Views of healthcare professionals on complementary and alternative medicine use by patients with diabetes: a qualitative study.

BACKGROUND: Recent estimates indicate that a significant proportion of diabetic patients globally, up to 51%, are utilizing complementary and alternative medicine (CAM). To improve patient-provider communication and optimize prescribed treatments, healthcare professionals (HCPs) must understand the factors associated with CAM use among diabetic patients. There is a dearth of literature on HCPs perspectives on CAM use by diabetic patients. This study explored HCPs knowledge, perspective, and views on their diabetic patients' use of CAM. METHODS: Qualitative study using one-to-one semi-structured interviews conducted with 22 HCPs involved in the care of diabetic patients (6 endocrinologists, 4 general practitioners, 4 nurses and 8 pharmacists). Participants were recruited through general practices, community pharmacies and a diabetic centre in Saudi Arabia. Data were analyzed using thematic analysis. RESULTS: Five key themes resulted from the analysis. HCPs generally demonstrated negative perceptions toward CAM, particularly regarding their evidence-based effectiveness and safety. Participants described having limited interactions with diabetic patients regarding CAM use due to HCPs' lack of knowledge about CAM, limited consultation time and strict consultation protocols. Participants perceived convenience as the reason why patients use CAM. They believed many users lacked patience with prescribed medications to deliver favourable clinical outcomes and resorted to CAM use. CONCLUSIONS: HCPs have noted inadequate engagement with diabetic patients regarding CAM due to a lack of knowledge and resources. To ensure the safe use of CAM in diabetes and optimize prescribed treatment outcomes, one must address the communication gap by implementing a flexible consultation protocol and duration. Additionally, culturally sensitive, and evidence-based information should be available to HCPs and diabetic patients.

Promoting participation in physical activity through Snacktivity: A qualitative mixed methods study.

BACKGROUND: Public health guidance acknowledges the benefits of physical activity of any duration. We have proposed a whole-day approach to promoting physical activity called Snacktivity™, which encourages frequent 2-5 minute 'activity snacks' of moderate-to-vigorous intensity. METHODS: Using repeated semi-structured interviews and a think aloud protocol, this study aimed to understand participants' experiences of integrating Snacktivity™ into daily life, to provide insights to refine the delivery of Snacktivity™ interventions. Physically inactive adults recruited via primary care and a community health service engaged with an intervention to encourage Snacktivity™ over three weeks, which included using a Fitbit and linked mobile phone app (SnackApp). Participants took part in semi-structured interviews on two occasions during the intervention, with a sub-group participating in a think aloud study. Three study data sets were generated and independently explored using inductive thematic analysis, with findings combined into a single set of themes. RESULTS: Eleven adults participated in the interview study who were interviewed twice (total interviews completed n = 21, 1 participant declined the second interview), of whom six completed the think aloud study (total voice recordings n = 103). Three main themes emerged from the combined data; lived experience of participating in Snacktivity™, motivation for Snacktivity™ and experiences with the Snacktivity™ technology. Participants undertook a variety of activity snacks, utilising their environment, which they believed improved their psychological wellbeing. Participants were enthusiastic about Snacktivity™, with some stating that activity snacks were more accessible than traditional exercise, but perceived they were often prevented from doing so in the presence of others. Participants were mostly enthusiastic about using the Snacktivity™ technology. CONCLUSION: Participants were able to incorporate Snacktivity™ into their lives, particularly at home, and found this approach acceptable. Participants felt they experienced health benefits from Snacktivity™ although barriers to participation were reported. This study offers insights for translating guidance into practice and supporting people to become more physically active.

Views of children with diabetes from underserved communities, and their families on diabetes, glycaemic control and healthcare provision: A qualitative evidence synthesis.

AIMS: Children and young people with diabetes (CYPD) from socio-economically deprived and/or ethnic minority groups tend to have poorer glucose control and greater risk of diabetes-related complications. In this systematic review of qualitative evidence (qualitative evidence synthesis, QES), we aimed to explore the experiences and views of clinical encounters in diabetes care from the perspectives of CYPD and their family/carers from underserved communities and healthcare professionals in diabetes care. METHODS: We searched 6 databases to March 2022 with extensive search terms, and used a thematic synthesis following methods of Thomas and Harden. RESULTS: We identified 7 studies and described 11 descriptive themes based on primary and secondary constructs. From these, three "analytical themes" were developed. (1) "Alienation of CYPD" relates to their social identity and interaction with peers, family and health service practitioners in the context of diabetes self- and family/carer management and is impacted by communication in the clinical encounter. (2) "Empowerment of CYPD and family/carers" explores families' understanding of risks and consequences of diabetes and taking responsibility for self- and family/carer management in the context of their socio-cultural background. (3) "Integration of diabetes (into self and family)" focuses on the ability to integrate diabetes self-management into the daily lives of CYPD and family/carers beyond the clinical consultation. CONCLUSIONS: The analytical themes are interdependent and provide a conceptual framework from which to explore and strengthen the therapeutic alliance in clinical encounters and to foster greater concordance with treatment plans. Communicating the biomedical aspects of managing diabetes in the clinical encounter is important, but should be balanced with addressing socio-emotional factors important to CYPD and family/carers.

