chronic depression and significantly worse than normative data for psychiatric outpatients. Chronic anxiety disorder with co-morbid depression has a more severe symptom profile than chronic anxiety disorder alone. LIMITATIONS: The follow-up sample, although broadly representative, may have a bias towards a more favourable picture of overall outcome. CONCLUSIONS: The long-term outcome of anxiety disorders, irrespective of diagnosis or active treatment, is diverse but with a tendency towards chronicity. Distinctions between acute and chronic presentations of common mental disorders are more important than distinctions between chronic anxiety and chronic depression.

Stories of weight management: factors associated with successful and unsuccessful weight maintenance.

OBJECTIVE: Although behavioural interventions are successful in achieving short-term weight loss, most individuals regain most or all of their weight within a few years. Our aim was to investigate factors that can help in long-term weight maintenance. DESIGN: Qualitative interviews were conducted in order to elicit experiences, successes, and difficulties associated with weight control over the lifespan. METHODS: Participants were 20 adult volunteers (aged 30-67) including lifelong weight maintainers, active weight maintainers who have maintained weight loss, and weight gainers. Thematic analysis was used to highlight differences between weight groups. RESULTS: Successful weight maintainers adopt a staged approach to weight management, including monitoring weight fluctuations and having a clear alarm signal for weight gain that triggers immediate action. They have several behavioural strategies for weight control, comprising relatively small adjustments to diet and/or exercise behaviour and also have clear strategies for coping with lifestyle interruptions. In contrast, unsuccessful weight maintainers display negative cognitive factors, including erratic or inconsistent weight vigilance, failure to respond to warning signs of weight gain, and failure to restrict weight unless in a positive mindset. Further, their coping strategies for weight gain or failed actions are poor. CONCLUSIONS: The results suggest that successful weight maintainers, irrespective of current weight band, adopt a staged behavioural approach to weight management that allows them to maintain a fairly stable weight. Encouraging the use of such strategies in those who typically regain weight after dieting may aid them in maintaining weight loss.

Adherence to medication in stroke survivors: a qualitative comparison of low and high adherers.

OBJECTIVES: The aim of this study was to investigate factors that may explain variance in adherence to medication in stroke patients. Design. A qualitative comparison of high and low adherers to medication. METHODS: Thirteen participants, selected from a sample of 180 stroke survivors because they self-reported the lowest adherence to medication regimes, were matched with 13 reporting maximal adherence. All took part in semi-structured qualitative interviews. RESULTS: Thematic analysis revealed that those with poor adherence to medication reported both intentional and non-intentional non-adherence. Two main themes emerged: the importance of stability of a medication routine and beliefs about medication and treatment. High adherers reported remembering to take their medication and seeking support from both family and health professionals. They also had a realistic understanding of the consequences of non-adherence, and believed their medicine did them more good than harm. Low adherers reported forgetting their medication, sometimes intentionally not taking their medication and receiving poor support from medical staff. They disliked taking their medication, had limited knowledge about the medication rationale or intentions, and often disputed its benefits. CONCLUSIONS: Our findings suggest that appropriate medication and illness beliefs coupled with a stable medication routine are helpful in achieving optimal medication adherence in stroke patients. Interventions designed to target both intentional and non-intentional adherence may help maximize medication adherence in stroke patients.

A health assessment tool for multiple risk factors for obesity: age and sex differences in the prediction of body mass index.

The aim was to establish the relative importance of multiple dietary, activity and other risk factors in determining BMI. A cross-sectional survey was conducted with 322 adults (71 % female; aged 18-79 years; BMI 16.5-40.9 kg/m2) using a previously developed, psychometrically tested, seventy-three-item questionnaire covering a wide range of obesity risk factors (consisting of five dietary, five activity and seven other risk factor subscales). Outcome was self-reported weight and height for BMI, cross-validated with items on clothes size and perceived need to lose weight. Stepwise regression analysis predicted 25-55 % of the variance in BMI with physical activity participation, current and past dieting behaviour, amount eaten, and age being the most important predictors. The association of lower BMI and younger age appeared to be due to higher activity levels, as younger participants reported much less healthy eating behaviour than the older age group. Amount eaten and physical activity participation were stronger predictors of BMI than other factors including healthy eating and use of mechanised transport. Results showed that the relationship between various risk factors and obesity may differ by both sex and age group, suggesting that different interventions may need to be targeted at different groups. The higher-risk eating behaviour observed in younger participants is of concern and needs to be addressed, if the current trend of rising obesity levels is to be halted.

