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Inequalities in the burden of sudden and unexpected deaths in infancy make targeted action by health professionals a viable option for intervention. Most of the deaths that now occur have at least one known modifiable risk factor present, so the potential impact of supporting families with implementing safer sleep strategies is great and may bring about a further reduction in infant deaths. This article describes the latest evidence for action on three of the major risk factors for SIDS: sleeping position; smoking; and co-sleeping. It will go on to discuss how to translate this evidence into effective communication strategies for families, including giving information about why or how the messages increase safety for sleeping babies.

IntroductionBrain-related visual impairments, also known as cerebral visual impairment (CVI), are related to damage or poor function in the vision-related areas of the brain. There is broad agreement that CVI is an appropriate term to describe visual impairments that are not accounted by disorders of the eye or optic nerve, but differences remain as to which impairments can be included in this term. The CVI project is a programme of work that includes the development of a complex intervention to share knowledge with teachers, so that they can make both targeted and universal changes to support children with CVI. A feasibility study for a cluster-randomised controlled trial to evaluate this intervention is underway. This paper describes the protocol for an accompanying process evaluation to explore how the intervention is implemented and provide context for the interpretation of the feasibility trial outcomes.Methods and analysisA logic model has been developed to guide data collection. Both qualitative and quantitative data will be collected to assess the feasibility and acceptability of the intervention, the study design and explore how any changes that occur are brought about. Interviews with key primary school staff and parents will investigate responses to the intervention and trial processes. Surveys will collect data on intervention implementation and knowledge of CVI. Photographs of classroom walls will document any changes to visual clutter and document analysis will look for changes to school special educational needs and disability (SEND) policies.Ethics and disseminationEthical approval was granted by the University of Bristol Faculty of Health Sciences Ethics Committee. Findings will contribute to the development of a full-scale cluster-randomised controlled trial to assess the effectiveness of the intervention with adequate statistical power. The results will also support the refinement of the intervention and its underlying theory.

BackgroundAdvice to families to sleep infants on their backs, avoid smoke exposure, reduce excess bedcovering and avoid specific risks associated with cosleeping has greatly reduced sudden unexpected death in infancy (SUDI) rates worldwide. The fall in rates has not been equal across all groups, and this advice has been less effective for more socially deprived families. Understanding decision-making processes of families with infants at risk would support the development of more effective interventions.AimTo synthesise the qualitative evidence on parental decision-making for the infant sleep environment among families with children considered to be at increased risk of SUDI.MethodsThis study was one of three related reviews of the literature for the Child Safeguarding Practice Review Panel’s National Review in England into SUDI in families where the children are considered at risk of harm. A systematic search of eight online databases was carried out in December 2019. Metasynthesis was conducted, with themes extracted from each paper, starting with the earliest publication first.ResultsThe wider review returned 3367 papers, with 16 papers (across 13 studies) specifically referring to parental decision-making. Six overall themes were identified from the synthesis: (1) knowledge as different from action; (2) external advice must be credible; (3) comfort, convenience and disruption to the routine; (4) plausibility and mechanisms of protection; (5) meanings of safety and risk mitigation using alternative strategies; and (6) parents’ own expertise, experience and instincts.ConclusionInterventions that are intended to improve the uptake of safer sleep advice in families with infants at risk of sleep-related SUDI need to be based on credible advice with mechanisms of protection that are understandable, consistent with other sources, widened to all carers of the infant and fit within the complex practice of caring for infants.

ObjectiveTo investigate mothers’ knowledge of reducing the risks for sudden infant death syndrome (SIDS) and attitudes towards safer sleep practices.Design and settingA cross-sectional survey was carried out in deprived areas of Bristol, UK. Recruitment took place in 2014 at local health visitor-led baby clinics.ParticipantsOf 432 mothers approached, 400 (93%) completed the face-to-face survey. Participants with infants at ‘higher’ risk of SIDS (using an algorithm based on a previous observational study) were compared with those at ‘lower’ risk.Main outcome measuresThe survey asked participants to recall three SIDS risk reduction strategies (unprompted), and scored responses to 14 SIDS risk-related infant sleep scenarios (prompted).ResultsOverall, 48/400 (12%) mothers were classified as higher risk. Mothers in the higher risk group were less likely to breast feed (multivariate OR=3.59(95% CI 1.46 to 8.86)), less likely to be able to cite two or more unprompted correct SIDS risk reduction strategies (multivariate OR=2.05(95% CI 1.02 to 4.13)) and scored lower on prompted safer sleep scenarios overall.Notably, only 206/400 (52%) of all mothers surveyed (33% in the higher risk group) from these deprived areas in Bristol identified infant sleep position as a risk reduction strategy for SIDS, despite 25 years of campaigns.ConclusionsMothers in the higher risk group were disadvantaged when it came to some aspects of knowledge of SIDS risk reduction and attitudes to safer sleep. The initial ‘Back-to Sleep’ message that dramatically reduced these deaths a generation ago needs more effective promotion for today’s generation of mothers.

