Tools to guide clinical discussions on physical activity, sedentary behaviour, and/or sleep for health promotion between primary care providers and adults accessing care: a scoping review

BACKGROUND

Health care providers have reported low knowledge, skill, and confidence for discussing movement behaviours (i.e., physical activity, sedentary behaviour, and sleep), which may be improved with the use of tools to guide movement behaviour discussions in their practice. Past reviews have examined the psychometric properties, scoring, and behavioural outcomes of physical activity discussion tools. However, the features, perceptions, and effectiveness of discussion tools for physical activity, sedentary behaviour, and/or sleep have not yet been synthesized. The aim of this review was to report and appraise tools for movement behaviour discussions between health care providers and adults 18 + years in a primary care context within Canada or analogous countries.

METHODS

An integrated knowledge translation approach guided this review, whereby a working group of experts in medicine, knowledge translation, communications, kinesiology, and health promotion was engaged from research question formation to interpretation of findings. Three search approaches were used (i.e., peer-reviewed, grey literature, and forward searches) to identify studies reporting on perceptions and/or effectiveness of tools for physical activity, sedentary behaviour, and/or sleep. The quality of included studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

In total, 135 studies reporting on 61 tools (i.e., 51 on physical activity, one on sleep, and nine combining two movement behaviours) met inclusion criteria. Included tools served the purposes of assessment (n = 57), counselling (n = 50), prescription (n = 18), and/or referral (n = 12) of one or more movement behaviour. Most tools were used or intended for use by physicians, followed by nurses/nurse practitioners (n = 11), and adults accessing care (n = 10). Most tools were also used or intended to be used with adults without chronic conditions aged 18-64 years (n = 34), followed by adults with chronic conditions (n = 18). The quality of the 116 studies that evaluated tool effectiveness varied.

CONCLUSIONS

Many tools were positively perceived and were deemed effective at enhancing knowledge of, confidence for, ability in, and frequency of movement behaviour discussions. Future tools should guide discussions of all movement behaviours in an integrated manner in line with the 24-Hour Movement Guidelines. Practically, this review offers seven evidence-based recommendations that may guide future tool development and implementation.

Developing and testing the usability, acceptability, and future implementation of the Whole Day Matters Tool and User Guide for primary care providers using think-aloud, near-live, and interview procedures

BACKGROUND

Canada's 24-Hour Movement Guidelines for Adults have shifted the focus from considering movement behaviours (i.e., physical activity, sedentary behaviour, and sleep) separately to a 24-h paradigm, which considers how they are integrated. Accordingly, primary care providers (PCPs) have the opportunity to improve their practice to promote all movement behaviours cohesively. However, PCPs have faced barriers to discussing physical activity alone (e.g., time, competing priorities, inadequate training), leading to low frequency of physical activity discussions. Consequently, discussing three movement behaviours may seem challenging. Tools to facilitate primary care discussions about physical activity have been developed and used; however, few have undergone usability testing and none have integrated all movement behaviours. Following a synthesis of physical activity, sedentary behaviour, and sleep tools for PCPs, we developed the Whole Day Matters Tool and User Guide that incorporate all movement behaviours. The present study aimed to explore PCPs' perceptions on the usability, acceptability, and future implementation of the Whole Day Matters Tool and User Guide to improve their relevancy among PCPs.

METHODS

Twenty-six PCPs were observed and audio-video recorded while using the Tool and User Guide in a think-aloud procedure, then in a near-live encounter with a mock service-user. A debriefing interview using a guide informed by Normalization Process Theory followed. Recordings were transcribed verbatim and analysed using content analysis and a critical friend to enhance rigour.

RESULTS

PCPs valued aspects of the Tool and User Guide including their structure, user-friendliness, visual appeal, and multi-behaviour focus and suggested modifications to improve usability and acceptability. Findings are further discussed in the context of Normalization Process Theory and previous literature.

