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Venepuncture distress and research in childhood
832
Venepuncture distress and research
in
childhood SIR,-Dr Mott and Dr Chambers believe that the new British Paediatric Association (BPA) guidelines for the ethical conduct of medical research involving children, by designating venepuncture as a low rather than a minimum risk procedure, might discourage important research that could benefit children. Clearly venepuncture can cause distress to many children. It should only be used in research when there is a compelling scientific reason and substantial likely benefits. However, in designating venepuncture as low risk because of its distressing effects the BPA report seems to have ignored important factors that alter the way children react to potentially distressing experiences and those such as children’s ability to consent and sympathise with others. Dislike of painful medical procedures is universal, but the fact that children express their distress more overtly than adults does not necessarily mean that they are more affected. Despite the fact that most children have injections during vaccinations, less than 7% of British schoolchildren are afraid of medical procedures.’ Moreover, self-report measures of children’s distress in health care settings do not correspond with measures of distress-related behaviours. The latter measures largely reflect an interpersonal dimension of distress and are probably related to the fact that many schoolchildren believe doctors are only aware of the painful nature of treatment if they cry.2 There is evidence that preparation of children-providing information, modelling, encouraging them to deal with stress and reduce anxiety reactions, distraction by both mothers and doctorscan reduce and virtually eliminate any overt sign of distress during venepuncture and other procedures.3,4 An implicit assumption in the BPA ethical guidelines is that adults can consent to the discomfort of injections but children cannot. This belief is contrary to the spirit of the new Children’s Act, which emphasises the importance of obtaining the child’s consent in decisions affecting him or her. Many children are able to consent to or refuse procedures. Whether they consent or not will depend on how procedures are explained to them, their trust in adults, the support offered, and their level of altruism. An ability to sympathise with illness in others and a desire to help is already present in young schoolchildren and increases steadily throughout childhood.s There are individual variations in children’s reactions to distress and these variations are related to temperamental features in the child, intelligence level, and previous experiences. All these factors should be taken into account in any research involving venepuncture. The BPA guidelines mention the need to consider psychosocial issues in research. Psychosocial assessment can help to predict distress reactions to medical procedures in children and should also help to reduce them. St Mary’s Hospital Academic Unit of Child and Adolescent Psychiatry, Central Middlesex Hospital, London NW10 7NS, UK
ELENA GARRALDA
1. Ollendick 2. 3. 4.
5.
TH, Yule W, Oilier K. Fears in British children and their relationship to manifest anxiety and depression. J Child Psychol Psychiatry 1991; 32: 321-32. Eiser C. Changes in understanding of illness as the child grows. Arch Dis Child, 1985; 60: 489-92. Rodin J. Will this hurt? London: Royal College of Nursing, 1983. Siegel LJ. Measuring children’s adjustment to hospitalization and to medical procedures. In: Karoly P, ed. Handbook of child health assessment. New York: John Wiley, 1988. Szagun G. Children’s understanding of the feeling experience and causes of sympathy. J Child Psychol Psychiatry 1992; 33: 1183-91.
Maternal
mortality estimation
SIR,-In 1988 Graham and co-workers1 reported the first field a new method for estimating maternal mortality in developing countries-the sisterhood method. Since then this demographic technique has provided the first community-based estimates in many populations in which death registration and health service statistics are seriously deficient. As experience has been gained, the sisterhood method has been refined, adapted, and
trial of
evaluated. We report its successful
application
in health
centre
users.
