David H. Stone

Design a questionnaire.

The design of questionnaires is a craft which has been badly neglected by the medical profession. A questionnaire should be appropriate, intelligible, unambiguous, unbiased, capable of coping with all possible responses, satisfactorily coded, piloted, and ethical. The key steps in designing a questionnaire are to: decide what data you need, select items for inclusion, design the individual questions, compose the wording, design the layout and presentation, think about coding, prepare the first draft and pretest, pilot, and evaluate the form, and perform the survey. Despite the apparently complicated nature of the task, theoretical knowledge is no substitute for practical experience.

Randomised controlled trial of home based motivational interviewing by midwives to help pregnant smokers quit or cut down

Abstract Objective To determine whether motivational interviewing—a behavioural therapy for addictions—provided at home by specially trained midwives helps pregnant smokers to quit. Design Randomised controlled non-blinded trial analysed by intention to treat. Setting Clinics attached to two maternity hospitals in Glasgow. Participants 762/1684 pregnant women who were regular smokers at antenatal booking: 351 in intervention group and 411 in control group. Interventions All women received standard health promotion information. Women in the intervention group were offered motivational interviewing at home. All interviews were recorded. Main outcome measures Self reported smoking cessation verified by plasma or salivary cotinine concentration. Results 17/351 (4.8%) women in the intervention group stopped smoking (according to self report and serum cotinine concentration < 13.7 ng/ml) compared with 19/411(4.6%) in the control group. Fifteen (4.2%) women in the intervention group cut down (self report and cotinine concentration less than half that at booking) compared with 26 (6.3%) in the control group. Fewer women in the intervention group reported smoking more (18 (5.1%) v 44 (10.7%); relative risk 0.48, 95% confidence interval 0.28 to 0.81). Birth weight did not differ significantly (mean 3078 g v 3048 g). Conclusion Good quality motivational interviewing did not significantly increase smoking cessation among pregnant women.

Independent predictors of breastfeeding intention in a disadvantaged population of pregnant women

BackgroundBreastfeeding rates in Scotland are very low, particularly in the more disadvantaged areas. Despite a number of interventions to promote breastfeeding very few women actually intend to breastfeed their baby. The aim of this study was to identify personal and social factors independently associated with intention to breastfeed.MethodsNine hundred and ninety seven women from two socio-economically disadvantaged housing estates located on the outskirts of Glasgow participated in a study that aimed to increase the prevalence of breastfeeding. Self-administered questionnaires completed by each participant collected information in early pregnancy, prior to exposure to the study intervention, on feeding intention, previous feeding experience and socio-demographic data.ResultsFive factors were independently predictive of breastfeeding intention. These were previous breastfeeding experience, living with a partner, smoking, parity and maternal age. After adjusting for these five factors, neither deprivation nor receipt of milk tokens provided useful additional predictive information.ConclusionIn this population of socially disadvantaged pregnant women we identified five variables that were independently predictive of breastfeeding intention. These variables could be useful in identifying women at greatest risk of choosing not to breastfeed. Appropriate promotional efforts could then be designed to give due consideration to individual circumstances.

Unintentional injury mortality in the European Union: how many more lives could be saved?

Aims: The wide variation of unintentional (accidental) injury mortality rates in the European Union (EU) member states suggests that there is high potential for prevention. This paper attempts to quantify the potential for saving lives in this part of the world if all 25 member states were to learn from the experience of countries with advanced injury prevention records. Methods: Unintentional injury mortality data (latest three available years), including denominator population estimates, were obtained from the World Health Organization (WHO) mortality database for all 22 EU countries with a population of more than one million. Annual average age-adjusted injury mortality rates were used to derive the potential for saving of lives under two scenarios: (a) if all EU member states matched the country with the lowest unintentional rate for all causes of injury combined; (b) if the benchmark was alternatively the country with the lowest unintentional injury cause-specific rate. Separate calculations were performed for children (0—14), adults (15—64), and the elderly (65 and over). Results: Under the first scenario, over 73,000 lives could have been saved in the EU 25 in a single year, notably nearly half (47.4%) fewer unintentional injury deaths could be observed in children, over half in adult (54%), and two-fifths (38%) in the elderly. Under the second, more optimistic, scenario 59% of childhood and adult and 75% of unintentional injury deaths among the elderly would have been avoided. Conclusions: A substantial proportion of lives lost due to unintentional injury might be saved if all countries were to achieve the lowest unintentional injury mortality rates in the EU. The above calculations are based on a simple theoretical model but there is increasing evidence on the array of existing effective preventive interventions and improved trauma care calls for public health action in each member state that could in practice halt, to the extent possible, the unintentional injury epidemic.

