Characteristics of children who do not attend their hospital appointments, and GPs' response: a mixed methods study in primary and secondary care.

BACKGROUND: Children who do not attend (DNA) their hospital outpatient appointments are a concern because this potentially compromises the child's health and incurs financial cost. Little is known about children who DNA or the views of GPs to non-attendance. AIM: To describe the characteristics of children who DNA hospital paediatric outpatient appointments, and explore how GPs view and respond to DNAs. DESIGN AND SETTING: A mixed methods study of data from all new referrals to a children's hospital in the South West of England between 1 September and 31 October 2012. METHOD: Data were extracted from patients' hospital and GP records, and Stata was used to analyse the data quantitatively. Analysis focused on describing the characteristics of children who DNA, and the process of care that followed. Practices that had either the highest or lowest number of DNAs were purposefully sampled for GPs who had referred children to secondary care at the study hospital within the previous year. Interviews were held between May 2014 and July 2015, and were analysed thematically. RESULTS: Children who DNA are more likely to be from an area of greater deprivation (adjusted odds ratio [AOR] 1.02, 95% confidence interval [CI] = 1.00 to 1.02, P = 0.04), and with a child protection alert in their hospital notes (AOR 2.72, 95% CI = 1.26 to 5.88, P = 0.01). Non-attendance is communicated poorly to GPs, rarely coded in patients' GP records, and few GP practices have a formal policy regarding paediatric DNAs. CONCLUSION: Non-attendance at hospital outpatient appointments may indicate a child's welfare is at risk. Communication between primary and secondary care needs to be improved, and guidelines developed to encourage GPs to monitor children who DNA.

Antenatal needs of couples following fertility treatment: a qualitative study in primary care.

BACKGROUND: It is known that couples may experience emotional distress while undergoing infertility treatment, but less is known about their experience of pregnancy following successful conception. Typically, couples are discharged from the fertility clinic to receive standard antenatal care. Recent research has raised questions about whether this care adequately meets their needs. AIM: To explore the antenatal experiences of females and males who have successfully conceived through infertility treatment. DESIGN AND SETTING: An exploratory qualitative approach was undertaken, using individual, in-depth interviews with females and males who had successfully undergone infertility treatment in one of three fertility clinics in the south of England. METHOD: Twenty participants were interviewed (12 females and eight male partners) when their pregnancy had reached 28 weeks' gestation. Participants were asked about their experiences of infertility treatment, pregnancy, and antenatal care. Interviews were audiorecorded, transcribed, and analysed thematically. RESULTS: Analysis of the interviews suggested females and males experienced a 'gap' in their care, in terms of time and intensity, when discharged from the fertility clinic to standard antenatal care. This gap, combined with their previous experience of infertility treatment, heightened their fear of pregnancy loss and increased their need for support from their health professionals. Participants' previous experience of infertility treatment also appeared to deter them from preparing for the birth and parenthood, and disclosing negative feelings to others about the pregnancy. CONCLUSION: Females and males who have successfully undergone infertility treatment may require additional support in primary care to address anxiety during pregnancy, enable disclosure of negative feelings, and to help them prepare for childbirth and parenthood.

The effectiveness of exercise as a treatment for postnatal depression: study protocol.

BACKGROUND: Postnatal depression can have a substantial impact on the woman, the child and family as a whole. Thus, there is a need to examine different ways of helping women experiencing postnatal depression; encouraging them to exercise may be one way. A meta analysis found some support for exercise as an adjunctive treatment for postnatal depression but the methodological inadequacy of the few small studies included means that it is uncertain whether exercise reduces symptoms of postnatal depression. We aim to determine whether a pragmatic exercise intervention that involves one-to-one personalised exercise consultations and telephone support plus usual care in women with postnatal depression, is superior to usual care only, in reducing symptoms of postnatal depression. METHODS: We aim to recruit 208 women with postnatal depression in the West Midlands. Recently delivered women who meet the ICD-10 diagnosis for depression will be randomised to usual care plus exercise or usual care only. The exercise intervention will be delivered over 6 months. The primary outcome measure is difference in mean Edinburgh Postnatal Depression Scale score between the groups at six month follow-up. Outcome measures will be assessed at baseline and at six and 12 month post randomisation. DISCUSSION: Findings from the research will inform future clinical guidance on antenatal and postnatal mental health, as well as inform practitioners working with postnatal depression. TRIAL REGISTRATION NUMBER: ISRCTN84245563.

Getting out and about in older adults: the nature of daily trips and their association with objectively assessed physical activity.

