A qualitative synthesis of the perceived factors that affect participation in physical activity among children and adolescents with type 1 diabetes.

AIMS: To explore the qualitative literature on the perceived factors, positive and negative, affecting participation by children and adolescents with type 1 diabetes in physical activity, from the perspective of children and adolescents with type 1 diabetes, their family members, teachers or sports coaches, and healthcare professionals. METHODS: MEDLINE, SPORTDiscus, PsycINFO, CINAHL and Scopus were systematically searched in July 2019. Eligible studies included any that reported qualitative findings on the perceived factors that affect participation in physical activity from either the perspective of children or adolescents with type 1 diabetes, their family members, teachers or coaches, and healthcare professionals. RESULTS: The literature search yielded a total of 7859 studies, of which 14 (13 qualitative studies and one mixed-methods study) met the review inclusion criteria. In total there were 12 unique populations containing 270 individuals, 105 children or adolescents with type 1 diabetes,108 family members, 37 teachers and 20 healthcare professionals. The main factors thought to influence physical activity for this population were the individual characteristics of children and adolescents, the requirement for self-blood glucose regulation, support systems including friends, family, teachers and professionals, education and knowledge, and communication. CONCLUSIONS: This review synthesizes views on the perceived factors from several different perspectives. The findings suggest that it is important to consider the needs of the wider support network, as well as the child's or adolescent's concerns and preferences, when developing new or existing strategies and programmes to promote physical activity in children and adolescents with type 1 diabetes.

Associations between neighbourhood environmental factors and the uptake and effectiveness of a brief intervention to increase physical activity: findings from deprived urban communities in an English city.

Background: Evidence suggests behavioural interventions may exacerbate health inequalities, potentially due to differences in uptake or effectiveness. We used a physical activity intervention targeting deprived communities to identify neighbourhood-level factors that might explain differences in programme impact. Methods: Individuals aged 40-65 were sent a postal invitation offering a brief intervention to increase physical activity. We used postcodes linkage to determine whether neighbourhood indicators of deprivation, housing, crime and proximity to green spaces and leisure facilities predicted uptake of the initial invitation or an increase in physical activity level in those receiving the brief intervention. Results: A total of 4134 (6.8%) individuals responded to the initial invitation and of those receiving the intervention and contactable after 3 months, 486 (51.6%) reported an increase in physical activity. Area deprivation scores linked to postcodes predicted intervention uptake, but not intervention effectiveness. Neighbourhood indicators did not predict either uptake or intervention effectiveness. Conclusions: The main barrier to using brief intervention invitations to increase physical activity in deprived, middle-aged populations was the low uptake of an intervention requiring significant time and motivation from participants. Once individuals have taken up the intervention offer, neighbourhood characteristics did not appear to be significant barriers to successful lifestyle change.

Social and psychosocial factors associated with high-risk sexual behaviour among university students in the United Kingdom: a web-survey.

In the UK there are limited data about university students' risky sexual behaviour. A cross-sectional web-survey was conducted to investigate factors associated with high-risk sex among students at two UK universities. High-risk sex was reported by 25% of 1108. High personal sexually transmitted infection (STI) risk perception and permissive attitudes towards casual sex were associated with high-risk sex for both men (odds ratio [OR]: 12.12; 95% confidence interval [CI]: 4.10-35.81; OR: 2.49; 95%CI: 1.11-5.56, respectively) and women (OR: 22.31; 95% CI: 9.34-53.26; OR: 3.02; 95% CI: 1.82-5.01, respectively). For men, drinking alcohol (OR: 17.67; 95% CI: 1.90-164.23) and for women age and frequent drinking (OR: 2.02; 95% CI: 1.05-3.89; OR: 1.89; 95% CI: 1.08-3.31, respectively) were associated with high-risk sex. However, perceiving an average student as more likely to contract STIs (men, OR: 0.34; 95% CI: 0.16-0.75) or HIV (men, OR: 0.44; 95% CI: 0.20-0.96; women, OR: 0.42; 95% CI: 0.28-0.63) and finding it difficult to discuss sexual matters (women, OR: 0.60; 95% CI: 0.39-0.91) were negatively associated with high-risk sex. Most of the factors found were similar to other populations, but some psychosocial factors showed complex patterns of association that require further investigation.

