The Daily Mile as a public health intervention : a rapid ethnographic assessment of uptake and implementation in South London, UK

Background: Existing evidence identifies health benefits for children of additional daily physical activity (PA) on a range of cardiovascular and metabolic outcomes. The Daily Mile (TDM) is a popular scheme designed to increase children’s PA within the school day. Emerging evidence indicates that participation in TDM can increase children’s PA, reduce sedentarism and reduce skinfold measures. However, little is known about the potential effects of TDM as a public health intervention, and the benefits and disbenefits that might flow from wider implementation in ‘real world’ settings. Methods: We aimed to identify how TDM is being implemented in a naturalistic setting, and what implications this has for its potential impact on population health. We undertook a rapid ethnographic assessment of uptake and implementation in Lewisham, south London. Data included interviews (n = 22) and focus groups (n = 11) with stakeholders; observations of implementation in 12 classes; and analysis of routine data sources to identify school level factors associated with uptake. Results: Of the 69 primary schools in one borough, 33 (48%) had adopted TDM by September 2018. There were no significant differences between adopters and non-adopters in mean school population size (means 377 vs 397, P = 0.70), mean percentage of children eligible for free school meals (16.2 vs 14.3%, P = 0.39), or mean percentage of children from Black and Minority Ethnic populations (76.3 vs 78.2%, P = 0.41). Addressing obesity was a key incentive for adoption, although a range of health and educational benefits were also hypothesised to accrue from participation. Mapping TDM to the TIDierR-PHP checklist to describe the intervention in practice identified that considerable adaption happened at the level of borough, school, class and pupil. Population health effects are likely to be influenced by the interaction of intervention and context at each of these levels. Conclusions: Examining TDM in ‘real world’ settings surfaces adaptions and variations in implementation. This has implications for the likely effects of TDM, and points more broadly to an urgent need for more appropriate methods for evaluating public health impact and implementation in complex contexts

Frequency of blood glucose monitoring in relation to glycaemic control: observational study with diabetes database

Objectives: To investigate patterns of self monitoring of blood glucose concentration in diabetic patients who use insulin and to determine whether frequency of self monitoring is related to glycaemic control. Setting: Diabetes database, Tayside, Scotland. Subjects: Patients resident in Tayside in 1993­-5 who were using insulin and were registered on the database and diagnosed with insulin dependent (type 1) or non­insulin dependent (type 2) diabetes before 1993. Main outcome measures: Number of glucose monitoring reagent strips dispensed (reagent strip uptake) derived from records of prescriptions. First recorded haemoglobin A1c concentration in the study period, and reagent strips dispensed in the previous 6 months. Results: Among 807 patients with type 1 diabetes, 128 (16%) did not redeem any prescriptions for glucose monitoring reagent strips in the 3 year study period. Only 161 (20%) redeemed prescriptions for enough reagent strips to test glucose daily. The corresponding figures for the 790 patients with type 2 diabetes who used insulin were 162 (21%; no strips) and 131 (17%; daily tests). Reagent strip uptake was influenced both by age and by deprivation category. There was a direct relation between uptake and glycaemic control for 258 patients (with recorded haemoglobin A1c concentrations) with type 1 diabetes. In a linear regression model the decrease in haemoglobin A1c concentration for every extra 180 reagent strips dispensed was 0.7%. For the 290 patients with type 2 diabetes who used insulin there was no such relation. Conclusions: Self monitoring of blood glucose concentration is associated with improved glycaemic control in patients with type 1 diabetes. Regular self monitoring in patients with type 1 and type 2 diabetes is uncommon

‘Translation is not enough’: Using the Global Person Generated Index (GPGI) to assess individual quality of life in Bangladesh, Thailand, and Ethiopia

Currently few subjective measures of Quality of Life (QoL) are available for use in developing countries, which limits their theoretical, methodological, and practical contribution (for example, exploring the relationship between economic development and QoL, and ensuring effective and equitable service provision). One reason for this is the difficulty of ensuring that translated measures preserve conceptual, item, semantic, operational, measurement; and functional equivalence (Herdman et al:331), which is illustrated by an account of the translation, pre-piloting, and administration of a new individualised QoL measure, the Global Person Generated Index or ‘GPGI’. The GPGI is based on the widely used Patient Generated Index (Ruta et al [31]) and offers many of the advantages of the participatory approaches commonly used in developing countries, with added methodological rigour, and quantitative outcomes. It was successfully validated in Bangladesh, Thailand, and Ethiopia, using quantitative and qualitative methods - open-ended, semi-structured interviews (SSIs), conducted immediately post-administration. Both the measure and method of ‘qualitative validation’ described later in the paper offer an exciting alternative for future researchers and practitioners in this field. The quantitative results suggest the GPGI shows cultural sensitivity, and is able to capture both the areas that are important to respondents, and aspects of life one would expect to impact on QoL in developing countries. There were strong correlation between scores from the GPGI and SSIs for the area of health, and moderate correlations for ‘material wellbeing' (MWB)i and children. Weak to moderate correlations were observed between the Satisfaction with Life Scale and the GPGI; however, the highest coefficient was between the GPGI and the most conceptually similar item. Statistically significant differences were seen in GPGI scores between rich and poor, urban and rural respondents, and different countries. Health and material wellbeing scores, derived from the SSIs, also showed a linear relationship with GPGI scores, with a suggestion of curvilinearity at the higher levels, as predicted by a general QoL causal model. In conclusion, the GPGI has great potential for use in this area, especially when supported by extensive interviewer training, and supplemented with a cognitive appraisal schedule

