The study of psychosocial outcomes of parents bereaved by pediatric illness: a scoping review of methodology and sample composition.

OBJECTIVE: Parents of children who died of a medical condition experience a range of psychosocial outcomes. The current scoping review aims to summarize the outcomes assessed, methodology, and sample characteristics of recent psychosocial research conducted with this population. METHODS: Included studies were limited to peer-reviewed, psychosocial outcomes research published between August 2011 and August 2022, written in English, and including caregiver study participants of children who died of a medical condition. Data sources were scholarly journal articles from 9 electronic databases, including Scopus, Web of Science, Academic Search Primer, ProQuest Research Library, PubMed, Embase, PsycINFO, Psychology & Behavioral Sciences Collection, and Health Source: Nursing/Academic Edition. The Mixed Methods Appraisal Tool-2018 evaluated methodological quality. RESULTS: The study sample included 106 studies, most of which were either qualitative (60%) or quantitative (29%). Mixed-methods studies (8%) and randomized clinical trials (2%) were also identified. Study quality was variable, but most studies met all quality criteria (73%). Studies primarily represented cancer populations (58%), White participants (71%), and mothers (66%). Risk-based psychosocial outcomes (e.g., grief) were more commonly assessed than resilience-based outcomes. CONCLUSIONS: The current scoping review revealed that recent research assessing the psychosocial outcomes of bereaved parents is limited in the representation of diverse populations, primarily qualitative, of broadly strong methodological quality, and oriented to psychosocial risk. To enhance the state of the science and inform evidence-based psychosocial services, future research should consider varied methodologies to comprehensively assess processes of risk and resilience with demographically and medically diverse populations.

Exploring Smartphone App use in older adults with a chronic respiratory disease: 'The biggest problem I have is I don't understand my phone at all.'

INTRODUCTION: In older people with a chronic respiratory disease, we explored; (i) usual Smartphone Application (App) use, (ii) the time taken to download and use an App and (iii) changes in self-efficacy for downloading an App after a single practice session. METHODS: Participants were invited to attend one or two separate assessment sessions (Part A and B). Those who attended Part A had data pertaining to their App usage over the previous week extracted from their Smartphone. Those who attended Part B were asked to download and use a pedometer App and 'think out loud' during the task. Before and after the task, participants rated their self-efficacy for downloading an App using a Visual Analogue Scale (0-10). RESULTS: Twenty-seven participants (mean±SD 74±5 years) completed Part A. Commonly used Apps related to communication (e.g. texting; median [interquartile range] 15 [9 to 25] min/day) and interest (e.g. news; 14 [4 to 50] min/day). Fifteen participants completed Part B (mean±SD 73±7 years). The median time taken to download and use the App was 24 [22 to 37] min. The 'think out loud' data converged into four domains: (i) low self-efficacy for using and learning Apps; (ii) reliance on others for help; (iii) unpleasant emotional responses and (iv) challenges due to changes associated with longevity. Self-efficacy increased by 4 (95% CI 3 to 6). CONCLUSION: This population used Apps mainly to facilitate social connection. It took participants almost half an hour to download and use an App, but a single practice session improved self-efficacy.

Quantifying uptake and completion of pulmonary rehabilitation programs in people with chronic obstructive pulmonary disease known to tertiary care.

BACKGROUND: People with symptomatic chronic obstructive pulmonary disease (COPD) benefit from pulmonary rehabilitation programs (PRPs), but program attrition is common. METHODS: For people with COPD who presented to tertiary care and appeared appropriate for a PRP, we prospectively mapped their PRP journey, explored factors influencing attendance to pre-program assessment and captured program attrition. RESULTS: Of the 391 participants, 31% (95% CI 27 to 36) were referred to a PRP (n = 123; age 68 ± 10years, 62 males [50%], FEV1 45 ± 19%predicted). Of those referred, 94 (76% [69 to 84]) attended a pre-program assessment. Ex-smokers and those who had a healthcare professional (HCP) explain they would be referred were more likely to attend a pre-program assessment (odds ratio [95%CI]; 2.6 [1.1 to 6.1]; and 4.7 [1.9 to 11.7], respectively). Of the 94 who attended, 63 (67% [58 to 77]) commenced; and of those who commenced, 35 (56% [43 to 68]) completed a PRP. All who completed (n = 35, 100%) were provided at least one strategy to maintain training-related gains. CONCLUSION: Attrition occurs throughout the PRP journey. Interactions with HCPs about PRPs positively influenced attendance. Understanding how HCPs can best contextualise PRPs to encourage referral acceptance and uptake is an important area for further work.