Supporting breastfeeding mothers: qualitative synthesis.

AIM: This paper is a report of a synthesis of mothers' and healthcare professionals' experiences and perceptions of breastfeeding support. BACKGROUND: Despite increasing knowledge, breastfeeding rates remain relatively static and mothers continue to report dissatisfaction with their experiences of breastfeeding. Greater understanding of breastfeeding may be achieved through rigorous qualitative research, and there has been a recent increase in such studies. DATA SOURCES: Electronic databases and citation lists of published papers were searched for articles listed between 1990 and 2005 and updated in May 2007. Studies were included if they used qualitative methods, were published in English, explored an aspect of breastfeeding and were based in a westernized country. REVIEW METHODS: Papers were included if they reported studies using qualitative methods to explore breastfeeding and were published in English and based in a westernized country. Each study was reviewed and assessed independently, key themes extracted and grouped, and secondary thematic analysis used to explore key concepts. RESULTS: From the 1990-2005 search, five themes emerged in health service support of breastfeeding: the mother-health professional relationship, skilled help, pressures of time, medicalization of breastfeeding and the ward as a public place. Social support had two themes: compatible and incompatible support. One additional theme emerged from the update to 2007: health professional relationships. CONCLUSION: Mothers tended to rate social support as more important than health service support. Health service support was described unfavourably with emphasis on time pressures, lack of availability of healthcare professionals or guidance, promotion of unhelpful practices and conflicting advice. Changes are required within the health services to address the needs of both mothers and staff.

A health assessment tool for multiple risk factors for obesity: psychometric testing and age differences in UK adults.

BACKGROUND: Although many individual health behaviours (e.g. diet/activity) have been implicated in the current rise in obesity levels, their confounding or cumulative effects have yet to be established. This study psychometrically tested a previously piloted comprehensive measure of obesity risk factors, designed to assess their relative importance at individual and population levels. MATERIAL AND METHODS: A user-friendly, self-report questionnaire, completed by 359 adult volunteers (71% female, age range 18-81 years), was subjected to exploratory factor analysis and related to body mass index (BMI) and age. RESULTS: The final solution had 74 items and showed a clear factor structure, with 5 dietary and 5 activity factors, plus 8 unrelated factors covering dieting behaviour, alcohol consumption, sleep, and varied developmental influences. Younger respondents generally reported unhealthier behaviours. Once age was controlled for, less healthy eating, more emotional eating, higher amounts eaten, less physical activity, more use of mechanised transport, and more/less successful dieting behaviour were all strongly related to higher BMI, with lesser associations for more TV watching and less parental encouragement to be active. CONCLUSION: This easy-touse self-report measure of multiple risk factors showed good psychometric properties and has merit in determining the contribution of varied factors in the tendency to overweight and obesity. The finding that younger adults generally reported less healthy dietary and activity behaviour indicates a pressing need for early intervention.

A systematic review of measures assessing mothers' knowledge, attitudes, confidence and satisfaction towards breastfeeding.

In order to support breastfeeding interventions, there is a need for objective, reliable, valid and sensitive measures of factors related to breastfeeding. Publications on the development and testing of tools measuring mothers' knowledge, attitudes, confidence or self-efficiency and/or satisfaction towards breastfeeding were systematically reviewed. Twenty-two papers evaluating 13 self-report measures matched our selection criteria, and were critically appraised by two independent reviewers. All scales were tested with pregnant women or breastfeeding mothers. The 13 measures varied markedly in ease of completion and cultural appropriateness and none reached our highest level of evidence grading. Four of the measures had sufficient evidence to support their use, including the Breastfeeding Attrition Prediction Tool, the Modified Breastfeeding Evaluation Scale, the Breastfeeding Self-Efficiency Scale and the Iowa Infant Feeding Attitude Scale. There has been a tendency to develop new measures rather than evaluate the strengths and weaknesses of existing measures, particularly in different populations.