No abstract

Acute respiratory infections are the leading cause of childhood death in developing countries. Current efforts at mortality control focus on case management and immunization, but other preventive strategies may have a broader and more sustainable effect. This review, commissioned by the World Health Organization, examines the relations between pneumonia and nutritional factors and estimates the potential effect of nutritional interventions. Low birth weight, malnutrition (as assessed through anthropometry), and lack of breast-feeding appear to be important risk factors for childhood pneumonia, and nutritional interventions may have a sizeable effect in reducing deaths from pneumonia. For all regions except Latin America, interventions to prevent malnutrition and low birth weight look more promising than does breast-feeding promotion. In Latin America, breast-feeding promotion would have an effect similar to that of improving birth weights, whereas interventions to prevent malnutrition are likely to have less of an effect. These findings emphasize the need for tailoring interventions to specific national and even local conditions. Am J Clin Nutr 1999;70:309-20.

Objectives To describe and evaluate two different models of a clinical informaticist service. Design A case study approach, using various qualitative methods to illuminate the complexity of the project groups' experiences. Setting UK primary health care. Interventions Two informaticist projects to provide evidence based answers to questions arising in clinical practice and thereby support high quality clinical decision making by practitioners.

Objective: Using a nationally representative sample, to identify groups among British children aged 1 1 = 2 À 4 1 = 2 years who report similar patterns of diet. Design: Nationally representative dietary survey, using 4 d weighed dietary records, of girls and boys aged 1 1 = 2 À 4 1 = 2 years living in private households in Great Britain in 1992-1993. Cluster analysis was used to aggregate individuals into diet groups. Setting: Great Britain. Participants: Eight hundred and forty-eight boys and 827 girls. Results: Three clusters were identified for girls and three for boys. Among boys the most prevalent cluster was 'Healthy Diet' (52?3 %), the second was 'Convenience Diet' (38?3 %) and the third was 'Traditional Diet' (9?3 %). Among girls, the most prevalent dietary cluster was 'Healthy Diet' (58?7 %), followed by a 'Convenience Diet' (36?6 %) and 'Traditional Diet' (4?3 %). There were important differences in nutrient profile, sociodemographic and behavioural characteristics between clusters. Conclusions: Cluster analysis identified three groups among both girls and boys which differed not only in terms of reported dietary intake, but also with respect to nutrient intake, social and behavioural characteristics. The groups identified could provide a useful basis for the development, monitoring and targeting of public health nutrition policy for pre-school children in the UK. Further research is needed on the consequences for chronic disease in the future for these children.

Objectives To explore general practitioners' perceptions of effective health care and its application in their own practice; to examine how these perceptions relate to assumptions about clinicians' values and behaviour implicit in the evidence based medicine approach. Design A qualitative study using semistructured interviews. Setting Eight general practices in North Thames region that were part of the Medical Research Council General Practice Research Framework. Participants 24 general practitioners, three from each practice. Main outcome measures Respondents' definitions of effective health care, reasons for not practising effectively according to their own criteria, sources of information used to answer clinical questions about patients, reasons for making changes in clinical practice. Results Three categories of definitions emerged: clinical, patient related, and resource related. Patient factors were the main reason given for not practising effectively; others were lack of time, doctors' lack of knowledge and skills, lack of resources, and "human failings." Main sources of information used in situations of clinical uncertainty were general practitioner partners and hospital doctors. Contact with hospital doctors and observation of hospital practice were just as likely as information from medical and scientific literature to bring about changes in clinical practice. Conclusions The findings suggest that the central assumptions of the evidence based medicine paradigm may not be shared by many general practitioners, making its application in general practice problematic. The promotion of effective care in general practice requires a broader vision and a more pragmatic approach which takes account of practitioners' concerns and is compatible with the complex nature of their work.