Improving physical activity for health among inactive adults aged 50 years and older: development, design and delivery of a community-based intervention

As adults get older, they acquire more chronic health conditions, but engage in less  physical activity. Most older adults do not meet the minimum physical activity guidelines  for health. Community-based interventions can address this, but evidence is needed to  understand how they work, and for associations between accelerometer-measured  physical activity and chronic health conditions and healthcare utilisation. The objectives  of this thesis are to: inform the recruitment to, and development of an intervention to  increase physical activity in adults aged 50 years and older – Move for Life; to design a  protocol to test the feasibility of the intervention; to investigate feasibility measures; and  to test the hypothesis that physical activity is related to chronic health conditions and  healthcare use.  Methods Paper 1 was a qualitative study, involving semi-structured interviews (n=18) and four  focus groups (n=29) with older adults, advocates and professionals; data were analysed  thematically. The purpose of paper 1 was to inform the intervention development and,  specifically, to optimise intervention recruitment, sustainability and scalability. Paper 2  outlined a protocol for a three-arm cluster pilot randomised controlled trial. The setting  was eight Local Sports Partnership (LSP) hubs; each hub was a unit of randomisation (cluster), and individuals were the units of analysis (participants). The hubs were  randomised: true control, usual programme or Move for Life intervention. The true control group was given information about physical activity but was not included in a  programme; the intervention arm involved augmentation of existing physical activity classes with the Move for Life intervention; and usual care groups had physical activity  classes delivered as normal. The recruitment target was 576 participants. Data were  collected at baseline (T0), upon completion of programmes (T1) and at three-month follow-up (T2). Data collected included: demographic data, information on chronic health  conditions, healthcare utilisation data, objective physical parameters, e.g., body mass  index and grip strength. All participants were asked to wear a device on the thigh for  measuring physical activity and sedentary behaviour (activPAL). The third paper used baseline data generated from a sample of adults recruited to the trial, that provided valid  activPAL data (n=485). Hierarchical cluster analysis was conducted using the  accelerometer-measured physical activity variables. Descriptive statistics were used to  investigate associations with chronic conditions and healthcare utilisation. Paper 4  provides a description of the intervention development, using the intervention mapping protocol. The process of intervention development involved: input from key stakeholders,  evidence from the published literature, behavioural change theory, and the experience of  an interdisciplinary team, who understood the context and environment of the setting.   Results Paper 1 reported on factors for successful recruitment and sustainability: Data analysis  produced three overarching themes. “Age appropriate” explains how communication and  the environment should be adapted to the needs of adults aged 50 years and older.  “Culture and connection” refer to the interplay of individual and social factors that  influence participation, including individual fears and insecurities, group cohesion and  added value beyond the physical gains in these programmes. “Roles and partnerships” outlines how key collaborations may be identified and managed and how local ownership  is key to success and scalability.   Paper 2 outlined a protocol for a three-arm feasibility RCT. Of the 733 participants who  were recruited, 531 were given an accelerometer at T0, 485 of which provided valid data. Of these, 383 were eligible as per the study protocol, i.e., they were aged 50 years and  over and were insufficiently active. Eighty-nine of them (23%) were lost to attrition and  a further 57 (15%) did not provide valid data at T2. Of the 383 eligible participants  providing reliable data at T0, 237 provided reliable data again at T1; the retention rate at  T1 was 61.9%. Of the 485 participants who provided valid activPAL data, 381 (78.6%)  were female, and 382 (80.6%) had private health insurance. In paper 3, four distinct physical activity behaviour profiles were identified: inactive?sedentary (n = 50, 10.3%), low activity (n = 295, 60.8%), active (n = 111, 22.9%) and  very active (n = 29, 6%). The inactive-sedentary cluster had the highest prevalence of  chronic illnesses, in particular, mental illness (p = 0.006) and chronic lung disease  (p = 0.032), as well as multi-morbidity, complex multi-morbidity and healthcare  utilisation. The prevalence of any practice nurse visit (p = 0.033), outpatient attendances  (p = 0.04) and hospital admission (p = 0.034) were higher in less active clusters. The  results have provided an insight into how physical activity behaviour is associated with  chronic illness and healthcare utilisation. A group within the group has been identified  that is more likely to be unwell. Provisions need to be made to reduce barriers for  participation in physical activity for adults with complex multi-morbidity and very low  physical activity.  Discussion The intervention was designed to fit within existing group-based structured physical  activity programmes run by LSPs, thus maximising the likelihood of translation into  policy and practice. Feasibility outcomes, including recruitment strategies, programme  attendance, attrition and acceptability, are reported. Limitations of the study include the  high proportion of females and participants with private health insurance, as well as the  high baseline levels of physical activity recorded. The thesis outlines recommendations  for a full trial including: an ongoing process of engagement with men and harder to reach  groups to encourage recruitment; engagement with ‘harder to keep’ participants identified  in this study, including those with multi-morbidity and mental health diagnoses; data  collection on income and ethnicity; and approaching target communities, with a view to  active participation, earlier in the planning stage. Trial registration number: ISRCTN11235176  </p