The sisterhood method is based
on
information obtained from
adults about the survival of their adult sisters Z One of its major advantages it that such data can be obtained from four basic questions being asked during a census or household sample survey. The method thus provides a low-cost route to estimating maternal mortality from an existing data collection activity. Although community-based censuses and surveys are often the only representative data sources in many developing countries, financial and logistical considerations restrict both their frequency and coverage. Additional opportunities for obtaining basic data for the sisterhood method were therefore sought. Experience from a method used for estimating child mortality, the preceding birth techniquesuggested that adults using primary health services could, in certain settings, provide a suitable opportunistic sample. In 1992 the chance arose to examine this approach in region I of Nicaragua. This is a mountainous area in the north of the country with a population of about 450 000. The region has a health centre in each of the 26 districts, plus seven health posts in the largest towns and fifty-eight scattered throughout rural areas. For each of these health units, a sample size proportional to population served was determined. Adults seeking health care for themselves or their children during July, 1992, were randomly selected until the designated sample size was reached. In most units this took about one week. A total of 9454 adults were interviewed by health unit personnel using the four basic questions for the sisterhood method. The lifetime risk of maternal death based on data from respondents under 50 years of age was 0-0144 (1 in 69). This corresponds to a maternal mortality ratio of about 241 maternal deaths per 100 000 live births. A community-based study with the sisterhood method had been done by the Ministry of Health in this region in November, 1991 (I. D. unpublished). In this household survey, 9663 adults were interviewed over 2-3 weeks, with the lifetime risk of maternal death being estimated at 0-0145. The two studies thus provided remarkably similar findings. However, the health services study was logistically simpler and less expensive than the community-based
study. The application of the sisterhood method in health services is clearly only appropriate in certain circumstances. Further detailed analyses of the Nicaraguan data are underway to characterise the population of health service users and to devise guidelines on suitable settings for this low-cost and efficient approach to estimating maternal mortality. Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK, and Ministry of Health,
Region I, Nicaragua
ISABELLA DANEL PEDRO CASTILLO WENDY GRAHAM
W, Brass W, Snow RW. Estimating maternal mortality m developing countries. Lancet 1988; i: 416-17. 2. Graham W, Brass W, Snow RW. Estimating maternal mortality using the sisterhood method. Stud Fam Plan 1989; 20: 125-35. 3. Brass W, Macrae S. Childhood mortality estimated from reports on previous births given by mothers at the time of a maternity I, preceding birth technique. Asian Pacific Forum 1985; 11: 5-8. 1. Graham
Breaking bad
news
SiR,-Since I achieved the lowest mark on our breaking bad medical school, I was interested in Dr Fallowfield’s
news course at
comprehensive review. Her report (Feb 20, p 476) draws attention to a common fallacy in this subject-that how you break bad news has a long-term impact on the recipient’s psychological outcome. There is absolutely no good evidence for this. In favour of the contention Fallowfield cites research on breast cancer psychological morbidity, but that particular study only suggests that patients who have a poor emotional outcome retrospectively view the advice they were given negatively. Which is cause and which is effect remains unclear. The only other study2 Fallowfield cites in support showed that those who received bad news delivered skillfully were more satisfied than a comparison group who dealt with professionals untrained in this -
skill. No
prospective long-term follow-up has yet demonstrated any significant impact on patients’ or relatives’ long-term adjustment of
Venepuncture distress and research
in
childhood SIR,-Dr Mott and Dr Chambers believe that the new British Paediatric Association (BPA) guidelines for the ethical conduct of medical research involving children, by designating venepuncture as a low rather than a minimum risk procedure, might discourage important research that could benefit children. Clearly venepuncture can cause distress to many children. It should only be used in research when there is a compelling scientific reason and substantial likely benefits. However, in designating venepuncture as low risk because of its distressing effects the BPA report seems to have ignored important factors that alter the way children react to potentially distressing experiences and those such as children’s ability to consent and sympathise with others. Dislike of painful medical procedures is universal, but the fact that children express their distress more overtly than adults does not necessarily mean that they are more affected. Despite the fact that most children have injections during vaccinations, less than 7% of British schoolchildren are afraid of medical procedures.’ Moreover, self-report measures of children’s distress in health care settings do not correspond with measures of distress-related behaviours. The latter measures largely reflect an interpersonal dimension of distress and are probably related to the fact that many schoolchildren believe doctors are only aware of the painful nature of treatment if they cry.2 There is evidence that preparation of children-providing information, modelling, encouraging them to deal with stress and reduce anxiety reactions, distraction by both mothers and doctorscan reduce and virtually eliminate any overt sign of distress during venepuncture and other procedures.3,4 An implicit assumption in the BPA ethical guidelines is that adults can consent to the discomfort of injections but children cannot. This belief is contrary to the spirit of the new Children’s Act, which emphasises the importance of obtaining the child’s consent in decisions affecting him or her. Many children are able to consent to or refuse procedures. Whether they consent or not will depend on how procedures are explained to them, their trust in adults, the support offered, and their level of altruism. An ability to sympathise with illness in others and a desire to help is already present in young schoolchildren and increases steadily throughout childhood.s There are individual variations in children’s reactions to distress and these variations are related to temperamental features in the child, intelligence level, and previous experiences. All these factors should be taken into account in any research involving venepuncture. The BPA guidelines mention the need to consider psychosocial issues in research. Psychosocial assessment can help to predict distress reactions to medical procedures in children and should also help to reduce them. St Mary’s Hospital Academic Unit of Child and Adolescent Psychiatry, Central Middlesex Hospital, London NW10 7NS, UK
ELENA GARRALDA
1. Ollendick 2. 3. 4.
5.
