Children and Adolescents’ Affective Responses to Physical Activity

Abstract Research suggests that optimising affect during exercise may be key to exercise adherence (Van Landuyt, Ekkekakis, Hall & Petruzzello, 2000; Williams et al. 2008; 2012). Recent advances in this area have explored factors that contribute to affective responses in adult populations (Ekkekakis, 2003), but whilst it has been hypothesised that these factors are the same for children and adolescents they have not been explored systematically in the same way. As such, one aim of this thesis was to investigate the relationships between affect and physical activity in child and adolescent populations. Following on from this, a further aim was to explore the factors that contribute to affective responses. Given the research that suggests positive affect experienced during exercise may result in enhanced adherence to physical activity (Williams et al. 2012), the final aim of this study was to determine how to elicit the most positive affective responses during an acute exercise session. This thesis comprises a review of relevant literature, and six study chapters which were the result of three empirical studies; two acute exercise studies and one questionnaire based study. The findings of Study 1 demonstrated that, as with adults, affective responses declined after the onset of ventilatory threshold in both children and adolescents, indicating that to achieve optimum affective responses, particularly with younger children, exercise needs to be prescribed at an intensity below the ventilatory threshold. The findings from studies 2 - 4 highlighted specific factors that contribute to affective responses, reporting that preference for, and tolerance of, different exercise intensities may be an important factor to consider when prescribing exercise (studies 2 & 4). Results also showed that affective associations with physical activity played a significant role in determining overall physical activity behaviour (study 3). The findings from studies 4 and 5a and b revealed that encouraging adolescents to self-select their own exercise intensity may elicit a more positive affective response during the exercise session compared to the affective responses elicited during a prescribed exercise session. This thesis provides substantial evidence to support the link between affect and physical activity in children and adolescents. More specifically, it highlights several important factors that should be considered when attempting to enhance affective responses during an acute exercise session

Addressing Obesity in Stevenage, Hertfordshire: A Consultation with Young People

Public Health England have identified that almost a quarter of children are overweight when they start primary school, which increases to a third when they leave in year 6 aged 10-11 years. This has implications for young peoples’ physical and mental health and also later in adult life. The newly launched NIHR Applied Research Collaboration (ARC) East of England is focusing on selected areas of health inequality and this includes neighbourhoods in Stevenage, Hertfordshire which have high rates of childhood obesity. In order to find out what young people think about these issues, Hertfordshire County Council and the University of Hertfordshire carried out a collaborative project in 2019. Hertfordshire County Council have adopted a Whole Systems approach to obesity and are keen to engage with young people in order to prioritise issues identified by them. The importance of ‘involving’ young people in shaping services has been widely documented. Two researchers met twice with 56 young people (from a range of schools) aged 16 years who were attending the National Citizen Service (NCS) scheme at a school in Stevenage in the summer holidays. A number of involvement activities were carried out during the sessions. The young people, with help from the researchers, facilitated their own informal discussion groups, using maps, flips charts, post-it notes and an anonymous suggestion box. The first session did not mention obesity but allowed open discussion about what it was like to live in Stevenage and the second session focussed more on the issue of ‘obesity and weight’. The young people were encouraged to find their own solutions and imagine if they “were in charge”. The four main themes that came from the sessions were; affordability, crime and anti-social behaviour, transport and places to go and eat. A number of solutions were suggested by the young people which included; healthy environment (e.g. cycle paths, street lights, regulation of shops), community approach (e.g. more affordable sports activities), schools (e.g. raise awareness, promote sport), focus on young people (e.g. activities for young people and healthy affordable eating outlets) and helping people maintain a healthy weight. The priorities identified by local young people and the wider issues they raised are important to take into consideration when shaping any intervention or public health initiative, especially when considering the wider determinants of health. Listening to the issues and solutions and using the language of young people is vital and young people should be included in co-designing any services that are aimed at them. Involving local young people who know an area and who can identify important issues is vital for any successful public health intervention

Can previously sedentary females use the feeling scale to regulate exercise intensity in a gym environment? an observational study