ObjectiveTo independently assess compliance with safe sleeping guidelines for infants DesignFull-day, in-situ observations of childcare practices (including sleep and non-sleep periods) conducted in 2016–2017.SettingAustralian home-based and centre-based licensed childcare services. All subject to national regulation and legislation to comply with safe sleeping guidelines.ParticipantsThe sample was 18 licensed childcare settings (15 centre-based, 3 home-based) that had infants Main outcomes and measuresStandard observations of childcare practices, including a 20-item infant Safe Sleeping Guideline checklist. Educator characteristics, including each individual’s knowledge, beliefs and attitudes regarding safe sleeping practices.Results83% of childcare services were observed to be non-compliant on at least 1 of 20 target guidelines (median 2.5, max=7); 44% were observed placing infants prone/side and 67% used loose bedding, quilts, doonas/duvets, pillows, sheepskins or soft toys in cots. 71% of the childcare settings had a copy of current safe sleeping guidelines displayed either in or at entry to the infant sleep room.ConclusionDespite 25 years of public health messaging, non-compliance with safe sleeping guidelines was observed to be high in childcare services. Understanding of the reasons underlying non-compliance, particularly in contexts were legislative mandate and access to information regarding safe sleeping is high, is critical to informing ongoing public health messaging and should be the focus of future studies.Trial registration numberANZCTR 12618001056280—pre-results.

ObjectivesIn 2008, new statutory national procedures for responding to unexpected child deaths were introduced throughout England. There has, to date, been no national audit of these procedures.Study designFamilies bereaved by the unexpected death of a child under 4 years of age since 2008 were invited to participate. Factors contributing to the death and investigations after the death were explored. Telephone interviews were conducted, and coroners’ documents were obtained. The nature and quality of investigations was compared with the required procedures; information on each case was reviewed by a multiagency panel; and the death was categorised using the Avon clinicopathological classification.ResultsData were obtained from 91 bereaved families (64 infant deaths and 27 children aged 1–3 years); 85 remained unexplained after postmortem examination. Documentation of multiagency assessments was poorly recorded. Most (88%) families received a home visit from the police, but few (37%) received joint visits by police and healthcare professionals. Postmortem examinations closely followed national guidance; 94% involved paediatric pathologists; 61% of families had a final meeting with a paediatrician to explain the investigation outcome. There was no improvement in frequency of home visits by health professionals or final meetings with paediatricians between 2008–2013 and 2014–2017 and no improvement in parental satisfaction with the process.ConclusionsStatutory procedures need to be followed more closely. The implementation of a national child mortality database from 2019 will allow continuing audit of the quality of investigations after unexpected child deaths. An important area amenable to improvement is increased involvement by paediatricians.

ObjectivesTo investigate whether decreased otoacoustic emission (OAE) signal recordings in the right ear are associated with an increased risk of sudden infant death syndrome (SIDS) and to monitor any temporal changes in risk factors.DesignRetrospective case–control study.SettingTelephone interviews with families recruited in England between July 2016 and October 2017 who experienced the unexpected death of a child ParticipantsWe recruited 91 (89%) of the 102 bereaved families who made initial contact, 64 deaths were under 1 year (sudden unexpected death in infancy) of which 60 remained unexplained (SIDS). Of the 220 control families, 194 (88%) follow-up interviews were conducted. We had analysable hearing data for 24 SIDS infants (40%) and 98 controls (51%).ResultsOAE signals were marginally increased rather than decreased among SIDS infants for the right ear, especially at lower frequencies, but not significantly so. The strongest predictors of SIDS were bed-sharing in hazardous (infant sleeping next to a carer who smoked, drank alcohol or slept on a sofa) circumstances (35% vs 3% controls, pConclusionsHearing data were difficult to obtain; larger numbers would be needed to determine if asymmetrical differences between the right and left ear were a marker for SIDS. A national prospective registry for monitoring and a renewed campaign to a new generation of parents needs to be considered underlining the initial message to place infants on their backs for sleep and the more recent message to avoid bed-sharing in hazardous circumstances.