General population screening for paediatric type 1 diabetes-A qualitative study of UK professional stakeholders.

AIMS: Identifying children at risk of type 1 diabetes allows education for symptom recognition and monitoring to reduce the risk of diabetic ketoacidosis at presentation. We aimed to explore stakeholder views towards paediatric general population screening for type 1 diabetes in the United Kingdom (UK). METHODS: Qualitative interviews were undertaken with 25 stakeholders, including diabetes specialists, policymakers and community stakeholders who could be involved in a future type 1 diabetes screening programme in the UK. A thematic framework analysis was performed using the National Screening Committee's evaluative criteria as the overarching framework. RESULTS: Diabetic ketoacidosis prevention was felt to be a priority and proposed benefits of screening included education, monitoring and helping the family to better prepare for a future with type 1 diabetes. However, diabetes specialists were cautious about general population screening because of lack of evidence for public acceptability. Concerns were raised about the harms of living with risk, provoking health anxiety and threatening the child's right to an 'open future'. Support systems that met the clinical and psychological needs of the family living with risk were considered essential. Stakeholders were supportive of research into general population screening and acknowledged this would be a priority if an immunoprevention agent were licensed in the UK. CONCLUSIONS: Although stakeholders suggested the harms of UK paediatric general population screening currently outweigh the benefits, this view would potentially be altered if prevention therapies were licensed. In this case, an evidence-based screening strategy would need to be formulated and public acceptability explored.

Snacktivity™ to promote physical activity and reduce future risk of disease in the population: protocol for a feasibility randomised controlled trial and nested qualitative study.

BACKGROUND: Many people do not regularly participate in physical activity, which may negatively impact their health. Current physical activity guidelines are focused on promoting weekly accumulation of at least 150 min of moderate to vigorous intensity physical activity (MVPA). Whilst revised guidance now recognises the importance of making small changes to physical activity behaviour, guidance still focuses on adults needing to achieve at least 150 min of MVPA per week. An alternative 'whole day' approach that could motivate the public to be more physically active, is a concept called Snacktivity™. Instead of focusing on achieving 150 min per week of physical activity, for example 30 min of MVPA over 5 days, Snacktivity™ encourages the public to achieve this through small, but frequent, 2-5 min 'snacks' of MVPA throughout the whole day. METHODS: The primary aim is to undertake a feasibility trial with nested qualitative interviews to assess the feasibility and acceptability of the Snacktivity™ intervention to inform the design of a subsequent phase III randomised trial. A two-arm randomised controlled feasibility trial aiming to recruit 80 inactive adults will be conducted. Recruitment will be from health and community settings and social media. Participants will be individually randomised (1:1 ratio) to receive either the Snacktivity™ intervention or usual care. The intervention will last 12 weeks with assessment of outcomes completed before and after the intervention in all participants. We are interested in whether the Snacktivity™ trial is appealing to participants (assessed by the recruitment rate) and if the Snacktivity™ intervention and trial methods are acceptable to participants (assessed by Snacktivity™/physical activity adherence and retention rates). The intervention will be delivered by health care providers within health care consultations or by researchers. Participants' experiences of the trial and intervention, and health care providers' views of delivering the intervention within health consultations will be explored. DISCUSSION: The development of physical activity interventions that can be delivered at scale are needed. The findings from this study will inform the viability and design of a phase III trial to assess the effectiveness and cost-effectiveness of Snacktivity™ to increase physical activity. TRIAL REGISTRATION: ISRCTN: 64851242.

Complementary and alternative medicine use in self-management of diabetes: A qualitative study of patient and user conversations in online forums.