Background Recent research suggests that the Feeling Scale (FS) can be used as a method of exercise intensity regulation to maintain a positive affective response during exercise. However, research to date has been carried out in laboratories and is not representative of natural exercise environments. The purpose of this study was to evaluate whether sedentary women can self-regulate their exercise intensity using the FS to experience positive affective responses in a gym environment using their own choice of exercise mode; cycling or treadmill. Methods Fourteen females (24.9 years ± 5.2; height 166.7 ± 5.7 cm; mass 66.3 ± 13.4 kg; BMI 24.1 ± 5.5)) completed a submaximal exercise test and each individual’s ventilatory threshold (V˙T) was identified. Following this, three 20 min gym-based exercise trials, either on a bike or treadmill were performed at an intensity that was self-selected and perceived to correspond to the FS value of +3 (good). Oxygen uptake, heart rate (HR) and ratings of perceived exertion (RPE) were measured during exercise at the participants chosen intensity. Results Results indicated that on average participants worked close to their V˙T and increased their exercise intensity during the 20-min session. Participants worked physiologically harder during cycling exercise. Consistency of oxygen uptake, HR and RPE across the exercise trials was high. Conclusion The data indicate that previously sedentary women can use the FS in an ecological setting to regulate their exercise intensity and that regulating intensity to feel ‘good’ should lead to individuals exercising at an intensity that would result in cardiovascular gains if maintained

Determining the Relationship Between Seizure-Free Days and Other Predictors of Quality of Life in Patients with Dravet Syndrome and Their Carers from FFA Registration Studies

INTRODUCTION Dravet syndrome (DS) is a rare, lifelong epileptic encephalopathy characterised by frequent and severe seizures associated with premature mortality. Typically diagnosed in infancy, patients also experience progressive behavioural, motor-function and cognitive decline. Twenty percent of patients do not reach adulthood. Quality of life (QoL) is impaired for both patients and their carers. Reducing convulsive seizure frequency, increasing convulsive seizure-free days (SFDs) and improving patient/carer QoL are primary treatment goals in DS. This study explored the relationship between SFDs and patients' and carers' QoL to inform a cost-utility analysis of fenfluramine (FFA). METHODS In FFA registration studies, patients (or their carer proxies) completed the Paediatric QoL inventory (PedsQL). These data were mapped to EuroQol-5 Dimensions Youth version (EQ-5D-Y) to provide patient utilities. Carer utilities were collected using EQ-5D-5L and mapped to EQ-5D-3L to align patient and carer QoL on the same scale. Linear mixed-effects and panel regression models were tested and Hausman tests identified the most appropriate approach for each group. On this basis, a linear mixed-effects regression model was used to examine the relationships between patient EQ-5D-Y and clinically relevant variables (age, frequency of SFDs per 28 days, motor impairments and treatment dose). A linear panel regression model examined the relationship between SFDs and carer QoL. RESULTS After adjustment for age and underlying comorbidities, the patient regression model showed that SFDs per 28 days was a significant predictor of QoL. Each additional patient-SFD increased utility by 0.005 (p < 0.001). The carer linear panel model also showed that increasing SFDs per 28 days was a significant predictor of improved QoL. Each additional SFD increased carer utility by 0.014 (p < 0.001). CONCLUSION This regression framework highlights that SFDs are significantly correlated with both patients' and carers' QoL. Treatment with effective antiseizure medications that increase SFDs directly improves QoL for patients and their carers

Key considerations when involving children in health intervention design: reflections on working in partnership with South Asian children in the UK on a tailored Management and Intervention for Asthma (MIA) study

Participatory research is an empowering process through which individuals can increase control over their lives, and allows researchers/clinicians to gain a clearer understanding of a child’s needs. However, involving children in participatory research is still relatively novel, despite national and international mandates to engage children in decision making. This paper draws on the learnings from designing the Management and Intervention for Asthma (MIA) study, which used a collaborative participatory method to develop an intervention-planning framework for South Asian children with asthma. There are currently 1 million children in the UK receiving treatment for asthma, making it one of the most prevalent chronic childhood illnesses. Symptoms of asthma are often underrecognized in children from South Asian communities in the UK, contributing to increased disease severity and increased attendance at the emergency department compared to White British children. Despite this, ethnic minorities are often excluded from research and thus absent from the ‘evidence base’, making it essential to hear their perspectives if health inequalities are to be successfully addressed. We worked alongside healthcare professionals, community facilitators, parents, and children to identify the key concerns and priorities they had and then designed the framework around their needs. Reflecting on the process, we identified several key considerations that need to be addressed when co-developing interventions with children. These include the power dynamics between the parent/researcher and child; navigating the consent/assent process; how parental involvement might affect the research; establishing a convenient time and location; how to keep children engaged throughout the process; tailoring activities to different levels of ability; and accounting for cultural differences. These factors were considered by the researchers when designing the study, however, implementing them was not without its challenges and highlighted the need for researchers to develop expertise in this field. Tailoring existing research methods allowed us to explore children’s perceptions, priorities, and experiences of illness more effectively. However, involving children in participatory research is a complex undertaking, and researchers need to ensure that they have the expertise, time, and resources necessary to be able to fully support the needs of child participants before deciding to commit to this approach