ObjectivesCerebral visual impairment (CVI) comprises a heterogeneous group of brain-related vision problems. A core outcome set (COS) represents the most important condition-specific outcomes according to patients, carers, professionals and researchers. We aimed to produce a COS for studies evaluating interventions for children with CVI, to increase the relevance of research for families and professionals and thereby to improve outcomes for affected children.DesignWe used methods recommended by the Core Outcome Measures in Effectiveness Trials Initiative. These included a proportionate literature review of outcomes used in previous studies; qualitative interviews with children and families; a two-round Delphi survey involving parents, children and professionals and a consensus meeting to ratify the most important outcomes.SettingTelephone interviews and online Delphi surveys of participants who all lived in UK or Eire.ParticipantsEighteen parents and six young people were interviewed. Delphi participants (n=80 did both rounds) included professionals working with children who have CVI (teachers, orthoptists, ophthalmologists, optometrists, qualified teachers for visually impaired, family members (parents and siblings) and affected children.ResultsThe literature review included 13 studies yielding 37 outcomes. Qualitative interviews provided 22 outcomes. After combining and refining similar items, the first round contained 23 outcomes and the second 46. At the consensus meeting, 5 attendees recommended 27 outcomes for inclusion in the CVI COS, of which 15 were ratified as most important, including 4 related to vision; 1 to family well-being; 1 to adults around the child being informed about CVI and the rest to the child’s abilities to engage with people and surroundings.ConclusionsGood engagement from participants led to the development of a COS. Future research will be useful to identify the best ways to measure COS items and potentially to update this COS as more interventions for CVI are developed.Trial registration numberISRCTN13762177.

IntroductionCerebral visual impairment (CVI) refers to a spectrum of brain-related vision problems. CVI is associated with poor educational and mental health outcomes. An intervention has been developed to help children with CVI, involving input from clinicians, teachers and parents. The effectiveness of this intervention needs to be evaluated. This study aims to guide any refinements to the intervention or the design of a future cluster-randomised trial that may be needed.Methods and analysisThis study will include all methods anticipated for a future cluster-randomised controlled trial. Eight primary schools will be recruited and randomised to receive the intervention or carry on with usual practice. The intervention will comprise an information pack for schools and access to a local paediatric ophthalmology clinic (who are prepared to assess them for CVI), for up to 5% of participating children. Outcome assessments will be carried out at baseline (before randomisation) and after 4–5 months of intervention period. Assessments will include children’s self-reported quality of life, their learning ability and behaviour as reported by teachers, and family functioning reported by parents. Cost data will include service use, family expenditure on additional support (eg, private appointments and administration) and school spending and resource used in helping children with special educational needs or disability. A process evaluation (PE) will collect additional data relating to the implementation of the intervention and the trial processes, in the school and clinic settings. The protocol for the PE will be reported separately.Ethics and disseminationEthical permission was obtained from the University of Bristol Faculty of Health Sciences Ethical Committee. The results will inform the design of a future trial to assess the effectiveness and cost-effectiveness of the intervention and will be shared with participants, CVI-support groups and peer-viewed journals.Trial registration numberISRCTN13762177; Pre-results.

In the 1980s, sudden infant death syndrome (also known as SIDS or cot death) was one of the most common post-neonatal causes of death in the UK. The dramatic 80% fall in these deaths over the last three decades is a testament to evidence-based research using the observational case–control study and even more impressive given the difficulties in funding studies without a randomized controlled trial design. This chapter will describe the initial breakthrough in the early 1990s, the characteristic profile of SIDS, the associated factors identified, the potential causal mechanisms, and the current risk reduction messages. Most of the risk reduction messages are non-controversial and have been readily accepted by health professionals and parents alike. The divergence of opinion regarding how we give preventative advice surrounding infant bed sharing and the strategies employed is addressed in more detail.