BACKGROUND: An important part of diabetes self-management includes discussing and seeking informal advice from others. AIM: This study aimed to explore beliefs and experiences of patients in relation to their use of CAM in diabetes through the use of data from online patient forum discussions. METHOD: Google search engine was used to identify relevant web-based online discussion forums in English language focussing on CAM use (including herbal and other unorthodox therapies) in diabetes and posted by either patients or carers. No date limit was imposed. A qualitative content analysis was adopted for analysis. RESULTS: Twenty-two online forums containing 77 threads with 1156 posts and replies were identified. Seven major themes emerged from the data analysis including: patient beliefs regarding CAM use, perceived effectiveness and safety of CAM, evidence base and information seeking. Patients used online forums to seek information about the benefits, side effects and share positive and negative experiences of CAM use. Feeling stressed, frustrated or overwhelmed with diabetes and prescribed medications was often linked to their decisions to use CAM. They described that healthcare professionals were often unaware or unable to help in regards to their queries around CAMs. CONCLUSION: Patients with diabetes use online forums to share information regarding CAM use. There is a scope for professional societies, patient charities and health systems to offer such online platforms to promote rationale use of CAM, provide evidence-based information to patients and alleviate fears and concerns around diabetes and prescribed medicines.

Cooking outdoors or with cleaner fuels does not increase malarial risk in children under 5 years: a cross-sectional study of 17 sub-Saharan African countries.

BACKGROUND: Smoke from solid biomass cooking is often stated to reduce household mosquito levels and, therefore, malarial transmission. However, household air pollution (HAP) from solid biomass cooking is estimated to be responsible for 1.67 times more deaths in children aged under 5 years compared to malaria globally. This cross-sectional study investigates the association between malaria and (i) cleaner fuel usage; (ii) wood compared to charcoal fuel; and, (iii) household cooking location, among children aged under 5 years in sub-Saharan Africa (SSA). METHODS: Population-based data was obtained from Demographic and Health Surveys (DHS) for 85,263 children within 17 malaria-endemic sub-Saharan countries who were who were tested for malaria with a malarial rapid diagnostic test (RDT) or microscopy. To assess the independent association between malarial diagnosis (positive, negative), fuel type and cooking location (outdoor, indoor, attached to house), multivariable logistic regression was used, controlling for individual, household and contextual confounding factors. RESULTS: Household use of solid biomass fuels and kerosene cooking fuels was associated with a 57% increase in the odds ratio of malarial infection after adjusting for confounding factors (RDT adjusted odds ratio (AOR):1.57 [1.30-1.91]; Microscopy AOR: 1.58 [1.23-2.04]) compared to cooking with cleaner fuels. A similar effect was observed when comparing wood to charcoal among solid biomass fuel users (RDT AOR: 1.77 [1.54-2.04]; Microscopy AOR: 1.21 [1.08-1.37]). Cooking in a separate building was associated with a 26% reduction in the odds of malarial infection (RDT AOR: 0.74 [0.66-0.83]; Microscopy AOR: 0.75 [0.67-0.84]) compared to indoor cooking; however no association was observed with outdoor cooking. Similar effects were observed within a sub-analysis of malarial mesoendemic areas only. CONCLUSION: Cleaner fuels and outdoor cooking practices associated with reduced smoke exposure were not observed to have an adverse effect upon malarial infection among children under 5 years in SSA. Further mixed-methods research will be required to further strengthen the evidence base concerning this risk paradigm and to support appropriate public health messaging in this context.

Effectiveness of interventions to reduce household air pollution from solid biomass fuels and improve maternal and child health outcomes in low- and middle-income countries: A systematic review and meta-analysis.

Interventions to reduce household air pollution (HAP) are key to reducing associated morbidity and mortality in low- and middle- income countries (LMICs); especially among pregnant women and young children. This systematic review aims to determine the effectiveness of interventions aimed to reduce HAP exposure associated with domestic solid biomass fuel combustion, compared to usual cooking practices, for improving health outcomes in pregnant women and children under five in LMIC settings. A systematic review and meta-analysis was undertaken with searches undertaken in MEDLINE, EMBASE, CENTRAL, GIM, ClinicalTrials.gov, and Greenfile in August 2020. Inclusion criteria were experimental, non-experimental, or quasi-experimental studies investigating the impact of interventions to reduce HAP exposure and improve associated health outcomes among pregnant women or children under 5 years. Study selection, data extraction, and quality assessment using the Effective Public Health Practice Project tool were undertaken independently by two reviewers. Seventeen out of 7293 retrieved articles (seven pregnancy, nine child health outcome; 13 studies) met the inclusion criteria. These assessed improved cookstoves (ICS; n = 10 studies), ethanol stoves (n = 1 study), and Liquefied Petroleum Gas (LPG; n = 2 studies) stoves interventions. Meta-analysis showed no significant effect of ICS interventions compared to traditional cooking for risk of preterm birth (n = 2 studies), small for gestational age (n = 2 studies), and incidence of acute respiratory infections (n = 6 studies). Although an observed increase in mean birthweight was observed, this was not statistically significant (n = 4). However, ICS interventions reduced the incidence of childhood burns (n = 3; observations = 41 723; Rate Ratio: 0.66 [95% CI: 0.45-0.96]; I2 : 46.7%) and risk of low birth weight (LBW; n = 4; observations = 3456; Odds Ratio: 0.73 [95% CI: 0.61-0.87]; I2 : 21.1%). Although few studies reported health outcomes, the data indicate that ICS interventions were associated with reduced risk of childhood burns and LBW. The data highlight the need for the development and implementation of robust, well-reported and monitored, community-driven intervention trials with longer-term participant follow-up.