TH, Yule W, Oilier K. Fears in British children and their relationship to manifest anxiety and depression. J Child Psychol Psychiatry 1991; 32: 321-32. Eiser C. Changes in understanding of illness as the child grows. Arch Dis Child, 1985; 60: 489-92. Rodin J. Will this hurt? London: Royal College of Nursing, 1983. Siegel LJ. Measuring children’s adjustment to hospitalization and to medical procedures. In: Karoly P, ed. Handbook of child health assessment. New York: John Wiley, 1988. Szagun G. Children’s understanding of the feeling experience and causes of sympathy. J Child Psychol Psychiatry 1992; 33: 1183-91.
Maternal
mortality estimation
SIR,-In 1988 Graham and co-workers1 reported the first field a new method for estimating maternal mortality in developing countries-the sisterhood method. Since then this demographic technique has provided the first community-based estimates in many populations in which death registration and health service statistics are seriously deficient. As experience has been gained, the sisterhood method has been refined, adapted, and
trial of
evaluated. We report its successful
application
in health
centre
users.
The sisterhood method is based
on
information obtained from
adults about the survival of their adult sisters Z One of its major advantages it that such data can be obtained from four basic questions being asked during a census or household sample survey. The method thus provides a low-cost route to estimating maternal mortality from an existing data collection activity. Although community-based censuses and surveys are often the only representative data sources in many developing countries, financial and logistical considerations restrict both their frequency and coverage. Additional opportunities for obtaining basic data for the sisterhood method were therefore sought. Experience from a method used for estimating child mortality, the preceding birth techniquesuggested that adults using primary health services could, in certain settings, provide a suitable opportunistic sample. In 1992 the chance arose to examine this approach in region I of Nicaragua. This is a mountainous area in the north of the country with a population of about 450 000. The region has a health centre in each of the 26 districts, plus seven health posts in the largest towns and fifty-eight scattered throughout rural areas. For each of these health units, a sample size proportional to population served was determined. Adults seeking health care for themselves or their children during July, 1992, were randomly selected until the designated sample size was reached. In most units this took about one week. A total of 9454 adults were interviewed by health unit personnel using the four basic questions for the sisterhood method. The lifetime risk of maternal death based on data from respondents under 50 years of age was 0-0144 (1 in 69). This corresponds to a maternal mortality ratio of about 241 maternal deaths per 100 000 live births. A community-based study with the sisterhood method had been done by the Ministry of Health in this region in November, 1991 (I. D. unpublished). In this household survey, 9663 adults were interviewed over 2-3 weeks, with the lifetime risk of maternal death being estimated at 0-0145. The two studies thus provided remarkably similar findings. However, the health services study was logistically simpler and less expensive than the community-based
study. The application of the sisterhood method in health services is clearly only appropriate in certain circumstances. Further detailed analyses of the Nicaraguan data are underway to characterise the population of health service users and to devise guidelines on suitable settings for this low-cost and efficient approach to estimating maternal mortality. Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1 E 7HT, UK, and Ministry of Health,
Region I, Nicaragua
ISABELLA DANEL PEDRO CASTILLO WENDY GRAHAM
W, Brass W, Snow RW. Estimating maternal mortality m developing countries. Lancet 1988; i: 416-17. 2. Graham W, Brass W, Snow RW. Estimating maternal mortality using the sisterhood method. Stud Fam Plan 1989; 20: 125-35. 3. Brass W, Macrae S. Childhood mortality estimated from reports on previous births given by mothers at the time of a maternity I, preceding birth technique. Asian Pacific Forum 1985; 11: 5-8. 1. Graham
Breaking bad
news
SiR,-Since I achieved the lowest mark on our breaking bad medical school, I was interested in Dr Fallowfield’s
news course at
comprehensive review. Her report (Feb 20, p 476) draws attention to a common fallacy in this subject-that how you break bad news has a long-term impact on the recipient’s psychological outcome. There is absolutely no good evidence for this. In favour of the contention Fallowfield cites research on breast cancer psychological morbidity, but that particular study only suggests that patients who have a poor emotional outcome retrospectively view the advice they were given negatively. Which is cause and which is effect remains unclear. The only other study2 Fallowfield cites in support showed that those who received bad news delivered skillfully were more satisfied than a comparison group who dealt with professionals untrained in this -
skill. No
prospective long-term follow-up has yet demonstrated any significant impact on patients’ or relatives’ long-term adjustment of