BACKGROUND: A key public health objective is increasing health-enhancing physical activity (PA) for older adults (OAs). Daily trip frequency is independently associated with objectively assessed PA volumes (OAs). Little is known about correlates and these trips' transport mode, and how these elements relate to PA. PURPOSE: to describe the frequency, purpose, and travel mode of daily trips in OAs, and their association with participant characteristics and objectively-assessed PA. METHODS: Participants (n = 214, aged 78.1 SD 5.7 years), completed a seven-day trips log recording daily-trip frequency, purpose and transport mode. Concurrently participants wore an accelerometer which provided mean daily steps (steps·d-1), and minutes of moderate to vigorous PA (MVPA·d-1). Participants' physical function (PF) was estimated and demographic, height and weight data obtained. RESULTS: Trip frequency was associated with gender, age, physical function, walking-aid use, educational attainment, number of amenities within walking distance and cars in the household. Participants reported 9.6 (SD 4.2) trips per week (trips·wk-1). Most trips (61%) were by car (driver 44%, passenger 17%), 30% walking or cycling (active) and 9% public transport/other. Driving trips·wk-1 were more common in participants who were males (5.3 SD 3.6), well-educated (5.0 SD 4.3), high functioning (5.1 SD 4.6), younger (5.6 SD 4.9), affluent area residents (5.1 SD 4.2) and accessing > one car (7.2 SD 4.7). Active trips·wk-1 were more frequent in participants who were males (3.4 SD 3.6), normal weight (3.2 SD 3.4), not requiring walking aids (3.5 SD 3.3), well-educated (3.7 SD 0.7), from less deprived neighbourhoods (3.9 SD 3.9) and with ≥ 8 amenities nearby (4.4 SD 3.8).Public transport, and active trip frequency, were significantly associated with steps·d-1 (p < 0.001), even after adjustment for other trip modes and potential confounders. Public transport, active, or car driving trips were independently associated with minutes MVPA·d-1 (p < 0.01). CONCLUSIONS: Daily trips are associated with objectively-measured PA as indicated by daily MVPA and steps. Public transport and active trips are associated with greater PA than those by car, especially as a car passenger. Strategies encouraging increased trips, particularly active or public transport trips, in OAs can potentially increase their PA and benefit public health.

Objectively measured physical activity in a diverse sample of older urban UK adults.

BACKGROUND: There are many health and social benefits of physical activity (PA) for older adults, but little is known about their activity patterns. PURPOSE: The purpose of this study was to objectively assess the PA patterns of older adults and the lifestyle and demographic factors associated with PA. METHODS: Participants (N = 230, aged 78.1 yr) recruited from medical practices (between 2007 and 2008) completed journey logs and wore accelerometers for 7 d. Mean daily steps, counts per minute (CPM), minutes of sedentary, light, or moderate-to-vigorous PA (MVPA), and frequency of journeys were analyzed (in 2009). RESULTS: Younger participants (age = 70-74.9 yr) were significantly (P < 0.001) more active (5660.8 steps per day) than older participants aged 80+ yr (3409.6 steps per day). Men performed significantly (P = 0.035) more minutes MVPA than women (23.1 vs 13.8 min MVPA per day). Normal weight participants were significantly (P < 0.05) more active (5368.9 steps per day) than overweight (4532.7 steps per day) and obese (3251.4 steps per day) groups. Those performing many journeys (>11.6 journeys per week) were significantly (P < 0.001) more active (5838.2 steps per day) than those performing few (<7 journeys per week) (3094.2 steps per day). PA was significantly (P < 0.001) greater in mornings (259.3 CPM) than afternoons (181.8 CPM) and evenings (102.5 CPM). Sundays were significantly (P < 0.001) less active (3331.7 steps per day) than Saturdays (4193.1 steps per day) and weekdays (4623.5 steps per day). Light activity was significantly (P = 0.005) higher in spring (3.4 h·d(-1)) than that in winter (2.7 h·d(-1)). CONCLUSIONS: Older adults' PA patterns differ by age, gender, and weight status. Daily journeys are associated with more activity for all groups. Variability in volume of activity is high for all age groups. Temporal patterns of PA indicate that journeys out of the house for shopping and personal business are important in their contribution to PA levels.

Therapist-delivered Internet psychotherapy for depression in primary care: a randomised controlled trial.

BACKGROUND: Despite strong evidence for its effectiveness, cognitive-behavioural therapy (CBT) remains difficult to access. Computerised programs have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown. We investigated the effectiveness of CBT delivered online in real time by a therapist for patients with depression in primary care. METHODS: In this multicentre, randomised controlled trial, 297 individuals with a score of 14 or more on the Beck depression inventory (BDI) and a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire, UK. Participants were randomly assigned, by a computer-generated code, to online CBT in addition to usual care (intervention; n=149) or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control; n=148). Participants, researchers involved in recruitment, and therapists were masked in advance to allocation. The primary outcome was recovery from depression (BDI score <10) at 4 months. Analysis was by intention to treat. This trial is registered, number ISRCTN 45444578. FINDINGS: 113 participants in the intervention group and 97 in the control group completed 4-month follow-up. 43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months (odds ratio 2.39, 95% CI 1.23-4.67; p=0.011), and 46 (42%) versus 26 (26%) at 8 months (2.07, 1.11-3.87; p=0.023). INTERPRETATION: CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT. FUNDING: BUPA Foundation.