Factors affecting complementary and alternative medicine (CAM) use by adult diabetic patients: A systematic review using the theoretical domains framework (TDF).

BACKGROUND: It is estimated that approximately 50% of patients with diabetes use some form of complementary and alternative medicine (CAM) to manage their condition. OBJECTIVES: The objective of this study was to undertake a systematic review to explore factors that influence the use of CAM by diabetic patients. METHODS: A systematic review of literature was conducted using Cochrane and PRISMA guidelines. Nine databases including MEDLINE and EMBASE were searched from 2010 to March 2021 using medical subject headings and natural language keywords. Data in relation to factors associated with use of CAM in diabetic patients 18 years of age and older were extracted and further categorised as per the theoretical domains framework (TDF). RESULTS: Forty-three studies from 28 countries were included. A total of 84 factors were identified. Key factors related to the 'intentions (to treat and relieve symptoms) and goals' domain of the TDF. Accessibility and affordability compared to physician visits and modern medicines (TDF- environmental context and resources), 'Social influences' from family members, friends, religious and spiritual scholars were amongst other factors reported to be important. Users also reported lack of trust in modern medicines and perceived CAMs to be safer and free from adverse effects. CONCLUSIONS: Decisions to use CAM in diabetes are multifactorial. Healthcare professionals' awareness of patients' CAM use and associated factors can inform counselling practices and promote treatment optimisation, adherence and patient safety through avoidance of drug-CAM interactions. Alleviating patients' concerns and reluctance to use prescribed treatments are imperative to achieve therapeutic goals. Improving access and affordability is imperative where high costs prevent use of prescribed medicines leading to many patients using CAM as a standalone therapy. [Systematic review registration: PROSPERO CRD42019125036].

Snacktivity™ to Promote Physical Activity: a Qualitative Study.

BACKGROUND: Adults should achieve a minimum of 150 min of moderate-to-vigorous intensity physical activity per week, but many people do not achieve this. Changes to international guidance have removed the requirement to complete physical activity in bouts of at least 10 min. Snacktivity is a novel and complementary approach that could motivate people to be physically active. It focuses on promoting shorter (2-5 min) and more frequent bouts, or 'snacks' of physical activity throughout the day. It is not known whether promoting physical activity in shorter bouts is acceptable to the public, or whether it likely to translate into health behaviour change. METHODS: As part of a larger research programme, this study explored the merits of using small bouts of physical activity to help the public become physically active (the Snacktivity™ programme). Thirty-one inactive adults used the approach for five days then participated in semi- structured interviews about their experiences. The data were analysed using the Framework approach. RESULTS: Whilst participants highlighted some potential barriers to implementation, they expressed the ease with which Snacktivity could be achieved, which gave them a new awareness of opportunities to do more physical activity throughout the day. Participants raised the importance of habit formation to achieve regular small bouts of physical activity. CONCLUSIONS: Findings demonstrated that participants liked the Snacktivity concept and viewed it as a motivating approach. Guidance about physical activity must lead to advice that has the best chance of preserving and promoting health and Snacktivity has potential to meet this ambition.

Comparison of Respiratory Health Impacts Associated with Wood and Charcoal Biomass Fuels: A Population-Based Analysis of 475,000 Children from 30 Low- and Middle-Income Countries.