Injury surveillance in an accident and emergency department : a year in the life of CHIRPP

BACKGROUND The design of childhood injury prevention programmes is hindered by a dearth of valid and reliable information on injury frequency, cause, and outcome. A number of local injury surveillance systems have been developed to address this issue. One example is CHIRPP (Canadian Hospitals Injury Reporting and Prevention Program), which has been imported into the accident and emergency department at the Royal Hospital for Sick Children, Glasgow. This paper examines a year of CHIRPP data. METHODS A CHIRPP questionnaire was completed for 7940 children presenting in 1996 to the accident and emergency department with an injury or poisoning. The first part of the questionnaire was completed by the parent or accompanying adult, the second part by the clinician. These data were computerised and analysed using SPSSPC for Windows. RESULTS Injuries commonly occurred in the child’s own home, particularly in children aged 0–4 years. These children commonly presented with bruising, ingestions, and foreign bodies. With increasing age, higher proportions of children presented with injuries occurring outside the home. These were most commonly fractures, sprains, strains, and inflammation/oedema. Seasonal variations were evident, with presentations peaking in the summer. CONCLUSIONS There are several limitations to the current CHIRPP system in Glasgow: it is not population based, only injuries presented to the accident and emergency department are included, and injury severity is not recorded. Nevertheless, CHIRPP is a valuable source of information on patterns of childhood injury. It offers local professionals a comprehensive dataset that may be used to develop, implement, and evaluate child injury prevention activities.

Pattern of injury mortality by age-group in children aged 0-14 years in Scotland, 2002-2006, and its implications for prevention.

BackgroundKnowledge of the epidemiology of injuries in children is essential for the planning, implementation and evaluation of preventive measures but recent epidemiological information on injuries in children both in general and by age-group in Scotland is scarce. This study examines the recent pattern of childhood mortality from injury by age-group in Scotland and considers its implications for prevention.MethodsRoutine mortality data for the period 2002–2006 were obtained from the General Register Office for Scotland and were analysed in terms of number of deaths, mean annual mortality rates per 100,000 population, leading causes of death, and causes of injury death. Mid-year population estimates were used as the denominator. Chi-square tests were used to determine statistical significance.Results186 children aged 0–14 died from an injury in Scotland during 2002–06 (MR 4.3 per 100,000). Injuries were the leading cause of death in 1–14, 5–9 and 10–14 year-olds (causing 25%, 29% and 32% of all deaths respectively). The leading individual causes of injury death (0–14 years) were pedestrian and non-pedestrian road-traffic injuries and assault/homicide but there was variation by age-group. Assault/homicide, fire and suffocation caused most injury deaths in young children; road-traffic injuries in older ones. Collectively, intentional injuries were a bigger threat to the lives of under-15s than any single cause of unintentional injury. The mortality rate from assault/homicide was highest in infants (<1 year) and decreased with increasing age. Children aged 5–9 were significantly less likely to die from an injury than 0–4 or 10–14 year-olds (p < 0.05). Suicide was an important cause of injury mortality in 10–14 year-olds.ConclusionInjuries continue to be a leading cause of death in childhood in Scotland. Variation in causes of injury death by age-group is important when targeting preventive efforts. In particular, the threats of assault/homicide in infants, fire in 1–4 year-olds, pedestrian injury in 5–14 year-olds, and suicide in 10–14 year-olds need urgent consideration for preventive action.

CAPTURE-RECAPTURE: A USEFUL METHODOLOGICAL TOOL FOR COUNTING TRAFFIC RELATED INJURIES?

Introduction—Although the capture-recapture technique is increasingly employed in studies of human populations to correct for under-ascertainment in traditional epidemiological surveillance, it has rarely been used in injury research. Objectives—To estimate the completeness of official data sources on traffic related injuries (TRIs) by using the capture-recapture technique and to calculate an ascertainment corrected number of fatal and serious TRIs among Scottish young people aged 15–24 years. The appropriateness of the approach in this context is also assessed. Method—A two sample capture-recapture technique was applied to two official sources of TRI data. Data on TRIs were obtained from the Scottish Health Service and the STATS19 dataset at the University of Essex Data Archive for 1995. Four standards (A-D) of matching were applied to fatalities and serious TRIs to allow plausible relaxation of matching standards within the context of the data collection setting. The completeness of each data source was assessed, and an ascertainment corrected number of fatalities and serious TRIs calculated. Results—The ascertainment corrected number of TRI fatalities among 15–24 year olds using standard D was 104. This represents only a small increase in the number of fatalities using capture-recapture than when using each individual dataset. The completeness of the Scottish Health Service database for TRI fatalities was 93%. The STATS19 database was 95% complete. The ascertainment corrected number of TRI hospital admissions was 1969. The STATS19 and the Scottish Health Service databases were approximately two thirds and three quarters complete respectively for non-fatal TRIs requiring hospitalisation. Conclusions—Injury researchers have advocated the linkage of major datasets to supplement and improve the quality of injury data. Using capture-recapture we found that routine databases enumerate TRI fatalities accurately, in contrast to injury morbidity databases that do not. Capture-recapture is a potentially useful method of evaluating the completeness of data sources and identifying biases within datasets. However, ascertainment corrected rates should be viewed with caution. A number of requirements of the capture-recapture technique are unachieved in this study of injury in the human population.

