A Balancing Act: An investigation of people’s experiences and explanations of recurrent hypoglycaemia and help-seeking behaviour

Diabetes is a rapidly growing health concern in the developed world. Hypoglycaemia is a major risk factor in people with diabetes. Each year, about 7000 calls relating to hypoglycaemia are made to the Scottish Ambulance Service (SAS), including a considerable number of repeat callers. Very little is known about people’s experiences and explanations of recurrent hypoglycaemia; in particular, why some individuals manage their recurrent hypoglycaemic episodes independently, while others require more direct healthcare support. This thesis investigated participants’ experiences and individual explanations of recurrent hypoglycaemic episodes, in order to understand their health help-seeking behaviour. To do this, it compared the experiences of people who had called the emergency services within one month prior to recruitment (SAS participants), with those people who had not done so (non-SAS participants). The study employed a multiple methods longitudinal approach to prospectively capture participants’ experiences of hypoglycaemic episodes, using qualitative semi-structured interviews, hypoglycaemia and blood glucose diaries and follow-up telephone interviews over a six month period. Thirty participants were involved in the study, recruited through the Scottish Ambulance Service, Diabetes UK (Scotland), and the University of Stirling. All participants resided in the central belt of Scotland. Qualitative data was analysed using the framework method, and quantitative data was analysed using descriptive statistics. This study found that hypoglycaemic episodes had a wide ranging impact on people’s everyday life. It was not only the actual hypoglycaemic episode that affected participants’ everyday life, but also fears and worries about future hypoglycaemic episodes, the preparations that participants engaged in, and the process of recovery. Hypoglycaemia unawareness was found to be a major problem for many people living with diabetes. It appeared to be associated with the likelihood of needing external help. There were differences between participant groups with regard to management of hypoglycaemia unawareness. Non-SAS participants adopted strategies to prepare for future hypoglycaemic episodes, and appeared to be more knowledgeable about their diabetes and its management, resulting in needing less external help. SAS participants experienced more severe hypoglycaemic episodes. Consequently, they relied more on external help. Findings of this study call for a re-conceptualisation of the previously recognised ‘balancing act’ of managing diabetes and hypoglycaemic episodes. This study introduces the concept of a hypoglycaemic episode balancing continuum (HEBC) which enables a deeper understanding of the factors involved in this balancing act: it demonstrates that people balance the various risks differently, depending on whether they prioritised their fear of hypoglycaemia over fears of long-term complications. People’s position on the continuum directly affected their management strategies for hypoglycaemic episodes. Most hypoglycaemic episodes were managed by the individual without requiring any external help. However, participants’ ability to self-care differed and deficits occurred, resulting in participants being more likely to need involvement of others (family/friends). When the capacity of others to help broke down, participants’ were more likely to need SAS emergency care. In order to explain how hypoglycaemic episodes are managed, this thesis has developed a hypoglycaemic episode help-seeking network (HEHS network), which helps to identify the various agents involved in helping to manage hypoglycaemic episodes. Findings from this study have implications for clinical practice. For example, looking at hypoglycaemia unawareness, this study has shown that current understanding may fail to take account of participants’ real experiences, which show hypoglycaemia unawareness to be a fluid phenomenon that can affect people at various times. If blood glucose levels can fail to predict onset of hypoglycaemic episodes, healthcare professionals may need to broaden the range of blood glucose readings that might indicate a hypoglycaemic episode and tailor specific advice to individual patients. To reduce the use of emergency services, more attention must be paid to hypoglycaemia unawareness and better advice provided about this condition. Also, more education should be provided for family members/carers, given the crucial role they play in the management of diabetes and hypoglycaemic episodes, and being a link in the process leading to increased use of emergency services. The HEBC could be developed into a useful ‘screening tool’ to help healthcare professionals identify those at greater risk of hypoglycaemic episodes and those at greater risk of long-term complications, and to target advice more specifically to these patient groups. Further research could explore family member/carer knowledge in more detail to better understand their role in helping to manage hypoglycaemic episodes