Reducing inequalities in access to health care: developing a toolkit through action research.

PROBLEM: Healthcare organisations are expected both to monitor inequalities in access to health services and also to act to improve access and increase equity in service provision. DESIGN: Locally developed action research projects with an explicit objective of reducing inequalities in access. SETTING: Eight different health care services in the Yorkshire and Humber region, including community based palliative care, general practice asthma care, hospital based cardiology clinics, and termination of pregnancy services. KEY MEASURES FOR IMPROVEMENT: Changes in service provision, increasing attendance rates in targeted groups. STRATEGIES FOR CHANGE: Local teams identified the population concerned and appropriate interventions using both published and grey literature. Where change to service provision was achieved, local data were collected to monitor the impact of service change. EFFECTS OF CHANGE: A number of evidence based changes to service provision were proposed and implemented with variable success. Service uptake increased in some of the targeted populations. LESSONS LEARNT: Interventions to improve access must be sensitive to local settings and need both practical and managerial support to succeed. It is particularly difficult to improve access effectively if services are already struggling to meet current demand. Key elements for successful interventions included effective local leadership, identification of an intervention which is both evidence based and locally practicable, and identification of additional resources to support increased activity. A "toolkit" has been developed to support the identification and implementation of appropriate changes.

Characteristics of non-responders to diabetes service use questionnaires.

Postal surveys of service use are likely to overestimate health service use and may also underestimate health needs in the population. A historical cohort study, using postal questionnaires and medical records, showed that non-respondents are registered at addresses in more-deprived wards, they are less likely to have attended a hospital diabetes clinic (38% vs 45%) and much less likely to have had a diabetes review in general practice (11% vs 26%). An analysis based on questionnaire respondents would only therefore both underestimate the level of material deprivation and overestimate the proportion receiving routine reviews in general practice in a population with a chronic condition.

Inequalities in access to diabetes care: evidence from a historical cohort study.

OBJECTIVE: To establish which factors predict attendance at a hospital diabetes clinic and for diabetes review in general practice. DESIGN: A historical cohort study of individuals with diabetes identified from general practice records. Information on service contacts and other clinical, social, and demographic variables was collected from general practice records and postal questionnaires. SETTING: Seven Leicestershire general practices. SUBJECTS: Individuals registered with study practices who had a diagnosis of diabetes made before 1990. MAIN OUTCOME MEASUREMENTS: Attendance at a hospital diabetes clinic or for a documented diabetes review in general practice at least once between 1990 and 1995. RESULTS: 124 (20%) had at least one recorded diabetes review in general practice and 332 (54%) attended a hospital diabetes clinic at least once. The main predictors of attending a hospital clinic were younger age, longer duration of diabetes, and treatment with insulin. Access to a car (OR 1.34, 95% CI 1.06 to 1.71), home ownership (OR 1.48, 95% CI 1.14 to 1.58) and a non-manual occupation (OR 1.56, 95% CI 1.09 to 2.24) were all associated with an increased likelihood of attending, although living in a less deprived area was not. The main predictors of attending for review in general practice were older age, less co-morbidity, and being white. Living in a more deprived area was related to a reduced chance of review in general practice (OR 0.81, 95% CI 0.76 to 0.86) while individual socioeconomic indicators were not. CONCLUSIONS: Whilst an indicator of area deprivation predicts reduced likelihood of review in general practice, individual indicators predict reduced likelihood of attending outpatients. This suggests a need for different approaches to tackling inequalities in access to care in primary and secondary care settings.

Factors associated with seeking emergency treatment following suspected chemical contamination of a leisure pool.