Despite the fall in numbers of unexpected infant deaths that followed the ‘Back to Sleep’ campaigns in the early 1990s in the UK and many other countries, such deaths remain one of the largest single groups of deaths in the postneonatal period in many Western countries. Changes in the ways in which unexpected infant deaths are categorised by pathologists and coroners, and increasing reluctance to use the term ‘sudden infant death syndrome’, make assessment of nationally and internationally collected data on incidence potentially inaccurate and confusing. In this paper, we review current understanding of the epidemiology and aetiology of unexpected deaths in infancy, and current hypotheses on the pathophysiology of the processes that may lead to death. We also review interventions that have been adopted, with variable degrees of effectiveness in efforts to reduce the numbers of deaths, and new approaches that offer the possibility of prevention in the future.

AIM: To describe how recipients of portable sleeping spaces (PSSs) for babies received and used these devices, offered as emergency baby beds in earthquake-ravaged Christchurch, New Zealand, 2011. METHOD: The PSS package responded to increased risk to babies from disrupted living and sleeping conditions in families. 'Door-to-door' distribution offered easy access to those in need. A subgroup of recipients gave feedback via a survey. RESULTS: From 642 families who received PSSs between March and August, 139 were invited to complete a survey on usage and 100 (72%) responded. Risks identified were 'earthquake related' (82%), bed-sharing (41%), smoking in pregnancy (26%) and prematurity or low birthweight (11%). PSSs were used for same-bed co-sleeping by 87%. They were used even though most families (96%) also had a cot or bassinet. Features most appreciated were 'having baby close' (90%), 'peace of mind' (88%) and portability (74%). CONCLUSION: PSSs were acceptable to parents and used as instructed. Enabling physical protection of babies when same-bed co-sleeping, they gave peace of mind to parents. PSSs could be considered in ordinary times for protecting babies from sudden infant death. Language: en

Aim This paper describes the usage, impact and reach of an online education tool for preventing sudden infant death. Methods A 24-slide presentation was formatted for online access. Content was designed for mainstream audiences to align current knowledge, attitudes and actions for a blitz approach to preventing sudden infant death in New Zealand (NZ). The tool was promoted through a network of ‘safe sleep’ champions across the country and collected basic information on usage, reach and impact. Results From 3286 completed online sessions between 18 November 2009 and 31 December 2011, there were 2683 (81.7%) with complete data. Average usage was 24.4 completed sessions/week, over a 2-year period, at a cost of NZD1.11 per completed session. Usage reached across regions, ethnic groups and roles. On completion of the course, most rated highly (7–9/9) (68.8%) their ‘increased confidence’ to discuss infant sleep safety with others. A high increased confidence rating was significantly influenced by spending more time per slide (P

CONTEXT: Swaddling is a traditional practice of wrapping infants to promote calming and sleep. Although the benefits and risks of swaddling in general have been studied, the practice in relation to sudden infant death syndrome remains unclear. OBJECTIVE: The goal of this study was to conduct an individual-level meta-analysis of sudden infant death syndrome risk for infants swaddled for sleep. DATA SOURCES: Additional data on sleeping position and age were provided by authors of included studies. STUDY SELECTION: Observational studies that measured swaddling for the last or reference sleep were included. DATA EXTRACTION: Of 283 articles screened, 4 studies met the inclusion criteria. RESULTS: There was significant heterogeneity among studies (I2 = 65.5%; P = .03), and a random effects model was therefore used for analysis. The overall age-adjusted pooled odds ratio (OR) for swaddling in all 4 studies was 1.58 (95% confidence interval [CI], 0.97–2.58). Removing the most recent study conducted in the United Kingdom reduced the heterogeneity (I2 = 28.2%; P = .25) and provided a pooled OR (using a fixed effects model) of 1.38 (95% CI, 1.05–1.80). Swaddling risk varied according to position placed for sleep; the risk was highest for prone sleeping (OR, 12.99 [95% CI, 4.14–40.77]), followed by side sleeping (OR, 3.16 [95% CI, 2.08–4.81]) and supine sleeping (OR, 1.93 [95% CI, 1.27–2.93]). Limited evidence suggested swaddling risk increased with infant age and was associated with a twofold risk for infants aged >6 months. LIMITATIONS: Heterogeneity among the few studies available, imprecise definitions of swaddling, and difficulties controlling for further known risks make interpretation difficult. CONCLUSIONS: Current advice to avoid front or side positions for sleep especially applies to infants who are swaddled. Consideration should be given to an age after which swaddling should be discouraged.