Mixed-method examination of factors associated with adolescent decision-making and involvement in care in the context of advanced cancer.

OBJECTIVES: Adolescents with cancer often experience significant symptom burden and aggressive treatment near end-of-life. Increased adolescent involvement in care and decision-making may benefit health outcomes. Limited research has examined factors associated with adolescents' involvement in care in the context of advanced disease. Thus, we examined the impact of background factors and decision-making perceptions on both adolescents' involvement in care and their desired change in involvement. METHODS: Adolescents with advanced cancer (<60% survival or refractory/relapsed disease), ages 10-23 (n = 41; Mage = 15.37), were recruited approximately 1 month after diagnosis to complete measures of decision-making perceptions and their family role. Hierarchical regressions examined the contributions of background factors and decision-making perceptions to adolescents' frequency and desired involvement in their care. Qualitative interviews regarding decision-making were analyzed using deductive analysis. RESULTS: The model examining frequency of involvement in care was significant, F(5,34) = 3.12, p = .02, R2= .31. Older age was the only significant predictor (ß = .13, p= .003). The model examining desired involvement was non-significant, F(5,34) = 2.22, p = .075. Qualitative analysis indicated that (1) older adolescents have more involvement in decision-making, (2) collaborative decision-making occurred between the adolescent and extended family, and (3) adolescents trusted others to make decisions. Integration of qualitative and quantitative data revealed congruence in findings. SIGNIFICANCE OF RESULTS: Adolescents with advanced cancer, who consider how decisions directly impact them and prefer greater autonomy, may be more involved in their medical care. Research is needed to identify other longitudinal predictors of decision-making and involvement in care. Providers should consider encouraging families to communicate their preferences and engage in shared decision-making.

Analysis of Direct-To-Consumer Healthcare Service Advertisements on Television: An Application of the Patient Expectation Framework.

Direct-to-consumer advertisements for healthcare services constitute a rare channel of public communication where consumers see and hear directly from their local providers and healthcare organizations. Although spending on these advertisements has increased drastically during the past decades, research on their content and effects remains rare. To fill this gap, we analyzed primetime television advertisements for healthcare services directly targeting consumers. The advertisements were collected from the two largest media markets in Nevada for one month. In total, 795 advertisements were identified, and 106 of them were non-duplicates. Analysis revealed that the advertisements focused on patients' good health outcomes by showing them smiling, going out and about, having fun with others, and enjoying rigorous physical activities. On the other hand, the advertisements focused less on the providers. Although the advertisements often showed providers in clinical settings, basic information about their professional degrees was often missing. Mentions of providers' other qualifications and professional experiences were even scarcer. Also, a substantial number of advertisements failed to show providers interacting with patients. Additional analysis of patient and provider characteristics revealed under-representation of racial or ethnic minority and older adult patients. Representation of women and minorities as providers was even more uncommon. We discussed the implications of these findings from the perspective of patient expectation and made suggestions to help providers improve their direct-to-consumer advertisements.

Characterising hospitalisation risk for chronic obstructive pulmonary disease exacerbations: Bedside and outpatient clinic assessments of easily measured variables.

OBJECTIVE: To identify the characteristics of people with chronic obstructive pulmonary disease (COPD) who require hospitalisation for exacerbations. METHODS: People with COPD were recruited either during hospitalisation or from out-patient respiratory medicine clinics. Hospital admissions were tracked throughout the 5-months recruitment period. For participants who were admitted, hospital readmissions were tracked for at least 30 days following discharge. Participants were grouped as either needing; (i) no hospital admission during the study period (no admission; ø-A), (ii) one or more hospital admissions during the study period but no readmission within 30 days of discharge (no rapid readmission; ø-RR) or (iii) one or more hospital admissions with a readmission within 30 days of discharge (rapid readmission; RR). RESULTS: Compared with the ø-A group (n=211), factors that independently increased the risk of ø-RR (n=146) and/or RR (n=57) group membership were being aged >60 years, identifying as an Indigenous person (relative risk ratio, 95% confidence interval 7.8 [1.8 to 34.0]) and the use of a support person or community service for activities of daily living (1.5 [1.0 to 2.4]. A body mass index ≥25 kg/m2 was protective. CONCLUSIONS: Variables recorded at the bedside or in clinic provided information on hospitalisation risk.