A leisure pool was evacuated when children complained of breathing difficulties, cough, and eye irritation subsequently thought to be due to high chloramine levels. The duration of the suspected contamination before the evacuation was unknown: it was suggested that some subsequent attendances at accident and emergency (A&E) departments had been prompted by news reports of the incident. The extent and nature of symptoms, the cause of the incident, and the impact of media reporting were investigated with the help of a postal questionnaire. One hundred and thirty-seven people (all but six under 20 years of age) attended A&E departments after the incident, most commonly with sore eyes (79%), cough (76%), and sore throat (71%). The number of different symptoms was associated with the length of time spent at the pool, but not with being present at the time of the evacuation or with having heard about the incident on radio or television.

Screening for Type 2 diabetes mellitus: a decision analytic approach.

AIMS: Screening for asymptomatic Type 2 diabetes mellitus has been advocated on the grounds that diabetes is a common condition associated with increased morbidity and mortality, but uncertainty remains about the impact of early treatment. This study aimed to determine whether the potential benefits of screening are likely to outweigh the potential harm and to explore which variables significantly influence the balance of benefit and harm resulting from screening. METHODS: A decision analysis comparing the relative impact of using a single fasting blood glucose screening test, between the ages of 45 and 60 years, with the impact of not screening. The model weighs the increase in quality adjusted life years (QALYs) from reduction in microvascular and cardiovascular complications against the potential decrease in QALYs associated with earlier diagnosis and treatment in an asymptomatic population. RESULTS: The baseline model suggests a saving of 10 QALYs for every 10,000 individuals screened: a gain of four from postponed microvascular complications and 17 from avoided cardiovascular complications, as opposed to a loss of 11 as a result of earlier diagnosis in screening detected cases. The balance of benefit and harm is sensitive to baseline cardiovascular risk, the effectiveness of cardiovascular interventions and the relative disutility assigned to early diagnosis and treatment for an individual without symptoms. CONCLUSIONS: The immediate disutility of earlier diagnosis and additional treatment may be greater than the potential long-term benefit from postponing microvascular complications. Screening decisions should therefore be based largely on consideration of cardiovascular risk and the availability of evidence based interventions to reduce cardiovascular risk.

Do diabetes clinic attendees stay out of hospital? A matched case-control study.

AIMS: To examine whether routine care for diabetes mellitus influences the risk of hospital admission. METHODS: All people with diabetes in five randomly selected general practices in the city of Leicester were identified from medical records and prescribing information. Cases with a hospital admission between 1992 and 1995 but no admission in the preceding 2 years were compared with age-matched controls in a nested study. RESULTS: The variables significantly associated with an increased risk of admission were duration of diabetes in years (OR 1.07, 95% confidence interval (CI) 1.03-1.11) and number of non-diabetic drugs prescribed (OR 1.51, 95% CI 1.27-1.79). Having attended a hospital clinic in the previous 2 years was associated with reduced risk of admission (OR 0.30, 95% CI 0.14-0.65), whilst having been seen for a diabetes review in general practice was not (OR 0.91, 95% CI 0.41-1.99). Similar results were found for both diabetes-related and unrelated admissions. CONCLUSIONS: Although general practice-based review was not associated with a change in the risk of admission, attendance at a hospital clinic was associated with a decreased risk of admission. These results may be explained by the characteristics of those who attend hospital clinics, as well as by the possible effectiveness of access to specialist services in reducing admissions.

Can the distance fallen predict serious injury after a fall from a height?

BACKGROUND: After a fall, the distance fallen is sometimes used to predict the injury severity. We aimed to examine how distance fallen performs as a predictor of major injury. METHOD: A cohort of trauma victims attending our emergency department after having fallen from a height was identified retrospectively, and data were collected regarding the fall and injuries sustained. Performance of threshold heights, ranging from 2 meters (6.6 feet) to 10 meters (32.8 feet), as a diagnostic test for major injury was assessed. RESULTS: Height fallen performed poorly over the range of thresholds used. At low thresholds, sensitivity was inadequate to rule out major trauma, whereas the low prevalence meant that, despite impressive specificity at higher thresholds, positive predictive value was poor. At the optimal threshold of 5 meters (16.4 feet), the positive predictive value was 0.17 and sensitivity was 0.33. CONCLUSION: Height of fall is a poor predictor of major injury.

