Developing a capacity-building intervention for healthcare workers to improve communication skills and awareness of hard of hearing and D/deaf patients: results from a participatory action research study

BACKGROUND

Healthcare workers (HCWs) are commonly not prepared to properly communicate with D/deaf and hard of hearing (HoH) patients. The resulting communication challenges reinforce the existing barriers to accessing and benefiting from quality of care in these populations. In response, this study aimed to develop and evaluate a capacity-building intervention for HCWs to raise their awareness of D/deaf and HoH individuals' experiences in healthcare and improve their capacity to communicate with these populations.

METHODS

This study featured a participatory action research design using qualitative and quantitative methods. The intervention was developed and tested through 4 iterative phases. Reactions (i.e., satisfaction and perception of the intervention content, quality, appropriateness and usefulness) were assessed quantitatively and qualitatively after the intervention, whereas perceived knowledge and self-efficacy in communicating with D/deaf and HoH patients and organizational payoffs (use frequency of basic rules and tools improving communication) were quantitatively assessed before, after and 6-month post-intervention.

RESULTS

Main qualitative and quantitative findings showed that the final version of the intervention reached high levels of satisfaction among participants. Next, perceived knowledge and self-efficacy scores obtained after receiving the intervention and 6 months later were significantly higher than those yielded in the initial assessment, although both scores significantly decreased at 6 months (compared to the scores obtained just after the intervention). Finally, findings showed no significant changes in organizational payoffs after receiving the intervention. Echoing these results, main qualitative findings documented that after receiving the intervention, participants felt more confident yet not more equipped to communicate with D/deaf and HoH patients.

CONCLUSIONS

Findings suggest that the capacity-building intervention is a promising means to sustainably increase HCWs' perceived knowledge and self-efficacy on how communicating with D/deaf and HoH patients, although complementary approaches and follow-up intervention reminders may be necessary to enable practice changes in the working environment.

Effect of a smartphone intervention as a secondary prevention for use among university students with unhealthy alcohol use: randomised controlled trial

OBJECTIVE

To estimate the effects of providing access to an alcohol intervention based on a smartphone.

DESIGN

Randomised controlled trial..

SETTING

Four higher education institutions in Switzerland.

PARTICIPANTS

1770 students (≥18 years) who screened positive for unhealthy alcohol use (ie, a score on the alcohol use disorders identification test-consumption (AUDIT-C) of ≥4 for men and ≥3 for women) were randomly assigned by 1:1 allocation ratio in blocks of 10.

INTERVENTION

Providing access to a brief, smartphone based alcohol intervention.

OUTCOME MEASURES

The primary outcome studied was number of standard drinks per week at six months and the secondary outcome was number of heavy drinking days (past 30 days). Additional outcomes were maximum number of drinks consumed on one occasion, alcohol related consequences, and academic performance. Follow-up assessments occurred at months three, six, and 12. Data were analysed by intention to treat and by using generalised linear mixed models with random intercepts for the recruitment site and participants nested within the recruitment site, and with intervention (v control), time (three months v six months; 12 months v six months), and baseline outcome values as fixed effects.

RESULTS

Between 26 April 26 2021 and 30 May 2022, 1770 participants (intervention group (n=884); control group (n=886)) were included. Mean age was 22.4 years (standard deviation 3.07); 958 (54.1%) were women; and 1169 (66.0%) were undergraduate students, 533 (30.1%) were studying for a master's degree, 43 (2.4%) were studying for a doctorate, and 25 (1.4%) were students of other higher education programme. The baseline mean number of standard drinks per week was 8.59 (standard deviation 8.18); the baseline number of heavy drinking days was 3.53 (4.02). Of 1770 participants, follow-up rates were 1706 (96.4%) at three months, 1697 (95.9%) at six months, and 1660 (93.8%) at 12 months. Of 884 students randomly assigned to the intervention group, 738 (83.5%) downloaded the smartphone application. The intervention had a significant overall effect on the number of standard drinks per week (incidence rate ratio 0.90 (95% confidence interval 0.85 to 0.96)), heavy drinking days (0.89 (0.83 to 0.96)), and the maximum number of drinks consumed on one occasion (0.96 (0.93 to 1.00), P=0.029), indicating significantly lower drinking outcomes in the intervention group than in the control group during the follow-up period. The intervention did not affect alcohol related consequences or academic performance.

CONCLUSIONS

Providing access to the smartphone application throughout the 12 month follow-up was effective at limiting the average drinking volume of university students who had self-reported unhealthy alcohol use at baseline.