Factors associated with mental health service use among families bereaved by pediatric cancer.

OBJECTIVES: We identified types of interventions used by bereaved family members and examined associations with demographic and medical factors. Furthermore, we examined associations between distress and intervention use among bereaved families. METHODS: Bereaved families (n = 85) were recruited from three children's hospitals 3-12 months after their child died of cancer. One eligible sibling (ages 8-17) per family was randomly selected for participation. During home visits 1-year post-death, parents reported on their own and the sibling's intervention use, helpfulness, and dose (self-help books, support groups, therapy, medication), and distress, defined as internalizing, externalizing, and total problems (Adult Self Report, Child Behavior Checklist). RESULTS: Fifty percent of mothers used medications (n = 43); utilization was low among fathers (17%, n = 9) and siblings (5%, n = 4). Individuals with more total problems were more likely to use medications (mothers: rpb = 0.27; p = 0.02; fathers: rpb = 0.32; p = 0.02; siblings: rpb = 0.26; p = 0.02). Mothers and siblings with more total problems used more services (r = 0.24; p = 0.03 and r = 0.29; p = 0.01, respectively). Among mothers, the overall regression was significant, R2 = 0.11, F(2, 80) = 4.954, p = 0.01; the deceased child's age at death was significantly associated with total services used (b = 0.052, p = 0.022). Among fathers, the overall regression was significant, R2 = 0.216, F(3, 49) = 4.492, p = 0.007; race and years of education were significantly associated with total services used (b = 0.750, p = 0.030 and b = 0.154, p = 0.010). Among siblings, the overall regression was significant R2 = 0.088, F(2, 80) = 3.867, p = 0.025; greater total problems were significantly associated with total services used (b = 0.012, p = 0.007). SIGNIFICANCE OF RESULTS: Although few background factors were related to intervention use, bereaved mothers and siblings may seek services if they have more distress. Healthcare providers should be aware of the types of services that are most often utilized and helpful to bereaved families to connect them with appropriate resources. Future research should investigate other predictors of intervention use and outcomes after the death of a child.

Factors affecting COVID-19 vaccine hesitancy in parents of children with cancer.

AIM: Little research exists on coronavirus (COVID-19) vaccine hesitancy among caregivers of children with cancer. We aimed to (a) describe vaccine hesitancy in parents of children with cancer for both their child and self, and (b) examine the mediating role of parent-reported COVID impact on the association between COVID exposure and vaccine hesitancy. PROCEDURE: We conducted a national survey of parents of children with cancer via Facebook and Momcology, a pediatric cancer community-based organization recruited February-May 2021. Parents completed standardized measures online. A series of mediation models assessed the role of COVID-19 impact (e.g., effects on parenting and well-being) on associations between COVID-19 exposure (e.g., direct/indirect exposure) and vaccine hesitancy. Moderation models examined the role of treatment status, COVID-19 exposure, impact, and vaccine hesitancy. RESULTS: Parents (n = 491; 90% mothers; 93% White) reported moderate vaccine hesitancy (M = 2.08, SD = 0.76). Specifically, 18.5% (n = 90) reported they would not vaccinate their child, and 24.4% (n = 119) would only consider vaccination. Parents expressed higher concerns about vaccine side effects for their children (M = 3.01, SD = 0.95) than for themselves (M = 2.61, SD = 1.03; t[479] = 9.07, p < .01). Mediation analysis revealed a significant indirect effect of impact (95% CI [-0.013, -0.001]) on the association between higher exposure and higher vaccine hesitancy (b = .02, p = .06). There was no moderating effect of treatment status. Income remained a significant covariate (b = -.11, p < .01). CONCLUSION: Lower parent-reported COVID exposure, higher COVID impact, concern for side effects, and lower income may be important factors related to vaccine hesitancy among parents of children with cancer. Providers of childhood cancer survivors should address vaccine hesitancy and potential health risks.

Survivors of Acute Lung Injury Have Greater Impairments in Strength and Exercise Capacity Than Survivors of Other Critical Illnesses as Measured Shortly After ICU Discharge.

