Low exercise among children with asthma: a culture of over protection? A qualitative study of experiences and beliefs.

BACKGROUND: Research shows that children are insufficiently active in most affluent societies. Although children with asthma may particularly benefit from physical activity, they are less active than their peers. AIM: To explore the reasons for low physical activity levels among children with asthma and to identify strategies to improve activity. DESIGN OF STUDY: A qualitative study using in-depth interviews and focus groups. SETTING: Six GP practices, a Paediatric Respiratory Unit, and four schools in Tayside, Scotland. METHOD: Purposive sampling identified 30 children with asthma, their parents (n = 38) and school staff (n = 28), who were interviewed or took part in focus groups. Data were examined using constant comparative analysis. RESULTS: The lower level of activity among children with asthma was supported by a climate of fear among parents and teachers about what was safe and possible for the child. Restrictions were imposed because of perceived dangers of exercising in the presence of 'triggers'. Physical activity was regarded as a threat to be managed rather than something beneficial. Teachers found it difficult to distinguish between children who were physically incapable of exercise due to asthma and those who were unmotivated. GPs were unknowingly drawn into the controversy by children and parents who cite medical advice to sanction exemption from exercise. CONCLUSION: GPs and asthma nurses need to provide clear management plans explaining what is appropriate and safe in terms of exercise on a child-by-child basis, to counter the considerable misunderstanding and disagreement among children, parents, and teachers.

Desktop software to identify patients eligible for recruitment into a clinical trial: using SARMA to recruit to the ROAD feasibility trial.

BACKGROUND: Recruitment to trials in primary care is often difficult, particularly when practice staff need to identify study participants with acute conditions during consultations. The Scottish Acute Recruitment Management Application (SARMA) system is linked to general practice electronic medical record (EMR) systems and is designed to provide recruitment support to multi-centre trials by screening patients against trial inclusion criteria and alerting practice staff if the patient appears eligible. For patients willing to learn more about the trial, the software allows practice staff to send the patient's contact details to the research team by text message. AIM: To evaluate the ability of the software to support trial recruitment. DESIGN OF STUDY: Software evaluation embedded in a randomised controlled trial. SETTING: Five general practices in Tayside and Fife, Scotland. METHODS: SARMA was used to support recruitment to a feasibility trial (the Response to Oral Agents in Diabetes, or ROAD trial) looking at users of oral therapy in diabetes. The technical performance of the software and its utility as a recruitment tool were evaluated. RESULTS: The software was successfully installed at four of the five general practices and recruited 11 of the 29 participants for ROAD (other methods were letter and direct invitation by a practice nurse) and had a recruitment return of 35% (11 of 31 texts sent led to a recruitment). Screen failures were relatively low (7 of 31 referred). Practice staff members were positive about the system. CONCLUSION: An automated recruitment tool can support primary care trials in Scotland and has the potential to support recruitment in other jurisdictions. It offers a low-cost supplement to other trial recruitment methods and is likely to have a much lower screen failure rate than blanket approaches such as mailshots and newspaper campaigns.

What can health care professionals in the United Kingdom learn from Malawi?

Debate on how resource-rich countries and their health care professionals should help the plight of sub-Saharan Africa appears locked in a mind-set dominated by gloomy statistics and one-way monetary aid. Having established a project to link primary care clinics based on two-way sharing of education rather than one-way aid, our United Kingdom colleagues often ask us: "But what can we learn from Malawi?" A recent fact-finding visit to Malawi helped us clarify some aspects of health care that may be of relevance to health care professionals in the developed world, including the United Kingdom. This commentary article is focused on encouraging debate and discussion as to how we might wish to re-think our relationship with colleagues in other health care environments and consider how we can work together on a theme of two-way shared learning rather than one-way aid.

Early experience of the use of short message service (SMS) technology in routine clinical care.

OBJECTIVE: To conduct a technical appraisal and qualitative interviews with short message service (SMS--mobile phone text message) users in mainstream health care. DESIGN: Observation of service usage followed by in-depth semi-structured interviews. SETTING: A National Health Service (NHS) general practice in Scotland. PARTICIPANTS: One hundred and eighty patients registered. MAIN OUTCOME MEASURES: Service utilisation and patients' views. RESULTS: It was technically feasible to open up access to mainstream NHS general practice services using SMS for appointment booking, repeat prescription ordering, clinical enquiries and remote access to the core clinical summary. CONCLUSION: Patients were able to use SMS services responsibly and found automation of prescription ordering particularly useful. Service utilisation was modest and did not adversely impact on the workload of general practitioners (GPs) or their staff.

Exploring and explaining low participation in physical activity among children and young people with asthma: a review.