TRIAL REGISTRATION

ISRCTN 10007691.

[Research about vulnerable populations: challenges and opportunities]

There is an important gap in health knowledge about vulnerable and hard-to-reach groups. The development of research projects and the implementation of interventions require strategies adapted to the particularities of these groups. This article reviews some of the main issues through the lens of recent projects conducted in French-speaking Switzerland.

Experiences of Frequent Users of Emergency Departments in Health Care Setting in French-Speaking Switzerland: A Qualitative Study

AIMS

Frequent users of the emergency department (FUED; five ED visits or more per year) often have negative experiences in health care settings, potentially aggravating their health problems. Scarce research has explored FUED experiences in health care in Europe, none in Switzerland. Thus, this study aimed to conduct an in-depth exploration of FUED experiences in health care settings in Switzerland.

METHODS

Semi-structured interviews were conducted among 20 FUED (75% female; mean age = 40.6, SD = 12.8). Qualitative data were subject to inductive content analysis.

RESULTS

Five main themes emerged from the analysis. The main findings documented that FUED experiences in health care were mostly negative, leading to negative emotions, dissatisfaction and a loss of confidence in the system, although some positive experiences were reported as well. The relationship with health care workers was perceived as playing a key role in FUED experiences.

CONCLUSION

The findings indicate that FUED often have negative experiences in the health care system in Switzerland. The relationship with the health care staff is reported as a decisive ingredient of the experience in health care. Future research is needed to develop awareness-raising interventions for health care staff to improve FUED experiences in health care.

Understanding the experience in the healthcare system of non-migrant and migrant frequent users of the emergency department in French-speaking Switzerland: a comparative qualitative study

BACKGROUND

Previous research revealed the vulnerability of frequent users of emergency department (FUED) because of concomitant medical, psychological and social issues. Case management (CM) provides FUED with effective medical and social support, however, the heterogeneity of this population has highlighted the need to explore the specific needs of FUED subpopulations. In response, this study aimed to explore qualitatively the lived experience of migrant and non-migrant FUED in the healthcare system to identify unmet needs.

METHODS

Adult migrant and non-migrant FUED (≥ 5 visits in the ED in the past 12 months) were recruited in a Swiss university hospital to collect qualitative data on their experience within the Swiss health system. Participants were selected based on predefined quotas for gender and age. Researchers conducted one-on-one semistructured interviews until reaching data saturation. Inductive conventional content analysis was used to analyse qualitative data.

RESULTS

In total, 23 semistructured interviews were conducted (11 migrant FUED and 12 non-migrant FUED). Four main themes emerged from the qualitative analysis: (1) self-evaluation of the Swiss healthcare system; (2) orientation within the healthcare system; (3) relationship with caregivers and (4) perception of own health. While both groups were overall satisfied with the healthcare system and care provided, migrant FUED reported language and financial barriers to access it. Both groups expressed overall satisfaction over their relationship with healthcare professionals, although migrant FUED reported a feeling of illegitimacy to consult the ED based on social status, whereas non-migrant FUED felt more often the need to justify their use of the ED. Finally, migrant FUED perceived their own health to be affected by their status.

CONCLUSION

This study highlighted difficulties specific to subpopulations of FUED. For migrant FUED, these included access to care and impact of migrant status on own health. Adapting CM to the specific needs of migrant FUED could help reduce their vulnerability.

Development of a Secondary Prevention Smartphone App for Students With Unhealthy Alcohol Use: Results From a Qualitative Assessment

BACKGROUND

Despite considerable efforts devoted to the development of prevention interventions aiming at reducing unhealthy alcohol use in tertiary students, their delivery remains often challenging. Interventions including information technology are promising given their potential to reach large parts of the population.

OBJECTIVE

This study aims to develop a secondary prevention smartphone app with an iterative qualitative design involving the target population.

METHODS

The app development process included testing a first prototype and a second prototype, developed based on the results of 2 consecutive qualitative assessments. Participants (aged ≥18 years, screened positive for unhealthy alcohol use) were students from 4 tertiary education institutions in the French-speaking part of Switzerland. Participants tested prototype 1 or prototype 2 or both and provided feedback in 1-to-1 semistructured interviews after 2-3 weeks of testing.