PURPOSE: To compare the physical function on ICU discharge in adults who survived an ICU admission for acute lung injury (ALI) with those admitted for a critical illness other than ALI. MATERIALS AND METHODS: Two groups were recruited, (i) those who survived an ICU admission for ALI and, (ii) those who survived an ICU admission for a critical illness other than ALI. Within 7 days of discharge from ICU, in all participants, measures were collected of peripheral muscle strength, balance, walking speed and functional exercise capacity. RESULTS: Recruitment was challenging and ceased prior to achieving the desired sample size. Participants with ALI (n = 22) and critical illness (n = 33) were of similar median age (50 vs. 57 yr, p = 0.09), sex proportion (males %, 45 vs. 58, p = 0.59) and median APACHE II score (21.5 vs. 23.0, p = 0.74). Compared with the participants with critical illness, those with ALI had lower hand grip (mean ± SD, 18 ± 9 vs. 13 ± 8 kg, p = 0.018) and shoulder flexion strength (10 ± 4 vs. 7 ± 3 kg, p = 0.047), slower 10-meter walk speed (median [IQR], 1.03 [0.78 to 1.14] vs. 0.78 [0.67 to 0.94] m/s, p = 0.039) and shorter 6-minute walk distance (265 [71 to 328] vs. 165 [53 to 220] m, p = 0.037). The Berg balance scores were similar in both groups. CONCLUSIONS: Compared with survivors of a critical illness that is not ALI, those with ALI are likely to have greater physical impairment when measured shortly after discharge to the ward.

Expiratory Muscle Strength Training for Drooling in Adults with Parkinson's Disease.

One of the most debilitating symptoms of advanced Parkinson's disease is drooling. Currently, the main treatment that is offered for drooling is botulinum toxin injections to the saliva glands which have a number of side effects and do not treat the causes of drooling, such as impaired swallowing and lip closure. This study explored the effect of an alternative therapy approach for drooling that aimed at improving the swallow, expiratory muscle strength training (EMST). Sixteen participants received EMST over a 6- to 8-week period. Measurements were taken pre- and post-training for drooling (Sialorrhea Clinical Scale for Parkinson's Disease; SCS-PD), swallowing, lip strength and peak cough flow. Measures of drooling, swallowing and peak cough flow were stable over pre-training assessments and improved following training (p < 0.01). The most conservative estimate of the within-group change for SCS-PD was - 2.50 (95% confidence interval -  3.22 to -  1.22). No adverse effects were reported and participants gave high satisfaction ratings for the training. A programme of EMST offers promise as a therapy to reduce drooling for people with Parkinson's disease. Adequately powered randomised controlled trials of EMST are now needed.

Prevalence of suspected poor bone health in people with chronic obstructive pulmonary disease - a cross-sectional exploratory study.

BACKGROUND: Compared to the general population, adults with chronic obstructive pulmonary disease (COPD) have an increased prevalence of osteoporosis. Despite the known risk factors and potential complications of compromised bone health in COPD, little is known about whether poor bone health is routinely suspected. We measured, in people with COPD, the prevalence of those who had one or more indicators suggestive of suspected poor bone health, and compared the characteristics of those with versus without these indicators. METHODS: Data were collected from adults with COPD presenting to three tertiary hospitals. Indicators of suspected poor bone health were defined as any of the following criteria: (i) self-reported problems with bone health, (ii) previous imaging for bone health, (iii) history of fragility fracture or, (iv) advised to use medication/supplements to optimise bone health. Characteristics compared between those with versus without indicators of suspected poor bone health comprised age, sex, body mass index (BMI), FEV1% predicted and recruitment setting. RESULTS: 361 participants were included (age 70 ± 10, BMI 27.9 ± 7.8 kg/m2, FEV1% predicted 49 ± 20; 161 [45%] female). Indicators suggestive of suspected poor bone health were present in 53% (95% confidence interval [CI] 47-58) of the participants. The odds of this outcome increased with advancing age (odds ratio; OR [95% CI] 1.05 [1.03 to 1.08]) and being female (OR [95% CI] 3.4 [2.2 to 5.7]) . CONCLUSION: In people with COPD, the odds of having indicators suggestive of suspected poor bone health increase with advancing age and in females. Further work is required to promote the importance of bone health in this population.

Communication within families about advanced pediatric cancer: A qualitative study.

