The lived experiences of young people (13-16 years) with Type 1 diabetes mellitus and their parents--a qualitative phenomenological study

AIMS

Within a programme of research aiming to develop a technology-based educational intervention for young people with Type 1 diabetes, this study aimed to explore adolescents' and parents' experiences of living with Type 1 diabetes from an interpretive phenomenological perspective.

METHODS

In-depth interviews were conducted with 20 adolescents with Type 1 diabetes from a diabetes clinic in North West England, and 27 of their parents.

RESULTS

Living with Type 1 diabetes in adolescence was characterized by three distinct stages: (1) adapting to the diagnosis; (2) learning to live with Type 1 diabetes; (3) becoming independent. Experiential learning was key to adolescents developing self-management skills and independence. Parents and health professionals were instrumental in facilitating environments that gave adolescents the freedom to learn through trial and error. They also provided the support, feedback and discussion necessary to facilitate such learning.

CONCLUSIONS

For adolescents to become independent in Type 1 diabetes self-management, they must develop capability through experiential learning. It is important that parents and health professionals understand the important role they play in this process and have the skills to support adolescents in this way. Data from this study have been used to develop an online interactive 'Adolescent Diabetes Needs Assessment Tool', which assesses individual learning and support needs to aid the process of feedback and discussion.

'McDonalds and KFC, it's never going to happen': the challenges of working with food outlets to tackle the obesogenic environment

BACKGROUND

Food outlets may make an important contribution to an obesogenic environment. This study investigated barriers and facilitators to public health work with food outlets in disadvantaged areas.

METHODS

In-depth qualitative interviews with 36 directors, managers and public health service delivery staff in a coterminous primary care trust and local authority in northwest England. Data were analysed using the constant comparative method.

RESULTS

Three interventions were available to engage with businesses; awards for premises that welcomed breastfeeding mothers or offered healthy menu options and local authority planning powers. Sensitivity to the potential conflict between activities that generate profit and those that promote health, led to compromises, such as awards for cafés that offer only one healthy option on an otherwise unhealthy menu. An absence of existing relationships with businesses and limited time were powerful disincentives to action, leading to greater engagement with public rather than private sector organizations. Hiring staff with commercial experience and incentives for businesses were identified as useful strategies, but seldom used.

CONCLUSIONS

Encouraging food outlets to contribute to tackling the obesogenic environment is a major challenge for local public health teams that requires supportive national policies. Commitment to engage with the local public health service should be part of any national voluntary agreements with industry.

The experience of community engagement for individuals: a rapid review of evidence

Community engagement is central to strategies to promote health and well-being and reduce health inequalities in many countries, particularly interventions which focus on improving health in disadvantaged populations. Despite the widespread use of community engagement approaches, however, there have been relatively few attempts to review the evidence on the impact that participation has on the lives of individuals involved. Drawing on a wider review of evidence carried out on behalf of the National Institute for Health and Clinical Excellence (NICE), this article reports on a rapid review of evidence of the effectiveness of initiatives which seek to engage communities in action to address the wider social determinants of health, to explore individuals' subjective experiences of engagement. The rapid review process was guided by NICE's public health methods manual, adapted to suit the diversity of the evidence. A total of 22 studies were identified containing empirical data on subjective experiences of community engagement for individuals. The findings of the rapid review suggest that the majority of 'engaged' individuals perceived benefits for their physical and psychological health, self-confidence, self-esteem, sense of personal empowerment and social relationships. Set against these positive outcomes, however, the evidence suggests that there are unintended negative consequences of community engagement for some individuals, which may pose a risk to well-being. These consequences included exhaustion and stress, as involvement drained participants' energy levels as well as time and financial resources. The physical demands of engagement were reported as particularly onerous by individuals with disabilities. Consultation fatigue and disappointment were negative consequences for some participants who had experienced successive waves of engagement initiatives. For some individuals, engagement may involve a process of negotiation between gains and losses. This complexity needs to be more widely recognised among those who seek to engage communities.