RESULTS

The mean age of the participants was 23.3 years. A total of 9 students (4/9 female) tested prototype 1 and participated in qualitative interviews. A total of 11 students (6/11 female) tested prototype 2 (6 who tested prototype 1 and 5 new) and participated in semistructured interviews. Content analysis identified 6 main themes: "General Acceptance of the App," "Importance of the Targeted and Relevant App Content," "Importance of Credibility," "Importance of the App Usability," "Importance of a Simple and Attractive Design," "Importance of Notifications to Ensure App Use over Time." Besides a general acceptance of the app, these themes reflected participants' recommendations toward increased usability; to improve the design; to include useful and rewarding contents; to make the app look serious and credible; and to add notifications to ensure its use over time. A total of 11 students tested prototype 2 (6 who tested prototype 1 and 5 new) and participated in semistructured interviews. The 6 same themes emerged from the analysis. Participants from phase 1 generally found the design and content of the app improved.

CONCLUSIONS

Students recommend prevention smartphone apps to be easy to use, useful, rewarding, serious, and credible. These findings may be important to consider when developing prevention smartphone apps to increase the likelihood of app use over time.

TRIAL REGISTRATION

ISRCTN registry 10007691; https://www.isrctn.com/ISRCTN10007691.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-4145-2.

Perspectives of Frequent Users of Emergency Departments on a Case Management Intervention: A Qualitative Study

BACKGROUND

Effective management of frequent users of emergency departments (FUED) remains challenging. Case management (CM) has shown to improve patient quality of life while reducing ED visits and associated costs. However, little data is available on FUED's perception of CM outside of North America to further improve CM implementation.

OBJECTIVES

Explore the FUED's perspectives about CM in Switzerland.

DESIGN, SETTING & PARTICIPANTS

Semi-structured qualitative interviews eliciting FUED's experiences of CM were conducted among 20 participants (75% female; mean age = 40.6, SD = 12.8) across 6 hospital ED.

OUTCOMES MEASURES & ANALYSIS

Inductive content analysis.

MAIN RESULTS

Most participants were satisfied with the CM program. In particular, FUEDs identified the working relationship with the case manager (cm) as key for positive outcomes, and also valued the holistic evaluation of their needs and resources. Overall, patients reported increased motivation and health literacy, as well as facilitated interactions within the healthcare system. Conversely, a small number of participants reported negative views on CM (ie, stigmatization, lack of concrete outcomes). Barriers identified were cm's lack of time, COVID-19's negative impact on CM organization, as well as lack of clarity on the objectives of CM. FUED perceived CM as useful, in particular establishing a working relationship with the cm. Our results suggest that CM can be further improved by (1) professionals remaining non-judgmental toward FUED, (2) making sure the aims and objectives of the CM are understood by the participants, and (3) allowing more time for the cm to carry out their work.

Implementation of Case Management in emergency departments: the view of the involved staff

Introduction

Frequent users of emergency departments (FUED; ≥ 5 ED visits in the previous 12 months) often present with somatic, psychological and substance use problems. Providing a Case Management (CM) intervention may reduce their number ED visits and improve their quality of life. However, there is limited knowledge about the implementation process of CM.

Methods

This study aimed to introduce CM into the EDs in the French-speaking part of Switzerland and to identify the facilitators, barriers and needs encountered in this process. Semi-structured interviews were conducted with ED involved staff. An inductive content analysis was conducted.

Results

Among 13 invited hospitals, 8 implemented CM (62%); 23 ED staff were sampled from all participating ED: 17 nurses (74%), 5 physicians (22%) and 1 healthcare manager (4%). The average age was 48,48 years (SD = 8,64) and 74% were female. Four main facilitators emerged from the analysis: 1) Direct hierarchy support and flexibility (e.g. time management, supplemental paid hours); 2) Exchange with colleagues (e.g. debriefing, support); 3) Supervision by the research team (training and toolkit consisting of a binder and USB stick containing the study presentation and implementation procedures); and 4) Motivation (pleasure to work on an innovative project, benefit for patients and caregivers). Lack of resources was an unanimously mentioned barrier (e. g., time to identify and contact FUED medical and social support). Finally, participants identified the following needs to enable CM implementation: official and protected time for the project, a dedicated room for CM, at least two team members involved in the project since its initiation with complementary skills (e.g.: somatic, psychiatric and social).

Conclusions

Our study suggests that successful CM implementation is a complex process that, in addition to motivated ED staff, requires significant dedicated resources, such as protected time and a devoted support team.

Key messages

Improving communication with hard of hearing and D/deaf patients: a capacity-building intervention

Background

D/deaf and hard of hearing (D&HoH) populations are disproportionally affected by physical and mental health problems while facing barriers to accessing health services. These barriers stem from communication challenges with healthcare providers, who are often unprepared to meet their specific needs. This study aimed to develop and evaluate an intervention to improve healthcare providers’ skills to communicate with these patients.