Emergency department injury surveillance systems: the best use of limited resources?

Although most routine health statistics provide information on injuries, the level of detail is often insufficient for injury prevention purposes. To fill this gap, many industrialised countries have introduced specially designed national and local injury surveillance systems based in emergency departments. Examples have been reported from Australia, Canada, Greece, New Zealand, the Netherlands, Norway, Sweden, the United States, and the UK.1 The European Home and Leisure Accident Surveillance System (EHLASS) operates in the 15 current member states of the European Union. The EHLASS system collects data on all (or most) patients presenting with an injury or poisoning to a sample of hospitals. Because of the high costs of data collection, the usefulness and cost effectiveness of such systems is coming under increasing scrutiny. Surveillance has been defined as the “continuous analysis, interpretation and feedback of systematically collected data”.2 Injury surveillance systems have a number of important virtues. They monitor injury incidence, identify risk factors, and assist in the planning and evaluation of injury prevention programmes.3 Emergency department based systems have helped fill a major gap in our understanding of non-fatal injuries, which comprise a large (but usually unknown) proportion of medically treated injuries. In comparison with routine data sources, these systems provide greater detail and are timely. Moreover, their stability over time allows the analysis of secular trends and the identification of rare events, and new and emerging hazards such as a dangerous new toy. Nevertheless, in spite of these advantages, several crucial questions regarding emergency department surveillance need to be addressed. The United States Centers for Disease Control have developed criteria for evaluating any surveillance system. …

Stages of development and injury: An epidemiological survey of young children presenting to an emergency department

BackgroundThe aim of our study was to use a local (Glasgow, west of Scotland) version of a Canadian injury surveillance programme (CHIRPP) to investigate the relationship between the developmental stage of young (pre-school) children, using age as a proxy, and the occurrence (incidence, nature, mechanism and location) of injuries presenting to a Scottish hospital emergency department, in an attempt to replicate the findings of a recent study in Kingston, Canada.MethodsWe used the Glasgow CHIRPP data to perform two types of analyses. First, we calculated injury rates for that part of the hospital catchment area for which reasonably accurate population denominators were available. Second, we examined detailed injury patterns, in terms of the circumstances, mechanisms, location and types of injury. We compared our findings with those of the Kingston researchers.ResultsA total of 17,793 injury records for children aged up to 7 years were identified over the period 1997–99. For 1997–2001, 6,188 were used to calculate rates in the west of the city only. Average annual age specific rates per 1000 children were highest in both males and females aged 12–35 months. Apart from the higher rates in Glasgow, the pattern of injuries, in terms of breakdown factors, mechanism, location, context, and nature of injury, were similar in Glasgow and Kingston.ConclusionWe replicated in Glasgow, UK, the findings of a Canadian study demonstrating a correlation between the pattern of childhood injuries and developmental stage. Future research should take account of the need to enhance statistical power and explore the interaction between age and potential confounding variables such as socio-economic deprivation. Our findings highlight the importance of designing injury prevention interventions that are appropriate for specific stages of development in children.

An evaluation of police reporting of road casualties

Background: Under-reporting of road traffic casualties in police records has been well documented. Objectives: To investigate the extent and nature of possible under-reporting of road traffic casualties in the West of Scotland. Design: A linked database comprising both police data (STATS19) and hospital in-patient records (SMR01) was created. The study period was 1997–2005 inclusive. Contrasting the number of SMR01-identified road casualties that were also recorded (“linked”) in STATS19 records with those that were not (“unlinked”) gives an indication of the extent and types of under-reporting of hospitalized road casualties by the police. Results: 45% of hospital admissions due to road casualties were not reported to (or recorded by) the police. The STATS19 “slight casualties” that were linked to the SMR01 data was the only category that showed an increase in numbers (+4%) over the study period, whereas the numbers of STATS19 KSI (killed or seriously injured—combining fatal and serious casualties) decreased substantially (−38%). Pedal cyclists and motorcyclists were most likely to be missed by police recording. No third-party involvement, older casualties, females, length of stay in hospital (day cases), and earlier year of crash were also significantly associated with under-reporting. Conclusions: A general decline in the completeness of STATS19 is unlikely to have occurred, but there may have been an increasing tendency over time for police officers to report injuries as slight rather than serious. To improve the quality of this information, routine linkage of road casualty data derived from police and hospitalization databases should be considered.