Students' attitudes to the communications employed during an outbreak of meningococcal disease in a UK school: a qualitative study

BACKGROUND

Following an outbreak of meningococcal disease in a school in the North West of England, the communication methods employed by the Health Protection Agency (HPA) were evaluated in order to explore ways of improving communication with the public.

METHODS

Qualitative questionnaires were distributed to Year 12 (sixth form) students. The Framework approach was used to analyse the data, which were coded, and emergent themes identified.

RESULTS

In the absence of clear communication from official sources, many participants suggested that circulating rumours caused confusion and anxiety in the student population. Rumours were spread through informal networks in person or through text and MSN messaging. It was generally perceived that accurate information in this period would have been useful to allay potentially unfounded anxiety. Most students surveyed reported that they were sufficiently aware of the situation prior to receiving official announcements. The information provided by the HPA through the school was generally perceived as being useful, but it came too late.

CONCLUSION

In outbreak situations, rumours will spread rapidly in the absence of early communication, and this can be a significant cause of anxiety. The use of digital communication strategies should be considered, since they can seed dependable information that will disseminate rapidly through peer groups.

Policy-makers' attitudes to decision support models for coronary heart disease: a qualitative study

OBJECTIVES

To explore attitudes to the use of models for coronary heart disease to support decision-making for policy and service planning.

METHODS

Qualitative study using semi-structured interviews with 33 policy- and decision-makers purposively sampled from the UK National Health Service (NHS) (national, regional and local levels), academia and voluntary organizations. Interviews were transcribed, coded and emergent themes identified using framework analysis aided by NVivo software.

RESULTS

Policy-makers and planners were generally enthusiastic about models to assist in decision-making through: predicting trends; assessing the effect of interventions on health inequalities; quantifying the impact of population level and targeted interventions, and facilitating economic evaluation. The perceived advantages of using models included: more rational commissioning; the facility for scenario testing; advocacy for population level interventions and off-the-shelf synthesis to aid real time decision-making. However, although participants were aware of models to support decision-making, these were not being used routinely. Some participants felt that models oversimplify complex situations and that there is a lack of shared understanding as to how models work. Factors that increase confidence in decision support models included: rigorous validation and peer review, the availability of user-support and increased transparency.

CONCLUSION

Policy-makers and planners were generally enthusiastic about the use of models to support decision-making, illustrating the potential uses for models and the factors that improve confidence in them. However, existing models are often not being used in practice. So new models that are fit for practice need to be developed.

Planning ahead in public health? A qualitative study of the time horizons used in public health decision-making

Background

In order to better understand factors that influence decisions for public health, we undertook a qualitative study to explore issues relating to the time horizons used in decision-making.

Methods

Qualitative study using semi-structured interviews. 33 individuals involved in the decision making process around coronary heart disease were purposively sampled from the UK National Health Service (national, regional and local levels), academia and voluntary organizations. Analysis was based on the framework method using N-VIVO software. Interviews were transcribed, coded and emergent themes identified.

Results

Many participants suggested that the timescales for public health decision-making are too short. Commissioners and some practitioners working at the national level particularly felt constrained in terms of planning for the long-term. Furthermore respondents felt that longer term planning was needed to address the wider determinants of health and to achieve societal level changes. Three prominent 'systems' issues were identified as important drivers of short term thinking: the need to demonstrate impact within the 4 year political cycle; the requirement to 'balance the books' within the annual commissioning cycle and the disruption caused by frequent re-organisations within the health service. In addition respondents suggested that the tools and evidence base for longer term planning were not well established.

Conclusion

Many public health decision and policy makers feel that the timescales for decision-making are too short. Substantial systemic barriers to longer-term planning exist. Policy makers need to look beyond short-term targets and budget cycles to secure investment for long-term improvement in public health.

Lay food and health worker involvement in community nutrition and dietetics in England: definitions from the field

BACKGROUND

Community-based food initiatives have developed in recent years with the aim of engaging previously 'hard to reach' groups. Lay workers engaged in community nutrition activities are promoted as a cost-effective mechanism for reaching underserved groups. The primary objective of the study was to explore perceptions and definitions of lay helping within the context of National Health Service (NHS) community nutrition and dietetic services to identify existing terms and definitions and propose an overarching term.