Management of bone fragility in primary care in Ireland

This study evaluated the prevention of bone fragility fractures in a representative sample of four Irish general practices. The clinical records of 243 patients potentially at risk of bone fragility were studied. One hundred and fourteen (47%) had a dual energy x-ray absorptiometry (DEXA) scan. Osteoporosis was established in 42 (17%) and osteopaenia in 28 (11%). One hundred and fifty-two (63%) were currently being prescribed bisphosphonates. Thirty-four (22%) of those on bisphosphonates did not have a baseline DEXA scan performed prior to commencing treatment and further analysis did not show a clear rationale for initiation of the treatment in this group of patients. Forty-six (30%) patients on bisphosphonates had been prescribed them for over 5 years without any apparent review to see if they were still indicated. There was no record of any of the practices having carried out a fracture risk score assessment prior to commencing bone fragility treatment. The implications are that bone fragility management warrants urgent review

Symbiotic relationships through longitudinal integrated clerkships in general practice

Background: Longitudinal integrated clerkships (LICs) are an innovation in medical education that are often success fully implemented in general practice contexts. The aim of this study was to explore the experiences and perspectives of general practitioner (GP)-tutors on the impact of LICs on their practices, patients and the wider community. Methods: GPs affiliated with the University of Limerick School of Medicine- LIC were invited to participate in in depth interviews. Semi-structured interviews were conducted in person and over the phone and were based on a topic guide. The guide and approach to analysis were informed by symbiosis in medical education as a conceptual lens. Data were recorded, transcribed and analysed using an inductive thematic approach. Results: Twenty-two GPs participated. Two main themes were identified from interviews: ‘roles and relationships’ and ‘patient-centred physicians’. Five subthemes were identified which were: ‘GP-role model’, ‘community of learning’, and ‘mentorship’, ‘student doctors’ and ‘serving the community’. Conclusion: LICs have the potential to develop more patient-centred future doctors, who have a greater understanding of how medicine is practised in the community. The LIC model appears to have a positive impact on all stakeholders but their success hinges on having adequate support for GPs and resourcing for the practices

Recruitment and characteristics of participants in trials of physical activity for adults aged 45 years and above in general practice: a systematic review

