The role of education and migration background in explaining differences in folic acid supplementation intake in pregnancy: results from a German birth cohort study.

OBJECTIVE: Official German recommendations advise women to start taking folic acid supplementation (FAS) before conception and continue during the first pregnancy trimester to lower the risk of birth defects. Women from lower socio-economic background and ethnic minorities tend to be less likely to take FAS in other European countries. As little is known about the determinants of FAS in Germany, we aimed to investigate the association between FAS and formal education and migration background, adjusting for demographic factors. DESIGN: We used data (2013-2016) on nutrition and socio-economic and migration background from the baseline questionnaire of the BaBi cohort study. We performed multivariate regressions and mediation analyses. SETTING: Bielefeld, Germany. PARTICIPANTS: Nine-hundred forty-seven women (pregnant or who had given birth in the past 2 months). RESULTS: 16.7% of the participants (158/947) did not use FAS. Migration-related variables (e.g. language, length of stay) were not associated with FAS in the adjusted models. FAS was lower in women with lower level of formal education and in unplanned pregnancies. Reasons given by women for not taking FAS were unplanned pregnancy and lack of knowledge of FAS. CONCLUSIONS: Health practitioners may be inclined to see migrant women as an inherently at-risk group for failed intake of FAS. However, it is primarily women who did not plan their pregnancy, and women of lower formal education level, who are at risk. Different public health strategies to counter low supplementation rates should be supported, those addressing the social determinants of health (i.e. education) and those more focused on family planning.

[Lessons learned: Challenges faced in the recruitment process for the cluster-randomized nursing home study HIOPP-3 iTBX]. / "Lessons learned" ­ Herausforderungen im Rekrutierungsprozess in der cluster-randomisierten Pflegeheimstudie "HIOPP-3 iTBX".

INTRODUCTION: The cluster-randomized multicenter HIOPP-3 iTBX study ('General Practitioners' Initiative to optimize Medication safety for Nursing Home Residents - using an interprofessional toolbox') aims to improve medication safety in nursing home residents through a complex interprofessional intervention focusing on neuroleptics and potentially inadequate medications. A stepwise recruitment process was used for all study participants (nursing homes, general practitioners, pharmacists, nursing home residents). The aim of this article is to describe the underlying recruitment strategy, the results of the recruitment and the measures undertaken to recruit the necessary number of participants. METHODS: The recruitment strategy and the response rates of nursing homes, general practitioners, pharmacists and nursing home residents are described. Measures to improve recruitment at the study sites and reasons for refusal to participate were documented. RESULTS: The response rate in nursing homes was 8.4 % (n=44). Of the pharmacists contacted by these nursing homes 70.3 % (n=52) participated, and 43.5 % (n=91) of all contacted general practitioners. Twenty-three (33.0 %) nursing homes had to be excluded from the study because no interprofessional team could be formed. Of all nursing home residents under the care of the participating general practitioners 862 (43,5%) persons and/or their caregivers gave consent to participate in the study. The recruitment for the study took 14 months. In the course of recruitment, recruitment strategies had to be adapted to local circumstances at the study sites. Reasons for non-participation varied between the different groups. DISCUSSION AND CONCLUSION: The main challenge in the HIOPP-3 iTBX study was to form interprofessional teams in each cluster. A stepwise, partly dependent recruitment process in a large group of potential participants presents organizational challenges that should be taken into account while planning the study. In order to reach the calculated sample size in the HIOPP-3 iTBX study, a pragmatic and flexible approach, adapted to local circumstances, was required. Further studies may benefit from the experiences made in the HIOPP-3 iTBX study.

Are Social Status and Migration Background Associated with Utilization of Non-medical Antenatal Care? Analyses from Two German Studies.

