Background: Despite evidence supporting the safety of vaginal birth after caesarean section (VBAC), rates are low in many countries. Methods: OptiBIRTH investigated the effects of a woman-centred intervention designed to increase VBAC rates through an unblinded cluster randomised trial in 15 maternity units with VBAC rates < 35% in Germany, Ireland and Italy. Sites were matched in pairs or triplets based on annual birth numbers and VBAC rate, and randomised, 1:1 or 2:1, intervention versus control, following trial registration. The intervention involved evidence-based education of clinicians and women with one previous caesarean section (CS), appointment of opinion leaders, audit/peer review, and joint discussions by women and clinicians. Control sites provided usual care. Primary outcome was annual hospital-level VBAC rates before the trial (2012) versus final year of the trial (2016). Between April 2014 and October 2015, 2002 women were recruited (intervention 1195, control 807), with mode-of-birth data available for 1940 women. Results: The OptiBIRTH intervention was feasible and safe across hospital settings in three countries. There was no statistically significant difference in the change in the proportion of women having a VBAC between intervention sites (25.6% in 2012 to 25.1% in 2016) and control sites (18.3 to 22.3%) (odds ratio adjusted for differences between intervention and control groups (2012) and for homogeneity in VBAC rates at sites in the countries: 0.87, 95% CI: 0.67, 1.14, p = 0.32 based on 5674 women (2012) and 5284 (2016) with outcome data. Among recruited women with birth data, 4/1147 perinatal deaths > 24 weeks gestation occurred in the intervention group (0.34%) and 4/782 in the control group (0.51%), and two uterine ruptures (one per group), a rate of 1:1000. Conclusions: Changing clinical practice takes time. As elective repeat CS is the most common reason for CS in multiparous women, interventions that are feasible and safe and that have been shown to lead to decreasing repeat CS, should be promoted. Continued research to refine the best way of promoting VBAC is essential. This may best be done using an implementation science approach that can modify evidence-based interventions in response to changing clinical circumstances.
This paper reports on the effects of an e-cycling incentive program in the province of North-Brabant, The Netherlands, in which commuters could earn monetary incentives when using their e-bike. The study used a longitudinal design allowing to observe behaviour change and mode shifts. The program appeared to be highly effective in stimulating e-bike use, as one month after the start of the program, the share of commute trips made by e-bike increased from 0% to 68%, with an increase up to 73% after half a year of participating. The environmental, congestion and health benefits of this shift are however mixed. Half of the e-bike trips substitute car trips, with positive effects on environment, congestion and health. The other half substitutes conventional cycling trips, implying fever health benefits. Our analyses further suggest that distance is an important factor for adopting e-cycling, where e-bike has a larger acceptable distance than a conventional bike. Nevertheless, we observed that the likelihood to use the e-bike decreased as commuting distance increased. Multivariate analyses suggest that a shift to e-cycling is affected by age, gender, physical condition, car ownership and household composition. Our study did find support for the hypothesis that having a strong car-commuting habit decreases the probability of mode shift to a new mode alternative. In contrast, multimodality may increase the likelihood of e-bike use as a result of openness to other travel options and a more deliberate mode choice. Lastly, dissatisfaction with the current travel mode positively influences mode shift towards the e-bike. Our results imply that stimulating e-cycling may be a promising way of stimulating physical activity, but that it will be most effective if targeted at specific groups who are not currently engaging in active travel.
LINK
Full text met een HU Account Objective: To quantify diversity in components of self-management interventions and explore which components are associated with improvement in health-related quality of life (HRQoL) in patients with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD), or type 2 diabetes mellitus (T2DM). Methods: Systematic literature search was conducted from January 1985 through June 2013. Included studies were randomised trials in patients with CHF, COPD, or T2DM, comparing self-management interventions with usual care, and reporting data on disease-specific HRQoL. Data were analysed with weighted random effects linear regression models. Results: 47 trials were included, representing 10,596 patients. Self-management interventions showed great diversity in mode, content, intensity, and duration. Although self-management interventions overall improved HRQoL at 6 and 12 months, meta-regression showed counterintuitive negative effects of standardised training of interventionists (SMD = 0.16, 95% CI: 0.31 to 0.01) and peer interaction (SMD = 0.23, 95% CI 0.39 to 0.06) on HRQoL at 6 months. Conclusion: Self-management interventions improve HRQoL at 6 and 12 months, but interventions evaluated are highly heterogeneous. No components were identified that favourably affected HRQoL. Standardised training and peer interaction negatively influenced HRQoL, but the underlying mechanism remains unclear. Practice implications: Future research should address process evaluations and study response to selfmanagement on the level of individual patients
MULTIFILE