BACKGROUND: The World Health Organisation reported that 45% of global acute respiratory infection (ARI) deaths in children under five years are attributable to household air pollution, which has been recognised to be strongly associated with solid biomass fuel usage in domestic settings. The introduction of legislative restrictions for charcoal production or purchase can result in unintended consequences, such as reversion to more polluting biomass fuels such as wood; which may increase health and environmental harms. However, there remains a paucity of evidence concerning the relative health risks between wood and charcoal. This study compares the risk of respiratory symptoms, ARI, and severe ARI among children aged under five years living in wood and charcoal fuel households across 30 low- and middle-income countries. METHODS: Data from children (N = 475,089) residing in wood or charcoal cooking households were extracted from multiple population-based Demographic and Health Survey databases (DHS) (N = 30 countries). Outcome measures were obtained from a maternal report of respiratory symptoms (cough, shortness of breath and fever) occurring in the two weeks prior to the survey date, generating a composite measure of ARI (cough and shortness of breath) and severe ARI (cough, shortness of breath and fever). Multivariable logistic regression analyses were implemented, with adjustment at individual, household, regional and country level for relevant demographic, social, and health-related confounding factors. RESULTS: Increased odds ratios of fever (AOR: 1.07; 95% CI: 1.02-1.12) were observed among children living in wood cooking households compared to the use of charcoal. However, no association was observed with shortness of breath (AOR: 1.03; 95% CI: 0.96-1.10), cough (AOR: 0.99; 95% CI: 0.95-1.04), ARI (AOR: 1.03; 95% CI: 0.96-1.11) or severe ARI (AOR: 1.07; 95% CI: 0.99-1.17). Within rural areas, only shortness of breath was observed to be associated with wood cooking (AOR: 1.08; 95% CI: 1.01-1.15). However, an increased odds ratio of ARI was observed in Asian (AOR: 1.25; 95% CI: 1.04-1.51) and East African countries (AOR: 1.11; 95% CI: 1.01-1.22) only. CONCLUSION: Our population-based observational data indicates that in Asia and East Africa there is a greater risk of ARI among children aged under 5 years living in wood compared to charcoal cooking households. These findings have major implications for understanding the existing health impacts of wood-based biomass fuel usage and may be of relevance to settings where charcoal fuel restrictions are under consideration.

Practice nurse-supported weight self-management delivered within the national child immunisation programme for postnatal women: a feasibility cluster RCT.

BACKGROUND: Pregnancy is a high-risk time for excessive weight gain. The rising prevalence of obesity in women, combined with excess weight gain during pregnancy, means that there are more women with obesity in the postnatal period. This can have adverse health consequences for women in later life and increases the health risks during subsequent pregnancies. OBJECTIVE: The primary aim was to produce evidence of whether or not a Phase III trial of a brief weight management intervention, in which postnatal women are encouraged by practice nurses as part of the national child immunisation programme to self-monitor their weight and use an online weight management programme, is feasible and acceptable. DESIGN: The research involved a cluster randomised controlled feasibility trial and two semistructured interview studies with intervention participants and practice nurses who delivered the intervention. Trial data were collected at baseline and 3 months later. The interview studies took place after trial follow-up. SETTING: The trial took place in Birmingham, UK. PARTICIPANTS: Twenty-eight postnatal women who were overweight/obese were recruited via Birmingham Women's Hospital or general practices. Nine intervention participants and seven nurses were interviewed. INTERVENTIONS: The intervention was delivered in the context of the national child immunisation programme. The intervention group were offered brief support that encouraged self-management of weight when they attended their practice to have their child immunised at 2, 3 and 4 months of age. The intervention involved the provision of motivation and support by nurses to encourage participants to make healthier lifestyle choices through self-monitoring of weight and signposting to an online weight management programme. The role of the nurse was to provide regular external accountability for weight loss. Women were asked to weigh themselves weekly and record this on a record card in their child's health record ('red book') or using the online programme. The behavioural goal was for women to lose 0.5-1 kg per week. The usual-care group received a healthy lifestyle leaflet. MAIN OUTCOME MEASURES: The primary outcome was the feasibility of a Phase III trial to test the effectiveness of the intervention, as assessed against three traffic-light stop-go criteria (recruitment, adherence to regular self-weighing and registration with an online weight management programme). RESULTS: The traffic-light criteria results were red for recruitment (28/80, 35% of target), amber for registration with the online weight loss programme (9/16, 56%) and green for adherence to weekly self-weighing (10/16, 63%). Nurses delivered the intervention with high fidelity. In the qualitative studies, participants indicated that the intervention was acceptable to them and they welcomed receiving support to lose weight at their child immunisation appointments. Although nurses raised some caveats to implementation, they felt that the intervention was easy to deliver and that it would motivate postnatal women to lose weight. LIMITATIONS: Fewer participants were recruited than planned. CONCLUSIONS: Although women and practice nurses responded well to the intervention and adherence to self-weighing was high, recruitment was challenging and there is scope to improve engagement with the intervention. FUTURE WORK: Future research should focus on investigating other methods of recruitment and, thereafter, testing the effectiveness of the intervention. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12209332. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 49. See the NIHR Journals Library website for further project information.