Background: General practice is well situated to promote physical activity (PA), but with PA levels declining after 45 years of age, often those  who are most likely to benefit from interventions tend to be the least likely recruited to participate in research. Aims and rationale: The aim of this study was to investigate recruitment and reporting of participant demographics in PA trials for adults aged  45 years and above. Specific objectives were: (i) to examine the reporting of demographics of participants; (ii) to investigate the strategies used  to recruit these participants; and, (iii) to examine the efficiency of recruitment strategies. Methods: Seven databases were searched, including: PubMed, CINAHL, the Cochrane Library Register of Controlled Trials, Embase, Scopus,  PsycINFO, and Web of Science. Only randomized control trials involving adults 45 years old or older recruited through primary care were included. The PRISMA framework for systematic review was followed, which involved 2 researchers independently conducting title, abstract, and  full article screening. Tools for data extraction and synthesis were adapted from previous work on inclusivity in recruitment. Results: The searches retrieved 3,491 studies of which 12 were included for review. Sample size of the studies ranged from 31 to 1,366, with  a total of 6,042 participants of which 57% were female. Of 101 participating practices, 1 was reported as rural. Reporting of recruitment lacked  detail—only 6 studies outlined how practices were recruited. 11/12 studies involved a database or chart review to identify participants that met  the inclusion criteria, followed by a letter of invitation sent to those people. The studies with higher recruitment efficiency ratios each employed  more than 1 recruitment strategy, e.g. opportunistic invitations and telephone calls. Conclusion: This systematic review has presented deficits in the reporting of both demographics and recruitment. Future research should aim  for a standardized approach to reporting. </p

Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review

Background Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections. Aims To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers’ prescribing decisions. Methods Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review. Results Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education. Conclusion There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative

Improving quality of referral letters from primary to secondary care: a literature review and discussion paper

Background: Referral letters sent from primary to secondary or tertiary care are a crucial element in the continuity of patient information transfer. Internationally, the need for improvement in this area has been recognised. This aim of this study is to review the current literature pertaining to interventions that are designed to improve referral letter quality. Methods: A search strategy designed following a Problem, Intervention, Comparator,Outcomemodelwas used to explore the PubMed and EMBASE databases for relevant literature. Inclusion and exclusion criteria were established and bibliographies were screened for relevant resources. Results: A total of 18 publications were included in this study. Four types of interventions were described: electronic referrals were shown to have several advantages over paper referrals but were also found to impose new barriers; peer feedback increases letter quality and can decrease ‘inappropriate referrals’ by up to 50%; templates increase documentation and awareness of risk factors;mixed interventions combining different intervention types provide tangible improvements in content and appropriateness. Conclusion: Several methodological considerations were identified in the studies reviewed but our analysis demonstrates that a combination of interventions, introduced as part of a joint package and involving peer feedback can improve

Physical activity and hypertension

Hypertension and physical inactivity are leading causes of premature mortality. While both are modifiable risk factors for cardiovascular disease, their prevalence remains high. As populations grow older, they are more likely to develop hypertension and to become less physically active. Scientific advances have contributed to understanding of how physical activity improves blood pressure and the clinically relevant ambulatory blood pressure, but this is not reflected in hypertension guidelines for clinical management of hypertension. The aim of this paper is to clearly present up to date knowledge from scientific studies that underpin the role of physical activity in hypertension management. Longitudinal studies in this review demonstrate a protective effect of higher physical activity levels as well as higher levels of cardiorespiratory fitness. Interventional studies report improvements in blood pressure associated with aerobic, resistance and concurrent exercise; the improvements in some studies were greatest among participant groups with established hypertensions; the effect was observed for groups with treatment-resistant hypertension also, a clinically important subgroup. The most recent research provides evidence for the synergy between physical activity and pharmacotherapy for the treatment of hypertension, providing an opportunity for clinicians to promote physical activity as an adjunctive treatment for hypertension as well as a preventative strategy. This review critiques the evidence and summarises the most up to date literature in the field of physical activity and hypertension.</p

Irish general practitioners' view of perinatal mental health in general practice: a qualitative study