Role and prevalence of impaired awareness of hypoglycaemia in ambulance service attendances to people who have had a severe hypoglycaemic emergency: a mixed-methods study

Objectives (1) To compare the experiences of people who are affected by diabetes-related hypoglycaemia and either do or do not require an emergency attendance and (2) to measure the prevalence of impaired awareness of hypoglycaemia in patients who are attended by an ambulance service due to a severe hypoglycaemic event.  Design A sequential mixed-methods study.  Setting A qualitative interview study was undertaken with 31 people with diabetes (types 1 and 2) resident in the central belt of Scotland. A national prevalence survey of 590 Scottish Ambulance Service patients who had recently experienced a severe hypoglycaemic emergency requiring ambulance clinicians attendance. Impaired awareness of hypoglycaemia was measured using two standardised measures.  Results Considerable differences in impaired awareness of hypoglycaemia were found in the experiences of participants who did or did not require the ambulance service to treat their severe hypoglycaemic events. Those who required an ambulance reported fewer warning signs and symptoms. The prevalence of impaired awareness of hypoglycaemia in ambulance service call-outs as assessed by two standardised measures was 53% and 60%, respectively.  Conclusions The prevalence of impaired awareness of hypoglycaemia among those who require an ambulance following a hypoglycaemic event is more than twice that found in the general population of people with diabetes. This may be because the experiences of impaired awareness in people who require an ambulance following a severe hypoglycaemic event differ to those who do not. This study provides important information to guide future prehospital clinical practice, and to develop and evaluate theoretically informed interventions. Improvements in prehospital care for this patient population could lead to global improvements in health outcomes and decreased service costs

Evidence use in E-cigarettes debates: scientific showdowns in a ‘wild west’ of research

Background: Against a backdrop of declining tobacco use, e-cigarette markets are growing. The UK now has a higher percentage of e-cigarette users than any other European country. These developments have prompted fierce discussions in scientific, advocacy and policy communities about how best to respond. This article is one of the first to examine the role of evidence in these debates. Methods: We analysed 121 submissions to two Scottish policy consultations on e-cigarettes (in 2014 and 2015) and undertook interviews with 26 key informants in 2015–2016, following up with a sub-set in 2019–2020. All data were thematically coded, and our analysis was informed by insights from policy studies and the sociology of science. Results: First, we affirm previous research in suggesting that e-cigarettes appeared to have triggered a breakdown of old public health alliances. Second, we demonstrate that, amid concerns about research quality and quantity, actors are guided by normative outlooks (and/or economic interests) in their assessments of evidence. Third, we show that, despite describing e-cigarette debates as contentious and polarised, actors engaging in Scottish policy debates exhibit a spectrum of views, with most interviewees occupying an uncertain ‘middle ground’ that is responsive to new evidence. Fourth, we suggest that the perceived divisiveness of e-cigarette debates is attributed to recurrent media simplifications and tensions arising from the behaviours of some actors with settled positions working to promote particular policy responses (including by strategically enrolling supportive evidence). Fifth, we argue that the actions of these actors are potentially explained by the prospect that e-cigarettes could usher in a new tobacco ‘policy paradigm’. Finally, we show how scientific authority is employed as a tool within these debates. Conclusions: E-cigarette debates are likely to reconcile only if a clear majority of participants in the uncertain ‘middle ground’ settle on a more fixed position. Our results suggest that many participants in Scottish e-cigarette debates occupy this ‘middle ground’ and express concerns that can be empirically assessed, implying evidence has the potential to play a more important role in settling e-cigarette debates than previous research suggests

Recovering breast cancer patients’ views about the use of in-vivo biosensors to personalise radiotherapy treatment