Using a picture-based book to support epilepsy care in clinical consultations for people with intellectual disabilities

Background and aims People with intellectual disabilities are more likely to have epilepsy than the general population. A picture-based book, Getting on with Epilepsy, may help to improve their epilepsy management and quality of life. The present study aimed to explore how the book could be best used in routine clinical care. Methods Twenty people with epilepsy and intellectual disabilities were video-recorded using the Getting on with Epilepsy book with a nurse or doctor. This was analysed using conversation analytic methods. Eighteen patients and five clinicians took part in interviews to explore their views on book use, which were thematically analysed. All data were then synthesised to form themes. Results Three themes were identified which demonstrated the importance of (1) understanding the book depicted seizures (2) relating the book to the participants’ experiences (3) using the book as an education and information tool. The themes highlighted the techniques and approaches that clinicians used to facilitate understanding. Some tensions and differences were noted between training and implementation in routine practice, particularly around prompts in themes 1 and 3 intended to correct or change participants’ interpretation of the book. Conclusions The Getting on with Epilepsy book can be used in routine clinical practice to support people with intellectual disabilities and epilepsy. There was a balance between exploring patients’ narratives and understanding with the need to convey clinical information, and this may also apply to the use of other accessible resources

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

The use of a collaborative structured methodology for the development of a multifaceted intervention programme for the management of asthma (the MIA project), tailored to the needs of children and families of South Asian origin: a community-based, participatory study

Background: Asthma is one of the most common chronic childhood illnesses in the UK. South Asian children are more likely to suffer from their asthma and be admitted to hospital. While this inequality needs to be addressed, standard behaviour-change interventions are known to be less successful in minority ethnic groups. Evidence suggests a need to enhance services provided to ethnic minority communities by developing culturally sensitive tailored interventions. Objectives: The Management and Interventions for Asthma (MIA) project aimed to test an iterative multiphase participatory approach to intervention development underpinned by the socioecological model of health, producing an intervention-planning framework and enhancing an evidence-based understanding of asthma management in South Asian and White British children. Design: Interviews and focus groups facilitated by community facilitators (CFs) were used to explore knowledge and perceptions of asthma among South Asian communities, children, families and healthcare professionals (HCPs). A smaller comparison group of White British families was recruited to identify aspects of asthma management that could be addressed either by generic interventions or by a tailored approach. Collaborative workshops were held to develop an intervention planning framework and to prioritise an aspect of asthma management that would be used as an exemplar for the development of the tailored, multifaceted asthma intervention programme. Setting: The community study was based in a largely urban environment in Leicester, UK. Participants: Participants were recruited directly from the South Asian (Indian, Pakistani and Bangladeshi) and White British communities, and through the NHS. Children were aged between 4 and 12 years, with a range of asthma severity. Intervention development: The study had four phases. Phase 1 consisted of an evidence review of barriers and facilitators to asthma management in South Asian children. Phase 2 explored lay understandings of childhood asthma and its management among South Asian community members (n = 63). Phase 3 explored perceptions and experiences of asthma management among South Asian (n = 82) and White British families (n = 31) and HCP perspectives (n = 37). Using a modified intervention mapping approach incorporating psychological theory, phase 4 developed an intervention planning framework addressing the whole asthma pathway leading to the development of an exemplar multifaceted, integrated intervention programme called ‘ACT [Awareness, Context (cultural and organisational) and Training] on Asthma’. Results: Data on the social patterning of perceptions of asthma and a lack of alignment between the organisation of health services, and the priorities and competencies of British South Asian communities and families were produced. Eleven key problem areas along the asthma pathway were identified. A four-arm multifaceted tailored programme, ‘ACT on Asthma’, was developed, focusing on the theme ‘getting a diagnosis’. This theme was chosen following prioritisation by families during the collaborative workshops, demonstrating the participatory, iterative, phased approach used for the intervention design. Conclusions: The MIA study demonstrated barriers to optimal asthma management in children at the family, provider and healthcare system levels and across the whole asthma pathway. Interventions need to address each of these levels to be effective. Minority ethnic communities can be successfully engaged in collaborative intervention development with a community-focused and culturally sensitive methodology. Future work: Further research is required to (1) assess the feasibility and effectiveness of the proposed ‘ACT on Asthma’ programme, (2) develop methods to increase active participation of children in research and service development, (3) develop and test strategies to enhance public understanding of asthma in South Asian communities and (4) identify effective means of engaging the wider family in optimising asthma management. Funding: The National Institute for Health Research Health Services and Delivery Research programme