OBJECTIVE: Non-medical antenatal care (ANC) refers to a range of non-medical services available to women during pregnancy aiming at supporting women and prepare them for the birth and the postpartum period. In Germany, they include antenatal classes, breastfeeding classes and pregnancy-specific yoga or gymnastics courses. Studies suggest that various types of non-medical ANC carry benefits for both the women and their babies. Little is known about the uptake of non-medical ANC among different socioeconomic population subgroups, but one may expect lower utilization among socio-economically disadvantaged women. We analyzed factors contributing to the utilization of non-medical ANC in general and antenatal classes in particular. METHODS: Baseline data of the Bielefeld BaBi birth cohort (2013-2016) and the Berlin perinatal study (2011-2012) were analyzed. Comparing the two cohorts allowed to increase the socio-economic and migration background variance of the study population and to capture the effect of the local context on uptake of services. Multivariate logistic regression analyses were performed to study associations between the uptake of non-medical ANC and socio-economic and migration status. RESULTS: In Berlin and Bielefeld, being a first generation migrant and having lower levels of education were associated with lower non-medical ANC uptake. In Berlin, being a 2nd generation woman or having a low income was also associated with lower uptake. CONCLUSIONS FOR PRACTICE: Our study suggests that non-medical ANC remains in some part the prerogative of non-migrant, well-educated and economically privileged women. Since differences in non-medical ANC have the potential to create inequalities in terms of birth outcomes and maternal health during pregnancy and post-partum, more efforts are needed to promote the use of non-medical ANC by all population groups.

Multidisciplinary intervention to improve medication safety in nursing home residents: protocol of a cluster randomised controlled trial (HIOPP-3-iTBX study).

BACKGROUND: Medication safety is an important health issue for nursing home residents (NHR). They usually experience polypharmacy and often take potentially inappropriate medications (PIM) and antipsychotics. This, coupled with a frail health state, makes NHR particularly vulnerable to adverse drug events (ADE). The value of systematic medication reviews and interprofessional co-operation for improving medication quality in NHR has been recognized. Yet the evidence of a positive effect on NHR' health and wellbeing is inconclusive at this stage. This study investigates the effects of pharmacists' medication reviews linked with measures to strengthen interprofessional co-operation on NHR' medication quality, health status and health care use. METHODS: Pragmatic cluster randomised controlled trial in nursing homes in four regions of Germany. A total of 760 NHR will be recruited. Inclusion: NHR aged 65 years and over with an estimated life expectancy of at least six months. Intervention with four elements: i) introduction of a pharmacist's medication review combined with a communication pathway to the prescribing general practitioners (GPs) and nursing home staff, ii) facilitation of change in the interprofessional cooperation, iii) educational training and iv) a "toolbox" to facilitate implementation in daily practice. ANALYSIS: primary outcome - proportion of residents receiving PIM and ≥ 2 antipsychotics at six months follow-up. Secondary outcomes - cognitive function, falls, quality of life, medical emergency contacts, hospital admissions, and health care costs. DISCUSSION: The trial assesses the effects of a structured interprofessional medication management for NHR in Germany. It follows the participatory action research approach and closely involves the three professional groups (nursing staff, GPs, pharmacists) engaged in the medication management. A handbook based on the experiences of the trial in nursing homes will be produced for a rollout into routine practice in Germany. TRIAL REGISTRATION: Registered in the German register of clinical studies (DRKS, study ID DRKS00013588 , primary register) and in the WHO International Clinical Trials Registry Platform (secondary register), both on 25th January 2018.

[Strategies for Recruiting Women with Migration History Using the Example of The BaBi-Birth Cohort Study]. / Rekrutierungsstrategien für Migrantinnen in einer Geburtskohorte am Beispiel der BaBi-Studie.