Background: women of lower educational attainment tend to have poorer quality diets and lower food involvement (an indicator of the priority given to food) than women of higher educational attainment. The present study reports a study of the role of food involvement in the relationship between educational attainment and quality of diet in young women. Methods: the first phase uses six focus group discussions (n = 28) to explore the function of food involvement in shaping the food choices of women of lower and higher educational attainment with young children. The second phase is a survey that examines the relationship between educational attainment and quality of diet in women, and explores the role of mediating factors identified by the focus group discussions. Results: the focus groups suggested that lower food involvement in women of lower educational attainment might be associated with negative affect (i.e. an observable expression of negative emotion), and that this might mean that they did not place a high priority on eating a good quality diet. In support of this hypothesis, the survey of 1010 UK women found that 14% of the effect of educational attainment on food involvement was mediated through the woman's affect (P ? 0.001), and that 9% of the effect of educational attainment on quality of diet was mediated through food involvement (P ? 0.001). Conclusions: women who leave school with fewer qualifications may have poorer quality diets than women with more qualifications because they tend to have a lower level of food involvement, partly attributed to a more negative affect. Interventions to improve women's mood may benefit their quality of diet

Effective communication is necessary for good relationships between healthcare practitioners and clients. This study examined barriers and facilitators to implementing new communication skills. One hundred and ten Sure Start Children's Centre staff attended one of 13 follow-up workshops in Southampton, UK between May 2009 and February 2011 to reflect on the use of new skills following a training course in communication, reflection and problem-solving. Barriers and facilitators were assessed with an adapted Problematic Experiences of Therapy scale (PETS). Staff reported frequency of skill use, and described what made it more difficult or easier to use the skills. Complete data were available for 101 trainees. The PETS indicated that staff had confidence in using the skills, but felt that there were practical barriers to using them, such as lack of time. Skills were used less often when staff perceived parents not to be engaging with them (Spearman's correlation r(s) = -0.42, P < 0.001), when staff felt less confident to use the skills (r(s) = -0.37, P < 0.001) and when there were more practical barriers (r(s) = -0.37, P < 0.001). In support of findings from the PETS, content analysis of free text responses suggested that the main barrier was a perceived lack of time to implement new skills. Facilitators included seeing the benefits of using the skills, finding opportunities and having good relationships with parents. Understanding the range of barriers and facilitators to implementation is essential when developing training to facilitate ongoing support and sustain skill use. Special attention should be given to exploring trainees' perceptions of time, to be able to address this significant barrier to skill implementation. Staff training requires a multi-faceted approach to address the range of perceived barriers.

For more than 25 years we have known that infants placed prone for sleep are at increased risk of dying unexpectedly, and avoiding the prone sleep position for infants leads to a much lower incidence of such deaths.1 2 What is less clear, despite many published investigations into the physiology and possible pathophysiology of sleep position in infants, is why this is the case. Multiple hypotheses of varying credibility have been proposed to account for the association between infants sleeping prone and increased risk of unexpected deaths,3 4 but no single clear pathophysiological mechanism has yet been identified to fully explain the link between observed physiology and the pathway leading to death. Physiological studies to date suggest the possibility of multiple, probably interacting mechanisms making infants more vulnerable in the prone sleep position. Several physiological features of the prone sleeping position in infants have been identified