Monitoring Outcomes of Care in Older People in a UK Community Setting: The North East Fife Outcomes Project

Although process measures of care have traditionally been used to assess the quality of healthcare, there is little evidence, for the majority of healthcare activities, to support a clear relationship between processes of care and resulting health gains. Outcomes monitoring is increasingly being advocated as a vital component of healthcare, particularly with the increasingly aging population. A consensus is emerging that routine systems of outcome monitoring are fundamental to rational clinical decision-making and public policy. There are several issues that need to be considered when implementing a routine system of outcome monitoring; this article addresses these issues in older people within a UK community setting in the context of an innovative observational feasibility study (The North East Fife Outcomes Project). This project 1. determined which outcomes of health and social care are the most important to this patient group; and 2. identified appropriate measures for relevant outcomes suitable for use in a community setting. Key patient characteristics and relevant clinical and social care process variables were then recorded, concomitant variables such as disease severity and comorbidities were taken into account and quality-of-life assessment measures recorded. For the success of any outcomes monitoring system, feedback to end-users is important. The North East Fife Project will assess the feasibility and value of feedback at the individual patient level and at the aggregate level. More research, particularly from large observational studies, is needed to address reliability and validity issues, biases and inaccuracies with routinely collected data and to further determine the value of routine outcomes monitoring.Elderly, Pharmacoeconomics, Quality of care

‘Translation is not enough’: Using the Global Person Generated Index (GPGI) to assess individual quality of life in Bangladesh, Thailand, and Ethiopia

Currently few subjective measures of Quality of Life (QoL) are available for use in developing countries, which limits their theoretical, methodological, and practical contribution (for example, exploring the relationship between economic development and QoL, and ensuring effective and equitable service provision). One reason for this is the difficulty of ensuring that translated measures preserve conceptual, item, semantic, operational, measurement; and functional equivalence (Herdman et al:331), which is illustrated by an account of the translation, pre-piloting, and administration of a new individualised QoL measure, the Global Person Generated Index or ‘GPGI’. The GPGI is based on the widely used Patient Generated Index (Ruta et al [31]) and offers many of the advantages of the participatory approaches commonly used in developing countries, with added methodological rigour, and quantitative outcomes. It was successfully validated in Bangladesh, Thailand, and Ethiopia, using quantitative and qualitative methods - open-ended, semi-structured interviews (SSIs), conducted immediately post-administration. Both the measure and method of ‘qualitative validation’ described later in the paper offer an exciting alternative for future researchers and practitioners in this field. The quantitative results suggest the GPGI shows cultural sensitivity, and is able to capture both the areas that are important to respondents, and aspects of life one would expect to impact on QoL in developing countries. There were strong correlation between scores from the GPGI and SSIs for the area of health, and moderate correlations for ‘material wellbeing' (MWB)i and children. Weak to moderate correlations were observed between the Satisfaction with Life Scale and the GPGI; however, the highest coefficient was between the GPGI and the most conceptually similar item. Statistically significant differences were seen in GPGI scores between rich and poor, urban and rural respondents, and different countries. Health and material wellbeing scores, derived from the SSIs, also showed a linear relationship with GPGI scores, with a suggestion of curvilinearity at the higher levels, as predicted by a general QoL causal model. In conclusion, the GPGI has great potential for use in this area, especially when supported by extensive interviewer training, and supplemented with a cognitive appraisal schedule.Citation: Camfield, L. & Ruta D. (2007). ''Translation is not enough': Using the Global Person Generated Index (GPGI) to assess individual quality of life in Bangladesh, Thailand, and Ethiopia', Quality of Life Research, 16(6), 1039-1051. [The original publication is available at springerlink.com]

Sen and the art of quality of life maintenance: towards a working definition of quality of life

The capability approach advocated by Amartya Sen provides a new philosophical framework for social policy. It also permits re-appraisal of a central concept in health and social care, and more recently international development - 'quality of life'. This paper begins by comparing Sen's capability view of quality of life with current views predominant in health care, and re-defines quality of life as 'the gap between desired and actual capabilities'. A causal pathway linking resources such as income, to capabilities (including health), and finally to quality of life, is postulated. The notion of 'cognitive homeostasis' is introduced to explain how a curvilinear relationship is observed between resources, capabilities, and quality of life. A separate set of factors (eg: spirituality, loss of a partner, chronic pain) is identified that act to sustain or destabilise the cognitive homeostatic mechanism. The paper concludes by examining some of the implications of this final causal model for social justice and policy evaluation

Sen and the art of quality of life maintenance: towards a general theory of quality of life and its causation

Sen's capability approach permits re-appraisal of a central concept in health and social care, and international development - 'quality of life' (QoL). We compare Sen's capability view of QoL with current views in health care, and re-define QoL as 'the gap between desired and actual capabilities'. A causal pathway linking resources to capabilities, and finally to QoL, is postulated. The notion of 'cognitive homeostasis' is introduced to explain the observed curvilinear relationship between resources and QoL. A separate set of factors is identified that act to sustain or destabilise QoL. We conclude by examining the model's implications for policy and evaluation