BACKGROUND: Recruitment of participants from all population groups is a known challenge in social epidemiological research. A multitude of potentially useful strategies for the recruitment of ethnic minorities and certain migrant groups have been proposed. However, existing publications have not answered the question whether such strategies are applicable to a birth cohort study in Germany. The aim of the present study was to present recruitment strategies for migrants in a birth cohort using the example of the BaBi study. METHODS: As a preparatory step, focus group discussions were conducted with pregnant and postpartum women and structured interviews with midwives and gynecologists in order to assess suitability of study information materials, questionnaires and language preferences. The pilot study, conducted from October 2013 to October 2016, tested different recruitment strategies. The entire recruitment period was accompanied by continuous evaluation in order to assess and adapt the process to ensure successful recruitment of migrants. RESULTS: Of the 980 participants, 390 had a migration background (40%). Both active and passive recruitment strategies were explored in which Turkish language translations and multicultural personnel were used. Passive recruitment via gynecological practices and midwives required pregnant women to have high levels of motivation. Active recruitment in postnatal wards (where women were approached by study nurses after birth) increased the proportion of participants with a migration background from 22 to 49%. Early monitoring of our recruitment strategy thus enabled us to improve participation rates. CONCLUSION: For recruitment of women with a migration background, it is crucial to use both careful preparation in the form of qualitative measures (focus groups, structured interviews) and a pilot study. Extra resources should be planned from the beginning for diverse recruitment strategies and a higher personnel demand (e. g., for translations and back translations). Efforts for the inclusions of migrants in social epidemiological studies in Germany should be a routine process.

Early childhood health in Bielefeld, Germany (BaBi study): study protocol of a social-epidemiological birth cohort.

INTRODUCTION: The heterogeneity among the German population is increasing. Sociodemographic differentials (eg, in education and migrant status) have been associated with health disparities. Life course studies show that a considerable part of these disparities is determined by exposures during pregnancy and early childhood. The BaBi study was established in 2012 to investigate the production of health disparities from foetal life to childhood in the city of Bielefeld, Germany. METHODS AND ANALYSIS: Between 2013 and 2016, detailed information on socioeconomic characteristics, migration background, lifestyle factors, environmental factors, healthcare use, and health status of 995 newborns, including 24 twins, and their families was collected using standardised instruments. Data collection started during pregnancy or shortly after birth with a computer-assisted personal interview of the pregnant woman/mother. Follow-up data will be collected until 2018 by computer-assisted telephone interviews around the first, second and after the third birthday of the child and by linking routine healthcare data. Blood samples are collected from a small subsample of 50 mothers for a substudy about stress during pregnancy (BaBi-Stress study). ETHICS AND DISSEMINATION: The study was approved by the ethical committee of the Medical Faculty of Muenster University and the Data Protection Board of Bielefeld University. Results will be published in scientific journals. Data sets and questionnaires will be made accessible for researchers based on access proposals and data usage contracts.

Determinants of dietary patterns and diet quality during pregnancy: a systematic review with narrative synthesis.

OBJECTIVE: To identify determinants of diet in pregnancy, by detecting factors in our multiple-determinants life course framework that are associated with dietary patterns, quality or guideline adherence. DESIGN: A systematic review of observational studies, published in English or German, was conducted. Sociodemographic, lifestyle, environmental and pregnancy-related determinants were considered. Four electronic databases were searched in January 2015 and updated in April 2016 and a total of 4368 articles identified. Risk of bias was assessed using adapted Newcastle-Ottawa Scales. SETTING: High- and upper-middle-income countries. SUBJECTS: Pregnant or postpartum women reporting their dietary intake during pregnancy. RESULTS: Seventeen publications of twelve studies were included and compared narratively due to heterogeneity. Diet in pregnancy was patterned along a social gradient and aligned with other health behaviours before and during pregnancy. Few studies investigated the influence of the social and built environment and their findings were inconsistent. Except for parity, pregnancy determinants were rarely assessed even though pregnancy is a physiologically and psychologically unique period. Various less well-researched factors such as the role of ethnicity, pregnancy intendedness, pregnancy ailments and macro-level environment were identified that need to be studied in more detail. CONCLUSIONS: The framework was supported by the literature identified, but more research of sound methodology is needed in order to conclusively disentangle the interplay of the different determinants. Practitioners should be aware that pregnant women who are young, have a low education or do not follow general health advice appear to be at higher risk of inadequate dietary intake.