This report covers an important component of the EPSRC-funded IMPACT project that is developing implantable biosensors to monitor the tumour micro-environment so as to target X-ray dosage to hypoxic areas, thereby maximising the effectiveness of the treatment (www.eng.ed.ac.uk/impact). This qualitative study explored the views of breast cancer patients about implanted biosensors through a series of semi-structured interviews with 32 women who had successfully completed a course of treatment. The aim was both to consider detailed aspects of patients’ willingness to benefit from a possible technological enhancement of treatment and also to understand their views on the challenges of living with what that treatment might mean

Message framing to inform cancer prevention pricing interventions in the UK and USA: a factorial experiment, 2019

Objectives: To advance understanding of how message framing can be used to maximise public support across different pricing policies for alcohol, tobacco and sugary drinks/foods that prevent consumption of cancer-causing products. Design: We designed a 3×4×3 randomised factorial experiment to test responses to messages with three pricing policies, four message frames and three products. Setting: Online survey panel (Qualtrics) in 2019. Participants: Adults (N=1850) from the UK and USA. Interventions: Participants randomly viewed one of 36 separate messages that varied by pricing policy (increasing taxes, getting rid of price discounts, getting rid of low-cost products), four frames and product (alcohol, tobacco, sugary drinks/foods). Primary and secondary outcome measures: We assessed the relationship between the message characteristics and four dependent variables. Three were related to policy support: (1) increasing taxes on the product mentioned in the message, (2) getting rid of price discounts and special offers on the product mentioned in the message and (3) getting rid of low-cost versions of the product mentioned in the message. One was related to reactance, a psychological response to having one’s freedom limited. Results: We found no effect for pricing policy in the message. Frames regarding children and reducing cancer risk moderated some outcomes, showing promise for real-world use. We found differences in support by product and reactance with greatest support and least reactance for tobacco policies, less support and more reactance for alcohol policies, and the least support and most reactance for sugary drinks/foods policies. Conclusions: Cancer prevention efforts using policy interventions can be informed by the message framing literature. Our results offer insights for cancer prevention advocacy efforts across the UK and USA and highlight that tax versus non-tax approaches to increasing the cost of cancer-causing products result in similar responses from consumers

Young People and Alcohol: Influences on How They Drink

The report identifies the influence of both existing cultural attitudes around alcohol, and new and emergent attitudes that separate younger drinkers' consumption from that of other age groups

Drinking to belong understanding young adults’ alcohol use within social networks.

This report explores young adults’ decisionmaking around alcohol against a cultural backdrop of historically high levels of consumption, affordability and availability in the UK

Scoping the Impact and Continuing Relevance of the Rights, Relationships and Recovery (3 R’s) in Mental Health Nursing

No abstract available

Scoping the Impact and Continuing Relevance of the Rights, Relationships and Recovery (3 R’s) in Mental Health Nursing

No abstract available

‘I don't think old people should go to clubs’: how universal is the alcohol transition amongst young adults in the United Kingdom?

Understanding the meanings, associations and ideas of appropriateness that shape young adults’ decision-making around alcohol will assist in developing strategies to promote healthy consumption and anticipate rates of future harm. Increases in per capita consumption as well as the affordability and availability of alcohol suggest the cultural environment in which young adults become consumers of alcohol has changed in recent years. This qualitative study investigated the role of alcohol within the transitions to adulthood of 18–25 year olds living in Glasgow, United Kingdom. The findings support previous research that has identified excessive consumption of alcohol as a component of a normative understanding of life-course that positions young adulthood as liminal and offering a safe space for boundary pushing and identity exploration. However, exploring differences in the opportunity to enact taken-for-granted alcohol and life-course related norms highlights the limits of universal understandings of young adulthood across different socio-economic experiences of this age group in the United Kingdom. Inequalities in alcohol and life-course related risk are identified that should be of interest to policy-makers and educators in the field of alcohol. The broad implications for policy direction are discussed. The project was funded by the Joseph Rowntree Foundation