After giving birth, many women find it hard to lose the weight that they gained during pregnancy. Research so far has focused on testing intensive weight loss programmes that cannot be given to all women who give birth because it would be too expensive. Instead, we tested a brief intervention delivered by practice nurses to mothers when they attended their practice to have their child immunised. We completed a study to test how well our recruitment methods worked, how well the intervention could be delivered by nurses during immunisation appointments and whether or not women followed the intervention. Women who were overweight/obese and had given birth at least 4 weeks previously were invited to participate. Women interested in participating were visited at home at the start and end of the study to measure their weight and to collect information about them. Participants were allocated to the intervention group or to a comparison group based on which practice they attended. For the intervention group, nurses encouraged women to monitor their weight weekly and record this on a record card in their child's health record (the 'red book') when they attended the practice to have their child immunised when their child was 2, 3 and 4 months old. Women were encouraged to use an online weight loss programme to help them lose weight and were advised to aim to lose 0.5­1 kg per week. Those in the comparison group were given a healthy living leaflet. Women and nurses were interviewed about their experiences of the study. Recruiting women to the study was difficult; however, women who did participate mostly followed the intervention well and weighed themselves weekly. Nurses liked the intervention; they felt that it could be incorporated into immunisation appointments and suggested some ideas for improvement. The study appeared feasible and acceptable, but better ways of recruiting women are needed.

The experiences of postnatal women and healthcare professionals of a brief weight management intervention embedded within the national child immunisation programme.

BACKGROUND: After childbirth, most women do not lose the extra weight gained during pregnancy. This is important because postnatal weight retention contributes to the development of obesity in later life. Research shows that postnatal women living with overweight would prefer to weigh less, are interested in implementing weight loss strategies, and would like support. Without evidence for the benefit of weight management interventions during pregnancy, postnatal interventions are increasingly important. Research has focused on intensive weight loss programmes, which cannot be offered to all postnatal women. Instead, we investigated the feasibility of a brief intervention delivered to postnatal women at child immunisation appointments. This qualitative study explored the views of women who received the intervention and healthcare professionals who delivered it. METHODS: The intervention was delivered within the context of the national child immunisation programme. The intervention group were offered brief support encouraging self-management of weight when attending general practices to have their child immunised at two, three and four months of age. The intervention involved motivation and support from practice nurses to encourage women to make healthier lifestyle choices through self-monitoring of weight and signposting to an online weight management programme. Nurses provided external accountability for weight loss. Women were asked to weigh themselves weekly and record this on a weight record card. Nested within this trial, semi-structured interviews explored the experiences of postnatal women who received the intervention and nurses who delivered it. RESULTS: The intervention was generally acceptable to participants and child immunisation appointments considered a suitable intervention setting. Nurses were hesitant to discuss maternal weight, viewing the postnatal period as a vulnerable time. Whilst some caveats to implementation were discussed by nurses, they felt the intervention was easy to deliver and would motivate postnatal women to lose weight. CONCLUSIONS: Participants were keen to lose weight after childbirth. Overall, they reported that the intervention was acceptable, convenient, and, appreciated support to lose weight after childbirth. Although nurses, expressed concerns about raising the topic of weight in the early postnatal period, they felt the intervention was easy to deliver and would help to motivate women to lose weight.

Global prevalence and types of complementary and alternative medicines use amongst adults with diabetes: systematic review and meta-analysis.

AIM: This study aimed to undertake a systematic review and meta-analysis of global prevalence and types of complementary and alternative medicine (CAM) use amongst adults with diabetes. METHODS: Nine databases, including MEDLINE and EMBASE, were searched for studies published between 2009 and 2019 which included extractable data for CAM use in adult patients with diabetes. Study characteristics, types of CAM, and overall and subgroup prevalence data in relation to CAM use were extracted. Meta-analysis of aggregate level data on prevalence and prevalence ratios (PRs) was performed using a random effects model. RESULTS: From the 38 studies included in the review, a total of 37 types of CAM and 223 types of herbs were identified. Pooled prevalence of CAM use was 51%. A wide variation in prevalence rates (predictive interval 8-93%) was observed. In the context of high heterogeneity, we found no evidence that CAM use was associated with gender, chronicity or type of diabetes. Approximately one third of patients did not disclose their use of CAM to healthcare professionals (95% PrI 25%, 97%). Herbal medicines, acupuncture, homoeopathy and spiritual healing were the common CAM types reported. CONCLUSIONS: A wide variation in prevalence of CAM use by patients with diabetes was identified. Healthcare professionals should be aware of their patients' use of CAM to ensure treatment optimization, avoid herb-drug interactions and promote medication adherence in diabetes. Diabetic reviews and clinical guidelines should incorporate exploration of patient use of CAM as many patients do not proactively disclose the use of CAM to their healthcare professionals. REGISTRATION: The protocol for this study was registered with the Centre for Review and Dissemination (CRD). Protocol registration number CRD42019125036.

Protocol for the feasibility and acceptability of a brief routine weight management intervention for postnatal women embedded within the national child immunisation programme: randomised controlled cluster feasibility trial with nested qualitative study (PIMMS-WL).