Objective: Qualitative interviews with mothers of babies at higher risk of sudden infant death syndrome (SIDS) were carried out to understand their views and decision-making process on the infant sleep environment and safe sleep messages.Design and setting: Twenty semi-structured interviews were conducted between February and November 2014 in deprived areas of Bristol, UK. Mothers were asked about their decision-making for the infant sleep environment and safe sleep messages including infant sleep position, co-sleeping, smoking, dummy use, feeding and disrupted routines. The interviews were transcribed, coded and thematic analysis carried out.Participants: Participants were invited based on an algorithm developed in a previous SIDS case control study that identified an increased risk of SIDS from four demographic characteristics: young maternal age, smoking during pregnancy, three or more children, and a measure of deprivation. The presence of three, or more characteristics led to being invited to take part in the qualitative study.Results: Factors influencing mothers' adherence to the safe sleep messages included previous experience and the credibility of the advice given. They described disrupted routines that led to risky scenarios with a belief that occasional risks were acceptable. Where circumstances made following the advice more difficult they found alternative strategies to reduce the risk, including the use of movement monitors, regular checking and a belief that lighter maternal sleep in the presence of a baby was protective.Conclusions: Safer sleep messages should be tailored to fit with the lived realities of mothers, especially those at higher risk. The traditional list of 'do's' and 'don'ts' was not well accepted by this group. Interventions that seek to influence this higher-risk group should acknowledge mothers' own protective instincts and consider their beliefs and understanding behind the safer sleep messages if they are to be effective and encourage this group to change.

For much of human history infant survival has been largely predicated by close and continuous contact between the infant and the primary carer - almost always the mother. Many factors in post-industrial human society - notably tobacco smoking, alcohol intake and the use of recreational drugs- have been associated with increased risk to infants sleeping in close proximity to their mothers. This is particularly true for mothers who choose not to breastfeed. The question of the risks and possible benefits of bed-sharing for mothers who plan to breastfeed, do not smoke, do not drink alcohol or take recreational drugs, and are aware of how to ensure a safe infant sleep environment need to be quantified. In this paper we review the evidence from several epidemiological studies and identify the factors that make bedsharing more or less hazardous for the infant. This analysis is important in allowing us to give parents accurate and unbiased information on which to make their own choices about optimal night time care of their infants without demonising normal parental behaviour or practices.

Objective\ud \ud The risk of sudden infant death syndrome (SIDS) among infants who co-sleep in the absence of hazardous circumstances is unclear and needs to be quantified.\ud \ud Design\ud \ud Combined individual-analysis of two population-based case-control studies of SIDS infants and controls comparable for age and time of last sleep.\ud \ud Setting\ud \ud Parents of 400 SIDS infants and 1386 controls provided information from five English health regions between 1993–6 (population: 17.7 million) and one of these regions between 2003–6 (population:4.9 million).\ud \ud Results\ud \ud Over a third of SIDS infants (36%) were found co-sleeping with an adult at the time of death compared to 15% of control infants after the reference sleep (multivariate OR = 3.9 [95% CI: 2.7–5.6]). The multivariable risk associated with co-sleeping on a sofa (OR = 18.3 [95% CI: 7.1–47.4]) or next to a parent who drank more than two units of alcohol (OR = 18.3 [95% CI: 7.7–43.5]) was very high and significant for infants of all ages. The risk associated with co-sleeping next to someone who smoked was significant for infants under 3 months old (OR = 8.9 [95% CI: 5.3–15.1]) but not for older infants (OR = 1.4 [95% CI: 0.7–2.8]). The multivariable risk associated with bed-sharing in the absence of these hazards was not significant overall (OR = 1.1 [95% CI: 0.6–2.0]), for infants less than 3 months old (OR = 1.6 [95% CI: 0.96–2.7]), and was in the direction of protection for older infants (OR = 0.1 [95% CI: 0.01–0.5]). Dummy use was associated with a lower risk of SIDS only among co-sleepers and prone sleeping was a higher risk only among infants sleeping alone.\ud \ud Conclusion\ud \ud These findings support a public health strategy that underlines specific hazardous co-sleeping environments parents should avoid. Sofa-sharing is not a safe alternative to bed-sharing and bed-sharing should be avoided if parents consume alcohol, smoke or take drugs or if the infant is pre-term.

A total of 148 health and social care practitioners were trained in skills to support behaviour change: creating opportunities to discuss health behaviours, using open discovery questions, listening, reflecting and goal-setting. At three time points post-training, use of the skills was evaluated and compared with use of skills by untrained practitioners. Trained practitioners demonstrated significantly greater use of these client-centred skills to support behaviour change compared to their untrained peers up to 1 year post-training. Because it uses existing services to deliver support for behaviour change, this training intervention has the potential to improve public health at relatively low cost.