BACKGROUND: Asthma is the most common chronic illness among children and accounts for 1 in 5 of all child GP consultations. This paper reviews and discusses recent literature outlining the growing problem of physical inactivity among young people with asthma and explores the psychosocial dimensions that may explain inactivity levels and potentially relevant interventions and strategies, and the principles that should underpin them. METHODS: A narrative review based on an extensive and documented search of search of CinAHL, Embase, Medline, PsycINFO and the Cochrane Library. RESULTS & DISCUSSION: Children and young people with asthma are generally less active than their non-asthmatic peers. Reduced participation may be influenced by organisational policies, family illness beliefs and behaviours, health care advice, and inaccurate symptom perception and attribution. Schools can be reluctant to encourage children to take part in physical education or normal play activity due to misunderstanding and a lack of clear corporate guidance. Families may accept a child's low level of activity if it is perceived that breathlessness or the need to take extra inhalers is harmful. Many young people themselves appear to accept sub-optimal control of symptoms and frequently misinterpret healthy shortness of breath on exercising with the symptoms of an impending asthma attack. CONCLUSION: A multi-faceted approach is needed to translate the rhetoric of increasing activity levels in young people to the reality of improved fitness. Physical activity leading to improved fitness should become part of a goal orientated management strategy by schools, families, health care professionals and individuals. Exercise induced asthma should be regarded as a marker of poor control and a need to increase fitness rather as an excuse for inactivity. Individuals' perceptual accuracy deserves further research attention.

The twinning of Scottish general practices and Malawian clinics: the provision of email and internet services.

Many patients and health care professionals in the developed world are uncomfortable about doing nothing in the face of the glaring inequities in health care between their own environment and that of Africa. In an effort to 'think global, act local' a Scottish GP practice used personal contacts to build a twinning link with a clinic serving a township in Malawi. This article describes the experience of establishing e-mail and internet services for Malawian health care staff to afford them the same level of access as developed world staff enjoy in accessing educational materials and professional supports. Using our twin link as an exemplar we are now matching other Scottish General Practices to Malawian Clinics around a common theme of modern communication media.

The UK General Practice Airways Group (GPIAG): its formation, development, and influence on the management of asthma and other respiratory diseases over the last twenty years.

This article describes the formation and development of the UK General Practice Airways Group (GPIAG), from its inception as a small respiratory special-interest group founded by six general practitioners in 1987 through to its transformation into the largest primary care specialist society in the UK. It highlights the historical context in which the GPIAG was founded - at a time when there was increasing concern about under-treatment and under-diagnosis of asthma in primary care - and describes the way in which its foundation was one of the major influences that led to profound innovation in the primary care management of respiratory disease as well as changes across the primary/secondary care interface. The GPIAG is now a registered charity, has an expanding membership, and has acquired a high profile both nationally and internationally as an advisory body on policy and strategy for the management of respiratory disease in primary care. This review is a 20th anniversary tribute not only to those who have contributed to the success of the GPIAG over the last twenty years, but also to its current membership who enable the GPIAG to continue working towards its charitable aim of "optimal respiratory care for all."

Clinical symptoms and 'off-label' prescribing in children with asthma.

A UK-wide database of structured asthma review consultations was used to investigate the prevalence of 'off-label' anti-asthma prescriptions in relationship to clinical symptoms of asthma control. The 1050 children (6.1%) aged 16 years or under issued with an off-label prescription reported more nighttime, daytime and activity asthma symptoms, and used more short-acting beta(2)-agonist medication than their peers. Off-label prescribing for children with asthma in UK primary care is associated with worse levels of self-reported asthma control.

Patient and health care professional views and experiences of computer agent-supported health care.

OBJECTIVES: To explore patient and health care professional (HCP) views towards the use of multi-agent computer systems in their GP practice. DESIGN: Qualitative analysis of in-depth interviews and analysis of transcriptions. SETTING: Urban health centre in Dundee, Scotland. PARTICIPANTS: Five representative healthcare professionals and 11 patients. MAIN OUTCOME MEASURES: Emergent themes from interviews revealed participants' attitudes and beliefs, which were coded and indexed. RESULTS: Patients and HCPs had similar beliefs, attitudes and views towards the implementation of multi-agent systems (MAS). Both felt modern communication methods were useful to supplement, not supplant, face-to-face consultations between doctors and patients. This was based on the immense trust these patients placed in their doctors in this practice, which extended to trust in their choice of communication technology and security. Rapid access to medical information increased patients' sense of shared partnership and self-efficacy. Patients and HCPs expressed respect for each other's time and were keen to embrace technology that made interactions more efficient, including for the altruistic benefit of others less technically competent. CONCLUSIONS: Patients and HCPs welcomed the introduction of agent technology to the delivery of health care. Widespread use will depend more on the trust patients place in their own GP than on technological issues.

An academic, pharmaceutical and practice collaboration to implement asthma guidelines.

AIMS: To investigate whether a patient review service changes the management of asthma in accordance with BTS/SIGN Guidelines. METHODS: An observational study of routine review consultations for patients with asthma registered at 862 practices throughout the United Kingdom. Practices recorded reviews on a computer template and returned the information to an academic unit for analysis. RESULTS: 41,493 patients had data returned with 14,790 (36%) patients reporting symptoms at rest or on a daily basis and 15,840 (38%) patients over-using their short-acting beta2-agonist. 4,556 (74%) of patients with symptoms who had a subsequent consultation reported a reduction in their symptoms, whilst 3,932 (63%) reported a reduction in short-acting beta2-agonist use. Night-time, daytime, and activity symptom scores, and short-acting beta2-agonist use, were significantly reduced for patients reviewed more than once. CONCLUSION: There are a large proportion of patients suffering symptoms at rest or on a daily basis. There was a significant reduction in symptom levels and use of reliever medication for patients who were reviewed. A review service implementing the BTS/SIGN guidelines for asthma management would seem to improve patient outcomes.