INTRODUCTION: On average women retain 5 to 9 kg 1 year after giving birth which can increase the risk of later obesity and chronic diseases. Some previous trials in this population have been effective in reducing weight, but are too intensive and costly to deliver at scale. There is a need for low-cost interventions to facilitate weight loss in this population. METHODS AND ANALYSIS: The primary aim is to assess the feasibility of delivering a weight management intervention for overweight/obese postnatal women within child immunisation appointments. We will conduct a randomised controlled cluster feasibility trial with a nested qualitative study to assess study recruitment and acceptability of the intervention. General practitioner practice (cluster) will be the unit of randomisation, with practices randomised to offer usual care plus the intervention or usual care only. Eighty women will be recruited. The intervention group will be offered brief support that encourages self-management of weight when attending child immunisation appointments. Practice nurses will encourage women to weigh themselves weekly and record this, and to make healthy lifestyle choices through using an online weight management programme. Women will be advised to aim for 0.5 to 1 kg/week weight loss. At each child immunisation the nurse will assess progress by weighing women. The comparator group will receive a healthy lifestyle leaflet. Data on weight, body fat, depression, anxiety, body image, eating behaviours and physical activity will be collected at baseline and follow-up. Women and nurses will be interviewed to ascertain their views about the intervention. The decision to proceed to the phase III trial will be based on prespecified stop-go criteria. ETHICS AND DISSEMINATION: Data will be stored securely at the University of Birmingham. Results will be disseminated through academic publications and presentations and will inform a possible phase III trial. The National Research Ethics Committee approved the study protocol. TRIAL REGISTRATION NUMBER: ISRCTN12209332.

GPs and paediatric oncology palliative care: a Q methodological study.

OBJECTIVE: This mixed-methods study set in the West Midlands region of the UK demonstrates the effectiveness of Q methodology in examining general practitioners' (GPs') perception of their role in children's oncology palliative care. METHODS: Using data obtained from the analysis of semistructured interviews with GPs who had cared for a child receiving palliative care at home and bereaved parents, 50 statements were identified as representative of the analysis findings. 32 GPs with a non-palliative child with cancer on their caseload were asked to rank the statements according to their level of agreement/disagreement on a grid. They were then asked to reflect and comment on the statements they most and least agreed with. The data were analysed using a dedicated statistical software package for Q analysis PQMethod V.2.20 (Schmolck 2012). A centroid factor analysis was undertaken initially with 7 factors then repeated for factors 1-6. Varimax and manual flagging was then completed. RESULTS: 4 shared viewpoints were identified denoting different GP roles: the GP, the compassionate practitioner, the team player practitioner and the pragmatic practitioner. In addition consensus (time pressures, knowledge deficits, emotional toll) and disagreement (psychological support, role, experiential learning, prior relationships) between the viewpoints were identified and examined. CONCLUSIONS: Q methodology, used for the first time in this arena, identified 4 novel and distinct viewpoints reflecting a diverse range of GP perspectives. Appropriately timed and targeted GP education, training, support, in conjunction with collaborative multiprofessional working, have the potential to inform their role and practice across specialities.

Patient experience of home and waiting room blood pressure measurement: a qualitative study of patients with recently diagnosed hypertension.

BACKGROUND: Out-of-office blood pressure (BP) measurement is advocated to confirm hypertension diagnosis. However, little is known about how primary care patients view and use such measurement. AIM: To investigate patient experience of out-of-office BP monitoring, particularly home and practice waiting room BP measurement, before, during, and after diagnosis. DESIGN AND SETTING: A cross-sectional, qualitative study with patients from two UK GP surgeries participating in a feasibility study of waiting room BP measurement. METHOD: Interviewees were identified from recent additions to the practice hypertension register. Interviews were recorded, transcribed, and coded thematically. RESULTS: Of 29 interviewees, 9 (31%) and 22 (76%) had used the waiting room monitor and/or monitored at home respectively. Out-of-office monitoring was used by patients as evidence of control or the lack of need for medication, with the printed results slips from the waiting room monitor perceived to improve 'trustworthiness'. The waiting room monitor enabled those experiencing uncertainty about their equipment or technique to double-check readings. Monitoring at home allowed a more intensive and/or flexible schedule to investigate BP fluctuations and the impact of medication and lifestyle changes. A minority used self-monitoring to inform drug holidays. Reduced intensity of monitoring was reported with both modalities following diagnosis as initial anxiety or patient and GP interest decreased. CONCLUSION: Home and practice waiting room measurements have overlapping but differing roles for patients. Waiting room BP monitors may be a useful out-of-office measurement modality for patients unwilling and/or unable to measure and record their BP at home.

Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial.