OBJECTIVES: This qualitative study examined how families share information and feelings about advanced pediatric cancer from the perspective of both parents and children, as well as how these perspectives vary by child developmental stage. METHODS: Participants (24 mothers, 20 fathers, 23 youth [children and adolescents]) were from a larger longitudinal study at an academic pediatric hospital. Eligible youth had advanced cancer (physician-estimated prognosis of <60%, relapse, or refractory disease), were aged 5-19 years (>8 years old to participate independently), had an English-speaking parent, and lived within 140 miles of the hospital. Interviews were completed at enrollment and asked how families share information and emotions about the child's cancer as a family. RESULTS: Saturation was reached at 20 interviews for mothers, fathers, and youth. Analyses revealed 4 major themes: (A) parents managing cancer-related information based on child age/developmental stage and processing styles of family members; (B) parents withholding poor prognosis information and emotions to maintain positivity; (C) lack of personal and familial emotion sharing; and (D) emotion sharing among their family and externally. Both parents and youth endorsed themes A, C, and D, but only parents endorsed theme B. Adolescents endorsed more themes than children. Parents of children (as opposed to adolescents) endorsed theme A more. SIGNIFICANCE OF RESULTS: Although both parents and youth with advanced cancer were generally willing to talk about treatment, emotions were not consistently shared. Perspectives varied depending on the child's developmental stage. Clinicians should assess parent and child information and emotion-sharing needs and provide individualized support to families regarding communication about advanced cancer.

Endurance cycle ergometry tests performed at a sub-maximal work rate elicit peak physiological and symptom responses in adults with cystic fibrosis.

Time to symptom limitation (Tlim ) achieved during constant work rate tests is considerably more responsive to change than measures commonly recorded during ramp-based tests, such as peak rate of oxygen uptake and maximal work rate (Wmax ). There is limited literature on the use of, and physiological and symptom responses to, constant work rate cycle ergometry tests in people with cystic fibrosis (CF). The results of this study provide evidence that the constant work rate cycle ergometry test, when conducted at 80% of the Wmax , elicits peak physiological and symptom responses and appears to be safe in adults with CF. For clinicians prescribing exercise at an intensity approaching or equivalent to 80% of the Wmax in a non-laboratory-based setting, consideration needs to be given to the level of supervision and patient monitoring required.

Aquatic high intensity interval training to improve aerobic capacity is feasible in adolescents with cerebral palsy: pilot randomised controlled trial.

OBJECTIVE: To investigate feasibility of aquatic high intensity interval training for adolescents with cerebral palsy, who can ambulate independently but may choose a mobility aid in some circumstances. DESIGN: Pilot randomised controlled trial. METHOD: Following baseline assessments, participants were randomised to usual care or ten weeks of twice weekly aquatic high intensity interval training. Each class comprised 10 one-minute exercise intervals separated by one-minute rest. High intensity exercise was defined as the attainment of ⩾80% of peak heart rate measured by telemetry. SETTING: Tertiary paediatric hospital. MAIN MEASURES: Primary outcomes related to the feasibility of the protocol to progress to a definitive trial. Consumer feedback was obtained. RESULTS: Of 119 potential participants, 46 appeared eligible and 17 consented, resulting in a recruitment fraction of 37% (95% CI 23-52). Twelve completed baseline assessments and were randomised (5 males; 14 years 7 months SD 2 years 0 months). In the intervention group, of the 1190 exercise stations (across all participants and sessions), heart rate data were available for 1180 stations and high intensity exercise was achieved during 1111 stations (93%, 95% CI 92-95). All randomised participants completed the study and reported that the intervention was fun and provided friendship opportunities. There were no major adverse events or exacerbation of pain. CONCLUSIONS: Aquatic high intensity interval training in ambulant adolescents with cerebral palsy is feasible, while maintaining adherence and fidelity. Uncertainty remains on the efficacy of the intervention, highlighting the need for a large definitive trial.

US direct-to-consumer medical service advertisements fail to provide adequate information on quality and cost of care.