Deliberate self-harm cases: a primary care perspective.

AIM: To observe case ascertainment and one-year outcome among patients presenting with deliberate self-harm (DSH) in an urban practice. METHOD: In this exploratory study, primary care team members recorded all DSH episodes presenting over six months and then tracked their pattern of care over the next 12 months using practice IT systems, patient records and discussions with staff who were involved with patients meeting inclusion criteria. Interviews were held with primary care team members, secondary care staff and voluntary sector staff. Patients were also offered an interview with the community psychiatric nurse, using local NHS trust global assessment and community department risk assessment tools. Relevant data from these sources were then collated and cross-referenced to identify any patterns. RESULTS: Twenty five patients aged between 15 and 44 (19 females) presented at the practice during the six-month period, 15 had taken a drug overdose, nine had self-cut, and one had involved self-stabbing. Most had a long history of similar episodes and substance use and misuse was almost universal. All patients were still alive after 12 months. Of the 13 patients initially in contact with secondary care services, only one established ongoing care. The remainder had very high use of GP services, often in a chaotic manner. CONCLUSION: DSH could best be regarded as a long-term health condition. Support services and intervention opportunities should be configured from within, not outside, general practice. There should be greater liaison between primary and secondary care and increased support for the primary care team.

A survey of GP attitudes to and experiences of email consultations.

Email is an accepted part of modern communication in business and education. The use of email could benefit communication between patients and healthcare professionals. Use of email within health care has been hampered by concerns about privacy, technical barriers, perceived fear of change and increased workload.Sixty-two general practitioners within Dundee in east Scotland responded to a questionnaire and indicated that they regularly used email for communication within their practices and with outside agencies, but rarely with patients. Many perceived a need to provide an email service for clinical enquiries and repeat prescription requests but felt constrained from doing so by a lack of an accepted system and workload concerns.

Email consultations in general practice.

BACKGROUND: Email is an established method of communication in business, leisure and education but not yet health care. AIM: To evaluate an email service enabling communication between patients and their general practice regarding repeat prescriptions, appointment booking and clinical enquiries. DESIGN: Qualitative analysis of interactions and an electronic user survey. SETTING: An urban practice in Dundee, Scotland. PARTICIPANTS: 150 patients aged 24 to 85. METHODS: We set up a practice facility to allow our patients to use email to book appointments, order repeat prescriptions and consult their general practitioner (GP). RESULTS: Patient satisfaction with the service was very high. Patients specifically commended the practice for setting up a facility to allow communication outside standard working hours and for the ease of ordering repeat prescriptions. Patients were pleased to have a means of seeking their doctor's comment or opinion without bothering him or her by making and attending a formal face-to-face consultation. Email dialogue was polite, factual, but less formal than standard letters. Staff did not experience any perceptible rise in workload. CONCLUSIONS: Use of an email consultation facility worked well within an urban practice, was deemed helpful by patients, and resulted in no apparent increase in GP workload. Our results suggest that there may be an unmet need amongst patients for clinical email services, and that such services may have positive outcomes for patients and practices.

Variance in practice emergency medical admission rates: can it be explained?

BACKGROUND: Emergency admission rates have been rising steadily in recent years, with the majority of the increase owing to emergency medical admissions. Possible causative factors include changing demography, incidence of disease, admission thresholds, multiple admissions, and appropriateness of admission. AIM: To investigate the impact of patient and practice factors on variance in general practices' emergency medical admissions rates. DESIGN OF STUDY: Multiple regression analysis relating emergency medical admission rates of general practices to patient and practice characteristics. SETTING: The study was conducted between 1996 and 1997 in the acute hospital trust serving the study area, Dundee, Scotland. METHOD: Scottish Morbidity Record 1 (SMR1) data, which contains details of all hospital consultant episodes, was used to calculate individual practices emergency medical admission rates. These rates were then standardised to an expected value of 100. Forward selection was used to find a suitable multiple regression model to predict each practice's emergency medical admission rate from practice and patient variables. RESULTS: Crude emergency medical admission rates for general practices showed a 1.8-fold variation between the top and bottom deciles. The deprivation status and age of patients explained 42% of the variance in admission rates (64% with the exclusion of one practice that had a poor fit to the model). After correcting for age and deprivation there was a 1.2-fold variation in general practices' emergency medical admission rates. CONCLUSION: The most important factors in explaining variance in general practices' emergency medical admission rates are socio-demographic, with age and deprivation explaining a large proportion of the variation. We found no evidence to support the contention that general practice factors were linked with admission rates.