Methods

This study featured a participative action research design. Consistently, the intervention was developed through iterative phases together with the target populations and key stakeholders. The finale version was tested in healthcare workers in Canton of Vaud in Switzerland. Participants completed a questionnaire before (T0) and 6 months after (T1) the intervention, assessing perceived knowledge of deafness and hard of hearing and tools to improve communication, self-efficacy on how to communicate with D&HoH patients and institutional benefits (application frequency of communication rules and tools).

Results

The final intervention aimed to increase participants’ 1) awareness of D&HoH experience and communication needs, 2) knowledge of the tools and basic rules to improve communication. Two D&HoH trainers led one half-day intervention among 28 healthcare providers (e.g., nurses, pharmacists; mean age=43.6). Paired-sample t-tests revealed significant increases in knowledge between T0 and T1, t (23) = -7.81, p < .001 and in self-efficacy, t (24) = -10.23, p < .001, whereas there was no significant difference between institutional benefits at T0 and T1.

Conclusions

Although findings suggest the intervention is a promising means to increase perceived knowledge and self-efficacy on how communicating with D&HoH patients, complementary approaches, such as a resource person within the institutions providing day-to-day support to the teams besides the intervention, may be necessary to induce institutional changes.

Key messages

• Future research should implement the intervention more broadly within inpatient and outpatient settings in Switzerland to increase knowledge on how communicating with D&HoH patients.

• Intervention implementation should be complemented by an additional structural approach to induce sustainable changes in practice and evaluated over 12 months to ensure sustainability.

Risk Perception Related to COVID-19 and Future Affective Responses Among Healthcare Workers in Switzerland: A Mixed-Methods Longitudinal Study

Objectives: Whereas early findings suggest that risk perceptions related to COVID-19 affect psychological well-being in healthcare workers (HCWs), the temporal associations between these variables need to be clarified and HCWs lived experience further explored. This study proposes a mixed evaluation of COVID-19-related risk perception and affective responses among HCWs.

Methods: A longitudinal mixed-method study was conducted. HCWs (N = 138) completed measures of COVID-19 risk perceptions, depression, anxiety, burnout and secondary traumatic stress (STS) at baseline and 6 months later. A subsample (n = 20) participated in semi-structured interviews exploring both risk perceptions and affective responses.

Results: Main quantitative findings showed positive associations between worry to contaminate others and depression (IRR = 1.04, p < 0.05), anxiety (IRR = 1.03, p < 0.01), STS (b = 0.3, p < 0.05), and perceptions of lacking protection (IRR = 1.04, p < 0.05) with anxiety scores. Four themes emerged from the thematic content analysis: 1) life was turned upside down; 2) skills were put in quarantine; 3) dealing with patient discomfort; 4) balance to be found between protection and restrictions.

Conclusion: These findings emphasize the importance to develop tailored interventions, such as group discussion sessions, to optimize risk perception and help manage uncertainty.

Frequent users of ED’s perspectives about a case management intervention in Western Switzerland

Background

Management of frequent users of the emergency department (FUED; ≥5 visits/year) is a known challenge. Studies show that case management (CM) improves FUEDs' quality of life while reducing their number of emergency department visits and associated costs. However, little is known about FUEDs' own perspectives on CM.

Methods

This qualitative study was part of a larger study aiming to implement CM for FUED in French-speaking Switzerland. Participants were FUEDs included in the parent study, who had either completed the CM intervention or were still enrolled. Semi-structured qualitative interviews were conducted with 20 participants (75% female; mean age=40.55, SD = 12.84), randomly drawn from the parent study sample. Content analysis was performed by two researchers to assess participants' perceptions on the CM intervention.

Results

Most participants endorsed general positive perceptions of CM. CM differed from their usual treatment by two characteristics: its holistic approach and the quality of the relationship with the case manager. Also, moral support was perceived as a main benefit. FUEDs perceived four outcomes: an increase in motivation (e.g., day-to-day life or health-related), better orientation in and interaction with the healthcare system and improved health literacy. Finally, FUEDs identified two negative aspects to the CM: few perceived benefits (e.g., not enough concrete outcomes) and negative consequences (e.g., feeling ashamed to come back to ED). Three obstacles were identified: case manager's lack of time, COVID-19's influence (e.g., less personal contact) and uncertainty around the program (e.g., organization, aims). The personal relationship with their case manager was perceived as the main driver to positive outcomes.