BACKGROUND: In the 1970s, the Federal Trade Commission declared that allowing medical providers to advertise directly to consumers would be "providing the public with truthful information about the price, quality or other aspects of their service." However, our understanding of the advertising content is highly limited. OBJECTIVE: To assess whether direct-to-consumer medical service advertisements provide relevant information on access, quality and cost of care, a content analysis was conducted. METHOD: Television and online advertisements for medical services directly targeting consumers were collected in two major urban centres in Nevada, USA, identifying 313 television advertisements and 200 non-duplicate online advertisements. RESULTS: Both television and online advertisements reliably conveyed information about the services provided and how to make an appointment. At the same time, less than half of the advertisements featured insurance information and hours of operation and less than a quarter of them contained information regarding the quality and price of care. The claims of quality were substantiated in even fewer advertisements. The scarcity of quality and cost information was more severe in television advertisements. CONCLUSION: There is little evidence that medical service advertising, in its current form, would contribute to lower prices or improved quality of care by providing valuable information to consumers.

Effect of Using a Wheeled Walker on Physical Activity and Sedentary Time in People with Chronic Obstructive Pulmonary Disease: A Randomised Cross-Over Trial.

PURPOSE: To determine the effects of providing a wheeled walker (WW) for use in the home and community, on daily physical activity (PA) and sedentary time (ST) in people with chronic obstructive pulmonary disease (COPD). METHODS: A randomised cross-over study in which participants with COPD characterised by a 6-min walk distance ≤ 450 m, who had recently finished pulmonary rehabilitation, completed two 5-week phases. During one phase, participants were provided a WW to use, whereas during the other phase, the WW was not available. The order of the phases was randomised. For the final week of each phase, measures of PA and ST were collected using wearable devices and health-related quality of life was measured using the Chronic Respiratory Disease Questionnaire (CRDQ). Wheeled walker use was also measured using an odometer attached to the device. RESULTS: 17 participants [FEV1 = median (interquartile range) 33 (25) % pred; ten males] aged mean (SD) 73 (9) years completed the study. Comparing the data collected when the WW was not available for use, the daily step count was greater (mean difference [MD] 707 steps/day (95% confidence interval [CI] 75 to 1340) and participants tended to report less dyspnoea during daily life (MD 0.5 points per item, 95% CI - 0.1 to 1.0) when WW was available. No differences were observed for ST, upright time or stepping time. The WW was used over 4504 m/week (95% CI 2746 to 6262). CONCLUSION: These data demonstrated that, when provided to selected patients with COPD, WWs increased daily step count. CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12609000332224.

Exercise testing and exercise training within cystic fibrosis centres across Australia and New Zealand: what is considered important and what is current practice?

BACKGROUND: Within Australian and New Zealand cystic fibrosis (CF) centres, exercise testing and exercise training are common components of clinical care, but current practices regarding these components have not been reported. AIM: To determine the extent, scope and importance placed on exercise testing and exercise training within CF centres across Australia and New Zealand. METHODS: Information pertaining to exercise testing and training practices was sought by administering a survey to health professionals working in CF centres across Australia and New Zealand. The survey comprised five sections (46 questions) and was sent via an online link (Qualtrics). Response rate was optimised using the Dillman approach. Approval for this study was granted from the Human Research Ethics Committee at Curtin University (HRE2018-074). Completion of the survey was taken as informed consent. RESULTS: A response rate of 80% (n = 32/40) was achieved. Each state/territory in Australia, except the Northern Territory was represented in the survey responses. Eight of the 12 major regions in New Zealand were also represented. Regarding tests of exercise capacity, field-based tests were performed more commonly than laboratory-based tests (n = 28/32; 88% vs n = 11/32 centres; 34%; difference: 54%; 95% confidence interval 31-70%). Most (89%) respondents perceived field tests to be at least 'somewhat' important, whereas 91% of respondents perceived laboratory tests to be 'a little' to 'somewhat' important. Physical activity and/or exercise were discussed by at least one health professional in the CF team at every clinic appointment and/or annual review. Most centred offered outpatient exercise training each year to their patients (n = 24/32; 75%). CONCLUSION: This survey captures the current practices of exercise testing and training in CF centres across Australia and New Zealand.