METHODS

Interpretive qualitative inquiry; semi-structured interviews with lay food and health worker (LFHW) and NHS professionals employed by community-based programmes, serving 'hard-to-reach' neighbourhoods, across England.

RESULTS

In total, 29 professionals and 53 LFHWs were interviewed across 15 of the 18 projects identified. Across all the projects, there was a preference for the use of one of two terms, either Community Food Worker or Community Nutrition Assistant, in reference to lay workers. There was no consensus in terms of a unifying term or definition for this new role.

CONCLUSIONS

Current variation in the terms and definitions used for this role is problematic and is hindering development and effective utilization of lay helping within the broad remit of community food and health and dietetics. The umbrella term 'Lay Food and Health Worker' is proposed based upon definitions and interpretations from the field.

Starting young? Children's experiences of trying smoking during pre-adolescence

Although the risks smoking poses to health are now well known, many young people continue to take up the habit. While numerous cross-sectional studies of adolescents have identified correlates of smoking initiation, much less prospective, longitudinal research has been conducted with young children to gather their accounts of early experiences of smoking, and this study fills that significant gap. Quantitative and qualitative data, collected using questionnaires, interviews and focus groups, are presented from the pre-adolescent phase of the Liverpool Longitudinal Study of Smoking. By age 11, 27% of the cohort had tried smoking, 13% had smoked repeatedly and 3% were smoking regularly. Rates of experimentation increased over time. Qualitative data revealed that curiosity and the role of peers were central to children's accounts of early smoking. By pre-adolescence, children are at different stages in their smoking careers, therefore interventions must be targeted to their varied experiences. Current prevention strategies often focus on restricting access to cigarettes, but a broad range of intervention measures is required which take account of the multifactorial nature of smoking onset. To be effective, policies that aim to prevent smoking must be grounded in children's lived experiences.

The social and economic consequences of childhood-onset Type 1 diabetes mellitus across the lifecourse: a systematic review

BACKGROUND

The incidence of childhood-onset (Type 1) diabetes is high, and increasing, particularly among the very young. The aim of this review was to determine the longer-term social consequences of having diabetes as a child and to determine whether adverse consequences are more severe for disadvantaged children.

METHODS

Results from published and unpublished studies were synthesized narratively to examine the impact of diabetes on education, employment and income in adulthood. The question of whether the impact differed for different social groups was also examined.

RESULTS

Case-control studies found that children with diabetes missed more school than healthy children. Most studies of attainment found no differences between children with diabetes and non-diabetic control subjects or the local population, although poor metabolic control, early-onset, longer illness duration and serious hypoglycaemic events were associated with underachievement. People with childhood-onset diabetes may experience disadvantage in employment, and have a lower income in adulthood, although diabetic complications appear to be the most important determinant of social consequences in later life.

CONCLUSIONS

Many children with diabetes--especially late-onset--perform equally well at school despite increased rates of absence, but it is not yet clear whether specific subgroups are at greater risk of educational underperformance. People with childhood-onset diabetes, however, do appear to experience some disadvantage in adult employment. Qualitative research and cohort studies are needed to fill key gaps in the existing evidence base. Future research must also examine the impact of diabetes-related risk factors on socio-economic consequences.

Lies, damned lies and statistics? Reliability and personal accounts of smoking among young people

Smoking remains a major problem among young people in Europe. However, within the research community examining the issue, debate continues about the best way of assessing the extent of that problem. Questions have been raised about the extent to which existing techniques for generating statistical representations of patterns of youth smoking can address a range of problems connected with identifying, accounting for and correcting unreliable self-report smoking data. Using empirical data from the UK Liverpool Longitudinal Smoking Study (LLSS), this paper argues that self-report measures of smoking, treated in isolation from participants' personal accounts, can disguise problems with the reliability and validity of a given study. Using longitudinal qualitative and quantitative data in dialogue, two main factors contributing to unreliable data are discussed: (a) participants' access to and familiarity with frameworks of everyday cultural knowledge about the practice of smoking, and (b) participants' retrospective revision of events in line with their current goals, aspirations and self-understandings. The conclusion drawn is that research has to employ multiple methods, minimally incorporating some personal contribution from participants, to explore the complex character of the problem of smoking and to avoid the difficulties posed by the models of smoking behaviour embodied within stand-alone statistical research.