Conclusions

FUED perceived the program as useful and considered the relationship with the case manager as key for positive outcomes. Our findings also suggest ways to improve CM, such as clarifying its organization and aims.

Key messages

In FUEDs’ opinion, the CM intervention had many positive outcomes, often relying on the relationship with the case manager.

However, the CM intervention had also some negatives.

Healthcare Providers' Perceptions of Challenges with Frequent Users of Emergency Department Care in Switzerland: A Qualitative Study

Frequent users of emergency departments (FUED; ≥ 5 ED visits/year) commonly cumulate medical, social, and substance use problems requiring complex and sustained care coordination often unavailable in ED. This study aimed to explore ED healthcare providers’ challenges related to FUED care to gain insight into the support and resources required to address FUED complex needs. An online survey was sent to all general adult emergency services within Switzerland (N = 106). Participants were asked to indicate the extent to which they perceived that FUED represented a problem and to describe the main challenges encountered. In total, 208 physicians and nurses from 75 EDs (70.7%) completed the survey. Among the 208 participants, 134 (64%) reported that FUED represented a challenge and 133 described 1 to 5 challenges encountered. A conventional content analysis yielded 4 main categories of perceived challenges. Negative consequences in the ED secondary to FUED’s presence (eg, ED overcrowding, staff helplessness, and fatigue) was the most frequently reported challenge, followed by challenges related to FUEDs’ characteristics (eg, mental health and social problems) leading to healthcare complexity. The third most frequently encountered challenge was related to the ED inappropriateness and inefficiency to address FUEDs’ needs. Finally, challenges related to the lack of FUED healthcare network were the least often mentioned. ED healthcare providers experience a wide range of challenges related to FUED care. These findings suggest that currently EDs nor their staff are equipped to address FUEDs’ complex needs.

Physicians' perceptions about managing enteral nutrition and the implementation of tools to assist in nutritional decision-making in a paediatric intensive care unit

BACKGROUND

For critically ill children hospitalised in paediatric intensive care units, adequate nutrition reduces their risk of morbidity and mortality. Barriers may impede optimal nutritional support in this population. Moreover, physicians are usually responsible for prescribing nutrition, although they are not experts. Therefore, tools may be used to assist in nutritional decision-making, such as nutrition protocols.

OBJECTIVES

The objective of this two-stage qualitative study was to explore the perceptions of physicians about their management of enteral nutrition in a paediatric intensive care unit and the implementation of a nutrition protocol and computerised system.

METHODS

This study involved semistructured interviews with physicians at the Paediatric Intensive Care Unit of Lausanne University Hospital, Switzerland. Research dietitians conducted interviews before (stage one) and after (stage two) the implementation of a nutrition protocol and computerised system. During stage one, six junior physicians and five fellows were interviewed. At stage two, 12 junior physicians, 12 fellows, and five senior physicians were interviewed. Interviews were recorded, with data transcribed verbatim before a thematic analysis using a framework method.

RESULTS

Three themes emerged from thematic analysis: "nutritional knowledge", "nutritional practices", and "resources to manage nutrition". During stage one, physicians, especially junior physicians, reported a lack of nutritional knowledge for critically ill children and stated that nutritional issues primarily depended on senior physicians, who themselves had various practices. All physicians were in favour of a nutrition protocol and computerised system. At stage two, interviewees stated that they used both tools regularly. They reported improved nutritional knowledge, more systematic and consistent nutritional practices, and increased attention to nutrition.

CONCLUSIONS

The implementation of a nutrition protocol and computerised system by a multiprofessional team helped physicians in the paediatric intensive care unit to manage nutritional support and increase their attention to nutrition.

Smartphone-based secondary prevention intervention for university students with unhealthy alcohol use identified by screening: study protocol of a parallel group randomized controlled trial

BACKGROUND

Unhealthy alcohol use is a leading cause of morbidity and mortality among young people, including university students. Delivering secondary prevention interventions against unhealthy alcohol use is challenging. Information technology has the potential to reach large parts of the general population. The present study is proposed to test a proactive secondary prevention smartphone-based intervention against unhealthy alcohol use.