Faltering growth of a baby in the womb and in infancy has been linked to the risk of developing chronic diseases later in life. The growth of a baby is dependent on its nutritional status, which is strongly influenced by the mother’s own eating habits (1) . Research has shown that women who are disadvantaged by leaving school with few or no qualifications eat a less-balanced and poorer-quality diet than women with qualifications (2) . Previous research suggests that differing levels of food involvement (the importance of food in an individual’s life) might explain differences in the quality of diet of these two groups of women (3) . This research was based on the construct of food involvement (4) . This notion of food involvement was explored by analysing six focus group transcripts, three from discussions with women of lower educational attainment (LEA) and three from discussions with women of higher educational attainment (HEA). Discussions were coded according to the five stages of the feeding cycle (acquisition, preparation, cooking, eating and disposal of food) as described previously (5) , on which the construct of food involvement (4) is based. The results of discussions with women of LEA were compared with those from women of HEA. Differences between the women of LEA and HEA were identified in the areas of acquisition, cooking and eating. There was very little discussion about preparation and disposal of food and both groups of women commented on these areas in a similar way. Women of LEA stated that what food they acquired was largely dictated by its cost and what they felt their partners and children would eat. Women of LEA also described how they felt it was important to cook for their partners and children but they did not value themselves enough to feed themselves properly. Some mentioned that they would enjoy cooking more if they lived alone. There was an absence of discussion about the enjoyment of eating food from the women of LEA, compared with the women of HEA who mentioned enjoying trying new foods, sitting down to eat with their family and going out to eat with friends and family. There appeared to be important differences between the two groups of women in what influenced their patterns of acquisition. Women of LEA seemed to feel they had less control over what food they bought. A lack of a sense of self worth in the women of LEA seemed to underlie the differences between the two groups of women in terms of their involvement in the cooking and eating of food, and there were also differences in how the two groups of women described their enjoyment of these areas of food involvement. Women of HEA spoke about how past experiences had encouraged them to experience the social aspect of cooking and eating, whereas the women of LEA did not speak about enjoyment or socialising as part of cooking and eating and described no past experiences where this notion could have been introduced. In women of LEA a perceived need to feed everyone before themselves and put their own dietary requirements last might begin to explain the differences in food involvement in women of LEA in Southampton. The lack of discussion in the areas of disposal and preparation of food suggest that the feeding cycle as described previously (5) may not be the ideal model to qualitatively conceptualise food involvement.

Purpose To establish whether the association between milk intake and prostate cancer operates via the insulin-like growth factor (IGF) pathway (including IGF-I, IGF-II, IGFBP-1, IGFBP-2, and IGFBP-3). Methods Systematic review, collating data from all relevant studies examining associations of milk with IGF, and those examining associations of IGF with prostate cancer risk and progression. Data were extracted from experimental and observational studies conducted in either humans or animals, and analyzed using meta-analysis where possible, with summary data presented otherwise. Results One hundred and seventy-two studies met the inclusion criteria: 31 examining the milk–IGF relationship; 132 examining the IGF–prostate cancer relationship in humans; and 10 animal studies examining the IGF–prostate cancer relationship. There was moderate evidence that circulating IGF-I and IGFBP-3 increase with milk (and dairy protein) intake (an estimated standardized effect size of 0.10 SD increase in IGF-I and 0.05 SD in IGFBP-3 per 1 SD increase in milk intake). There was moderate evidence that prostate cancer risk increased with IGF-I (Random effects meta-analysis OR per SD increase in IGF-I 1.09; 95% CI 1.03, 1.16; n = 51 studies) and decreased with IGFBP-3 (OR 0.90; 0.83, 0.98; n = 39 studies), but not with other growth factors. The IGFBP-3 -202A/C single nucleotide polymorphism was positively associated with prostate cancer (pooled OR for A/C vs. AA = 1.22; 95% CI 0.84, 1.79; OR for C/C vs. AA = 1.51; 1.03, 2.21, n = 8 studies). No strong associations were observed for IGF-II, IGFBP-1 or IGFBP-2 with either milk intake or prostate cancer risk. There was little consistency within the data extracted from the small number of animal studies. There was additional evidence to suggest that the suppression of IGF-II can reduce tumor size, and contradictory evidence with regards to the effect of IGFBP-3 suppression on tumor progression. Conclusion IGF-I is a potential mechanism underlying the observed associations between milk intake and prostate cancer risk. Electronic supplementary material The online version of this article (doi:10.1007/s10552-017-0883-1) contains supplementary material, which is available to authorized users.