Background: Identification of perinatal mental health problems and effective care for women who experience them are important considering the potentially serious impact that they may have on the wellbeing of the woman, her baby, family and wider society. General practitioners (GPs) play a central role in identifying and supporting women and this study aimed to explore GPs' experiences of caring for women with perinatal mental health problems in primary care. The results of this study may provide guidance to inform policy, practice, research and development of curriculum and continuous professional development resources. Method: In-depth semi-structured interviews were undertaken between March and June 2017 with GPs (n = 10) affiliated with a University training programme for general practice in Ireland. Thematic data analysis was guided by Braun and Clarkes (2013) framework. Results: Data were categorised into three themes with related subthemes: identification of perinatal mental health problems, decision making around perinatal mental health and preparation for a role in perinatal mental health. GPs described the multifaceted nature of their role in supporting women experiencing perinatal mental health issues and responding to complex psychological needs. Inbuilt tools on existing software programmes prompted GPs to ask questions relating to perinatal mental health. Limited access to referral options impacts on assessment and care of women. GPs desire further continuous professional development opportunities delivered in an online format and through monthly meetings and conference sessions. Conclusions: GPs require access to culturally sensitive; community based perinatal mental health services, translation services and evidence based perinatal psychological interventions. A standardised curriculum on perinatal mental health for trainee GPs needs to be established to ensure consistency across primary care and GP education should incorporate rotations in community and psychiatry placements

Is problem alcohol use being detected and treated in Irish general practice?

Background: The pattern of alcohol consumption in Ireland has serious societal and health consequences. General practice is well placed to screen for problem alcohol use and to carry out brief interventions. The aims of this study were to investigate the prevalence of documentation of problem alcohol use in patient records in Irish general practice, and to describe the documentation of its diagnosis and treatment. Methods: General practitioners (GPs) affiliated with an Irish medical school were invited to participate in the study. One hundred patients were randomly selected from each participating practice using the practice software and the clinical records were reviewed for evidence of problem alcohol use. The following was recorded: patient demographics, whether problem alcohol use was documented, whether they had an intervention, a psychotropic medication or if a referral was made. Descriptive statistics and an estimate of the prevalence were calculated using SPSS and SAS software. Results: Seventy one percent of the practices participated (n = 40), generating a sample of 3, 845 active patients. Only 57 patients (1.5%, 95% confidence interval 1 to 2%) were identified as having problem alcohol use in the previous two years. 29 (51%) of those with documented problem alcohol use were referred to other specialist services. 28 (49%) received a psychological intervention. 40 (70%) were prescribed psychotropic medications. Conclusion: This is the first large scale study of patient records in general practice in Ireland looking at documentation of screening and treatment of problem alcohol use. It highlights the current lack of documentation of alcohol problems and the need to re-inforce positive attitudes among GPs in relation to preventive work

Benefits of post-operative oral protein supplementation in gastrointestinal surgery patients: A systematic review of clinical trials.

AIM: To evaluate published trials examining oral postoperative protein supplementation in patients having undergone gastrointestinal surgery and assessment of reported results. METHODS: Database searches (MEDLINE, BIOSIS, EMBASE, Cochrane Trials, Cinahl, and CAB), searches of reference lists of relevant papers, and expert referral were used to identify prospective randomized controlled clinical trials. The following terms were used to locate articles: “oral’’ or “enteral’’ and “postoperative care’’ or “post-surgical’’ and “proteins’’ or “milk proteins’’ or “dietary proteins’’ or “dietary supplements’’ or “nutritional supplements’’. In databases that allowed added limitations, results were limited to clinical trials that studied humans, and publications between 1990 and 2014. Quality of collated studies was evaluated using a qualitative assessment tool and the collective results interpreted. RESULTS: Searches identified 629 papers of which, following review, 7 were deemed eligible for qualitative evaluation. Protein supplementation does not appear to affect mortality but does reduce weight loss, and improve nutritional status. Reduction in grip strength deterioration was observed in a majority of studies, and approximately half of the studies described reduced complication rates. No changes in duration of hospital stay or plasma protein levels were reported. There is evidence to suggest that protein supplementation should be routinely provided post-operatively to this population. However, despite comprehensive searches, clinical trials that varied only the amount of protein provided via oral nutritional supplements (discrete from other nutritionalcomponents) were not found. At present, there is some evidence to support routinely prescribed oral nutritional supplements that contain protein for gastrointestinal surgery patients in the immediate post-operative stage. CONCLUSION: The optimal level of protein supplementation required to maximise recovery in gastrointestinal surgery patients is effectively unknown, and may warrant further study