The social and economic consequences of childhood asthma across the lifecourse: a systematic review

BACKGROUND

Asthma prevalence rates are high, and may be increasing in the Western world, particularly among children. The aim of this study was to evaluate the longer-term social and economic consequences of having asthma as a child and to determine whether adverse consequences are more severe for poorer children.

METHODS

Results from published and unpublished, quantitative and qualitative studies were synthesized narratively to examine the impact of childhood-onset asthma on school attendance, academic achievement and employment in adulthood. The question of whether the impact differed for different social groups was also examined.

FINDINGS

Twenty-nine good quality studies were identified, including in total 12 183 children with asthma or wheeze. Compared with asymptomatic children, those with asthma missed more days of school (additional absence as a result of asthma ranged from 2.1 to 14.8 days). Studies of academic achievement found that children with asthma performed as well as their healthy peers. The existing evidence on labour market performance is sparse, but there is an indication that people with asthma during childhood experience disadvantage in later employment. In an examination of consequences by social position, children with asthma from deprived areas were more likely to miss school than their more affluent peers, and minority ethnic children were also more likely to have poor school attendance. The only qualitative study suggested that children with asthma strove to participate fully in every aspect of their daily lives.

INTERPRETATION

Although asthma limits children's daily activities and affects their social activities, this research synthesis found little evidence of major, adverse long-term social and economic consequences in studies reviewed. Further longitudinal research using comparison groups is needed to fill key gaps in the existing evidence base.

Why do primary school children smoke? A longitudinal analysis of predictors of smoking uptake during pre-adolescence

The objectives of this longitudinal study were to determine the prevalence of smoking among primary school children in Liverpool, and to identify the predictors of experimentation with cigarettes during pre-adolescence. A cohort of children (n = 270) completed questionnaires that elicited patterns of child smoking behaviour and children's experiences of smoking in their families and communities each year between the ages of 9 and 11 years. Parents also completed questionnaires. Children's first trials with cigarettes and repeated smoking were reported. The independent variables measured were socio-economic status, familial and peer smoking, and intentions to smoke. By age 11, 27% of children had tried smoking, 12% had smoked repeatedly and 3% were smoking regularly. Variables measured at age 9 predicting experimentation with cigarettes by age 11 were male gender 9P = 0.041) paternal smoking (P = 0.001) fraternal smoking (P = 0.017) a best friend who smoked (P = 0.026) and knowing someone with a smoking-related disease (P = 0.006) Intentions to smoke at age 9 did not predict smoking at age 11 (P < 0.001). In univariate analyses, child smoking was also associated with maternal smoking (P = 0.002 at age 11), living in a low-income household (P < 0.001 at age 10) and living in a deprived area ( P = 0.025 at age 11). Early smoking presents a considerable challenge to health promoters, not least because it is socially patterned. The interventions required must tackle the structural and social pressures that shape smoking behaviour during childhood.

Physicians and caries prevention. Results of a physician survey on preventive dental services

Physicians are aware of and support selected caries preventive techniques involving fluoride, particularly community water fluoridation, fluoridating school water supplies, and the prescription of dietary fluoride supplements. Physicians are generally less informed about the relative worth of other caries preventive measures. The role of the practicing physician in the provision of caries prevention methods is a very active one, with physicians prescribing fluoride supplements, counseling on diet, and providing oral hygiene education. Children would be better served in caries prevention if the interest and initiative of the medical practitioners were encouraged and current information was made available to them. These findings represent the preliminary analysis of a mailed survey to a stratified, systematic sample of 2,000 physicians who treat child patients in the nation.