How do individuals with diabetes use the accident and emergency department?

OBJECTIVE: To determine whether the frequency and pattern of use of the accident and emergency (A&E) department by individuals with diabetes is different from that of the general population. METHODS: A historical cohort of 696 individuals with diabetes from six randomly selected general practices and a non-diabetic comparison cohort matched on age, sex, and general practice were identified. The use of an urban A&E department by the two cohorts was compared for number of visits between 1984 and 1996 for injuries, diabetes related and non-diabetes related illness, proportion referred by a general practitioner, proportion arriving by ambulance, and proportion admitted. RESULTS: More visits were made by the diabetic cohort (1002 v 706, P = 0.0001); 121 visits were directly related to diabetes, including 52 for hypoglycaemia. The diabetic cohort also had more visits for medical illness unrelated to diabetes (357 v 231, P = 0.0001). The number of visits for injuries was similar (524 v 475, P = 0.3). Individuals with diabetes who attended A&E were not significantly more likely to be referred by a general practitioner (14% v 16%) or admitted (20% v 17%). CONCLUSIONS: Individuals with diabetes made more frequent visits than the general population to the A&E department. Since there was no excess of visits for injuries and the proportion requiring admission was similar, the hypothesis that they have a different threshold for attending is not supported.

Trauma triage: a comparison of CRAMS and TRTS in a UK population.

The CRAMS scale and the Triage Revised Trauma Score (TRTS) were compared to assess their potential use as a prehospital method of activating hospital trauma teams. We studied patients from the resuscitation room of Leeds General Infirmary who had enough data recorded to allow calculation of the admission TRTS and CRAMS scale. Patients were defined as having major injury if they died in hospital, were admitted to the ICU or had an Injury Severity Score (ISS) of > 15. Each triage scale was compared by calculating multiple sensitivity/specificity pairs and plotting the results on a receiver operator (ROC) curve. The optimal cut-offs on each scale were compared directly. Ninety-seven (46 per cent) of a total of 213 patients fulfilled the study criteria for major injury. The best cut-off points were a CRAMS of < 9 and a TRTS of < 12. The TRTS was significantly more specific (0.9 versus 0.75) but at a cost of poor sensitivity (0.6 versus 0.69, not significant). The performance of both scales was similar when compared on the ROC curve. CRAMS and the TRTS were unable to identify major injuries in our sample with sensitivity and specificity adequate to support their use as a tool to activate trauma teams in the UK.

Why don't all general practices offer structured diabetes care? A comparison of practices that do not with those that do.

The aim of the study was to examine whether the minority of practices not qualifying for payment for structured diabetes care programmes differ systematically from those that do. Information was collected for all Leicestershire general practices on practice size, population structure, deprivation indices, diabetes related admissions over two years and number of insulin treated patients on the district register. The 21 practices not offering structured diabetes care had a median list size of 3204, compared to 6340 for the other 124 practices (P < 0.001). Jarman and Townsend scores were higher for these practices and estimated prevalence of diabetes was 29% higher (95% CI: 26-32%). Crude admission rates were significantly higher in those practices not offering structured care. However rates adjusted for diabetes prevalence were similar (39.3 vs 39.2 per 100 insulin treated diabetics per year, P = 0.9). These results suggest that some practices face specific problems related both to small practice size and higher prevalence. If these issues are not addressed, inequalities in access to diabetes care between practice populations will persist. There is no evidence that the provision of structured care is associated with lower admission rates in this district. However more information, particularly in relation to prevalence of diabetes, is needed in order to accurately quantify this relationship. Variations in prevalence between practices should be adjusted for in any comparison of admission rates or spurious conclusions may be drawn.