BACKGROUND: Studies evaluating titration of antihypertensive medication using self-monitoring give contradictory findings and the precise place of telemonitoring over self-monitoring alone is unclear. The TASMINH4 trial aimed to assess the efficacy of self-monitored blood pressure, with or without telemonitoring, for antihypertensive titration in primary care, compared with usual care. METHODS: This study was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mm Hg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group). Randomisation was by a secure web-based system. Neither participants nor investigators were masked to group assignment. The primary outcome was clinic measured systolic blood pressure at 12 months from randomisation. Primary analysis was of available cases. The trial is registered with ISRCTN, number ISRCTN 83571366. FINDINGS: 1182 participants were randomly assigned to the self-monitoring group (n=395), the telemonitoring group (n=393), or the usual care group (n=394), of whom 1003 (85%) were included in the primary analysis. After 12 months, systolic blood pressure was lower in both intervention groups compared with usual care (self-monitoring, 137·0 [SD 16·7] mm Hg and telemonitoring, 136·0 [16·1] mm Hg vs usual care, 140·4 [16·5]; adjusted mean differences vs usual care: self-monitoring alone, -3·5 mm Hg [95% CI -5·8 to -1·2]; telemonitoring, -4·7 mm Hg [-7·0 to -2·4]). No difference between the self-monitoring and telemonitoring groups was recorded (adjusted mean difference -1·2 mm Hg [95% CI -3·5 to 1·2]). Results were similar in sensitivity analyses including multiple imputation. Adverse events were similar between all three groups. INTERPRETATION: Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care. FUNDING: National Institute for Health Research via Programme Grant for Applied Health Research (RP-PG-1209-10051), Professorship to RJM (NIHR-RP-R2-12-015), Oxford Collaboration for Leadership in Applied Health Research and Care, and Omron Healthcare UK.

Attitudes and barriers to exercise in adults with a recent diagnosis of type 1 diabetes: a qualitative study of participants in the Exercise for Type 1 Diabetes (EXTOD) study.

OBJECTIVES: To explore attitudes and barriers to exercise in adults with new-onset type 1 diabetes mellitus (T1DM). DESIGN: Qualitative methodology using focus group (n=1), individual face-to-face (n=4) and telephone interviews (n=8). Thematic analysis using the Framework Method. SETTING: Nineteen UK hospital sites. PARTICIPANTS: Fifteen participants in the Exercise for Type 1 Diabetes study. We explored current and past levels of exercise, understanding of exercise and exercise guidelines, barriers to increasing exercise levels and preferences for monitoring of activity in a trial. RESULTS: Five main themes were identified: existing attitudes to exercise, feelings about diagnosis, perceptions about exercise consequences, barriers to increasing exercise and confidence in managing blood glucose. An important finding was that around half the participants reported a reduction in activity levels around diagnosis. Although exercise was felt to positively impact on health, some participants were not sure about the benefits or concerned about potential harms such as hypoglycaemia. Some participants reported being advised by healthcare practitioners (HCPs) not to exercise. CONCLUSIONS: Exercise should be encouraged (not discouraged) from diagnosis, as patients may be more amenable to lifestyle change. Standard advice on exercise and T1DM needs to be made available to HCPs and patients with T1DM to improve patients' confidence in managing their diabetes around exercise. TRIAL REGISTRATION NUMBER: ISRCTN91388505; Results.

Typologies for Restructuring Relationships in Cancer Survivorship: Temporal Changes in Social Support and Engagement With Self-Management Practices.

BACKGROUND: Cancer survivors with good social support are generally more motivated to undertake self-management behaviors and make lifestyle changes. However, the impact of changes in social support over time, from prediagnosis through treatment and into survivorship, on the health and recovery of cancer survivors with a range of cancer diagnoses has not been explored. OBJECTIVE: The aim of this study was to examine how temporal changes in social support offered to cancer survivors by family and friends influence their engagement with self-management practices and adaptation to lifestyle changes. METHODS: The interview study took place in a teaching hospital in the West Midlands, United Kingdom. Forty participants were purposively sampled. A narrative approach to data collection was chosen, and data were thematically analyzed. RESULTS: Six typologies of restructuring relationships postcancer were identified. A greater understanding of the changes to social relationships that a cancer diagnosis can incur and the impact of this on people's outlook and ability to self-manage was developed. CONCLUSION: The restructuring of social relationships by cancer survivors over time can impact their outlook and ability to self-manage in survivorship, shaping their engagement with health promoting activities and reconciling cancer within the wider context of their lives. IMPLICATIONS FOR PRACTICE: Appropriate clinical nursing processes and tailored interventions are required to support cancer survivors and promote engagement with self-management practices. Nurses are a vital component of the social support that enables patients to make the best health and lifestyle choices available to them.