METHODS

This is a parallel-group, randomized controlled trial (1:1 allocation ratio) among 1696 university students with unhealthy alcohol use, identified by screening and followed up at 3, 6, and 12 months. Participants will be randomized to receive access to a smartphone-based intervention or to a no intervention control condition. The primary outcome will be self-reported volume of alcohol drunk over the past 30 days, reported as the mean number of standard drinks per week over the past 30 days, measured at 6 months. Secondary outcomes will be number of heavy drinking days over the past 30 days, at 6 months. Additional outcomes will be maximum number of drinks on any day over the past 30 days, alcohol-related consequences (measured using the Short Inventory of Problems (SIP-2R), and academic performance.

DISCUSSION

The aim of this trial is to close the evidence gap on the efficacy of smartphone-based secondary prevention interventions. If proven effective, smartphone-based interventions have the potential to reach a large portion of the population, completing what is available on the Internet.

TRIAL REGISTRATION

ISRCTN, 10007691. Registered on 2 December 2019. Recruitment will start in April 2020.

Healthcare providers’ perceptions of difficulties related to frequent users of emergency departments

Background

Frequent users of emergency department (FUEDs; ≥ 5 ED visits/ year) are often vulnerable individuals cumulating medical, social and substance use problems. FUEDs often require complex and sustained care coordination generally unavailable in ED and are commonly considered contributing to ED crowding. In view of supporting ED health-care providers through specific training and interventions tailored to FUEDs, this study aimed to explore ED healthcare providers’ perceptions of difficulties related to FUEDs.

Methods

Participants (N = 208) were ED healthcare providers (i.e., nurses, physicians) from 75 university and community hospitals in Switzerland (71% of all EDs) who answered a questionnaire on FUEDs. They were asked to indicate the extent to which FUEDs represent a problem in their ED. Perceived difficulties related to FUEDs were elicited by an open-ended question. Conventional content analysis was used to extract common categories and themes.

Results

Among the 208 participants, 134 (64%) reported that FUEDs represent a problem. Of those, 132 provided 1 to 5 answers to the open-ended question. Twenty-eight categories were identified and organized in 4 themes. First, participants reported difficulties related to FUEDs’ characteristics themselves (e.g., problem’s chronicity; behavioural difficulties) leading to healthcare complexity. Second, participants perceived negative consequences related to the presence of FUEDs in the ED (e.g., work overload, staff helplessness and fatigue). Third, ED healthcare offer was considered inappropriate and inefficient to respond to FUEDs needs and fourth collaborating with FUEDs’ existing healthcare network was perceived as difficult.

Conclusions

ED healthcare providers experience a wide range of difficulties related to the management of FUEDs. Providing training and implementing a case management intervention tailored to FUEDs might support ED health-care providers and contribute to address FUEDs’ complex needs.

Key messages

ED healthcare providers perceive FUEDs to represent a problem. Perceived difficulties might decrease through training and case management support might contribute to better address FUEDs complex needs.

[Assessment of restrictive episiotomy use and impact on perineal tears in the Burgundy's Perinatal Network]

OBJECTIVES

To analyse episiotomy and perineal tears rates in Burgundy after French National College of Obstetricians and Gynecologists (CNGOF) guidelines in 2005.

MATERIALS AND METHOD

Multicenter retrospective study, between 2003-2005 (period 1) et 2012-2014 (period 2), conducted on singletons vaginal deliveries, in cephalic presentation from 37 weeks. We compared the episiotomy rate (ER), and perineal lesions in normal deliveries (ND) and instrumental deliveries (ID) between the two periods.

RESULTS

A total of 74,268 women were included. The overall ER significantly decreased from 35.8 to 16.7% (P<0.01), without increasing third degree perineal tears (0.73% vs. 0.66%) or fourth degree (0.14% vs 0.14%). First degree perineal tears rose (42.1% vs 17.6%, P<0.001), second degree decreased (13.5% vs 20.5%, P<0.001). ER decreased whatever the level of motherhood, healthcare ward, vaginal delivery type, or the instrument used.

CONCLUSION

Our study found a strong impact in Burgundy of the French guidelines for the practice of restrictive episiotomy for both ND and for ID without increasing sphincter tears and in decreasing spontaneous morbidity.

[Unwanted pregnancy as conflict. Potential for developmental steps?]

Problems of pregnancy-conflicts are presented from the point of view of counselors of the family planning service at the university clinic for obstetrics and gynecology in Bern. By means of case examples and a literature review, the possible backgrounds of undesired pregnancies are elucidated.

A centrifugation technique for cytochemical preparations

A centrifugation technique for microscopical preparations of cells or cell particles either unfixed or previously fixed in suspension has been developed. It allows more consistent results of cytofluorometric and interferometric measurements than the conventional smear technique.