OPTImising the implementation of pulMonary rehAbiLitation in people with chronic obstructive pulmonary disease (the OPTIMAL study): mixed methods study protocol.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common respiratory condition characterised by dyspnoea during daily life. As the disease progresses, people with COPD can experience poor quality of life, reduced exercise capacity, worsening of symptoms and increased hospital admissions. Pulmonary rehabilitation, which includes exercise training, optimises both psychological and physical function, reduces symptoms and mitigates healthcare utilisation in people with COPD. There is, however, a gap in implementation of pulmonary rehabilitation programs, with global access limited to a small fraction of people with COPD. The overall aim of this study is to gather evidence that will optimise the implementation of pulmonary rehabilitation in people with COPD living in Perth, Western Australia. METHODS: This is a mixed methods study protocol informed by a critical realist perspective. The study will comprise four phases. In Phase 1, we will quantify target behaviours of healthcare professionals and people with COPD which are related to the implementation of pulmonary rehabilitation at three tertiary hospitals. In Phase 2, we will conduct semi-structured interviews to explore the determinants of these target behaviours from the perspectives of healthcare professionals, people with COPD and their primary support person. In Phase 3, knowledge gained in Phases 1 and 2 will be used by healthcare professionals and people with COPD to co-create, field test and apply strategies that optimise these target behaviours. In Phase 4, we will re-quantify these target behaviours to determine the influence of co-created strategies. The cost effectiveness of implementing the co-created strategies will be explored by an economic analysis. DISCUSSION: Understanding current clinical practice and the determinants of target behaviours pertaining to the implementation of pulmonary rehabilitation is crucial when developing strategies that successfully bridge the pulmonary rehabilitation implementation gap. If co-created strategies are effective, more people with COPD living in Perth, Western Australia will have access to pulmonary rehabilitation enabling them to derive the health benefits associated with this intervention.

Exercise training for adults hospitalized with an acute respiratory condition: a systematic scoping review.

OBJECTIVE: In adults hospitalized with an acute or chronic respiratory condition, to determine what has been reported regarding exercise programmes in terms of content, tolerability, evaluation and adverse events. DATA SOURCES: A systematic search was conducted of electronic databases (PubMed, EMBASE, CINAHL, PEDro, The Cochrane Library), trial registries and conference abstracts (Thoracic Society of Australia and New Zealand Annual Scientific Meeting, the European Respiratory Society Congress, the American Thoracic Society International Conference). REVIEW METHODS: Studies were included if they (1) recruited adults hospitalized with an acute or chronic respiratory condition, (2) described an exercise programme that targeted peripheral muscles and (3) reported that ⩾80% of the sample had initiated training within 72 hours of hospitalization. RESULTS: The last search was conducted on 2 June 2019. Of the 6282 records identified, 20 met the study criteria. These described 18 separate studies (2018 participants). Studies were conducted in adults hospitalized with an exacerbation of chronic obstructive pulmonary disease or with community-acquired pneumonia. The content of exercise programmes included aerobic and/or resistance training, neuromuscular electrical stimulation, whole-body vibration or movement out of bed. In eight studies (44%), the initial session was prescribed using objective measures of exercise capacity, peripheral muscle force and the ability to undertake activities of daily living. Across 7420 training sessions, seven adverse events were reported. CONCLUSION: Methods used to prescribe and titrate exercise programmes in adults hospitalized with an acute or an exacerbation of a chronic respiratory condition were disparate. When reported, programmes were well tolerated and adverse events were infrequent.

Determinants of Sedentary Behaviour in Individuals with COPD: A Qualitative Exploration Guided by the Theoretical Domains Framework.

In people with chronic obstructive pulmonary disease (COPD), there is increasing recognition that the prolonged accumulation of sedentary time (ST) is associated with adverse cardio-metabolic health outcomes. Nevertheless, changing this lifestyle, which has evolved over several decades, is likely to be challenging. This study reports the determinants, perceived by individuals with COPD, as being important for reducing ST. An in-depth understanding of this information is essential when planning an intervention to reduce ST. Fourteen individuals with COPD completed semi-structured one-on-one interviews, which were audio recorded and transcribed verbatim. Both the interview schedule and mapping of data items extracted from the interview transcripts were informed by the Theoretical Domains Framework (TDF). A total of 867 quotes were mapped to the 14 TDF domains. Seven of the fourteen domains were identified as being important determinants for reducing ST: knowledge, beliefs about consequences, beliefs about capabilities, environmental context and resources, social influences, social/professional role and identity, and behavioural regulation. There was a lack of knowledge regarding the meaning of sedentary behaviour. Participants' desire to be educated by knowledgeable health professionals in a formal programme was a dominant theme across multiple domains. The most frequently reported barriers to reducing ST related to the domains of social/professional role and identity and environmental context and resources, while the most frequently reported enablers were related to the domains pertaining to beliefs about consequences and social influences. Potential strategies to reduce ST among people with COPD include education and other determinants identified in this research.