CONCLUSIONS

The Tool and User Guide were revised, including adding plain language, reordering and renaming sections, reducing text, and clarifying instructions. Results also informed the addition of a Preamble and a Handout for adults accessing care (i.e., patients/clients/service-users) to explain the evidence underpinning the 24-Hour Movement Guidelines for Adults and support a person-centered approach. These four resources (i.e., Tool, User Guide, Preamble, Handout) have since undergone a consensus building process to arrive at their final versions before being disseminated into primary care practice.

Five ways to counter ableist messaging in medical education in the context of promoting healthy movement behaviours

One in five Canadians have a disability and there are well-documented gaps in care for this equity-deserving group that have roots in medical education. In this paper, we highlight the unintended consequences of ableist messaging for persons living with disabilities, particularly in the context of promoting healthy movement behaviours. With its broad reach and public trust, the medical community has a responsibility to acknowledge the reality of ableism and take meaningful action. We propose five strategies to counter ableist messaging in medical education: (1) increase knowledge and confidence among physicians and trainees to optimize movement behaviours in persons living with disabilities, (2) perform personal and institutional language audits to ensure terminology related to disability is inclusive and avoids causing unintended harm, (3) challenge ableist messages effectively, (4) address the unmet healthcare needs of persons living with disabilities, and (5) engage in efforts to reform medical curricula so that persons living with disabilities are represented and treated equitably. Physicians and trainees are well-positioned to deliver competent and inclusive care, making medical education an opportune setting to address health inequities related to disability.

Moving toward co-production: five ways to get a grip on collaborative implementation of Movement Behaviour curricula in undergraduate medical education

Several "calls to action" have imposed upon medical schools to include physical activity content in their overextended curricula. These efforts have often neither considered medical education stakeholders' views nor the full complexity of medical education, such as competency-based learning and educational inflation. With this external pressure for change, few medical schools have implemented physical activity curricula. Moreover, Canada's new 24-Hour Movement Guidelines focus on the continuum of movement behaviours (physical activity, sedentary behaviour, and sleep). Thus, a more integrated process to overcome the "black ice" of targeting all movement behaviours, medical education stakeholder engagement, and the overextended curriculum is needed. We argue for co-production in curriculum change and offer five strategies to integrate movement behaviour curricula that acknowledge the complexity of the medical education context, helping to overcome our "black ice." Our objectives were to investigate 24-Hour Movement Guideline content in the medical curriculum and develop an integrated process for competency-based curriculum renewal. Stakeholders were equal collaborators in a two-phased environmental scan of 24-Hour Movement Guideline content in the Queen's University School of Medicine. Findings and a working curriculum map highlight how new, competency-based content may be embedded in an effort to guide more relevant and feasible curriculum changes.

Exercise is Medicine® Canada on Campus Casebook: Evaluation of a novel knowledge translation tool and lessons learned

The Exercise is Medicine® Canada on Campus (EIMC-OC) program aims to integrate exercise prescription into healthcare and encourage students to implement physical activity initiatives on campus. However, multi-site interventions like EIMC-OC are often challenged with communicating and sharing strategies across geographically dispersed groups. The EIMC-OC Casebook was created as an accessible method to enhance program success by sharing ideas and implementation strategies between groups, but its potential utility is unknown as few studies have evaluated casebooks. This study evaluated the usability and value of the EIMC-OC Casebook for promoting physical activity and established end-users' insight on Casebook future directions. The Casebook was shared and semi-structured interviews were conducted with established and developing EIMC-OC groups. Five themes discussing the usability, value, and future directions of the Casebook were identified. Participants implemented the Casebook to varying degrees, found it to be a valuable communication medium, and recommended revisions, which may enhance its implementation. The EIMC-OC Casebook is a valuable tool that exemplifies campus-based efforts to promote physical activity, augments between-group communication, and helps groups conduct effective initiatives. Program leaders and researchers may benefit from a similar Casebook approach, and recommendations are provided to evaluators aiming to enhance the effectiveness of multi-site programs.

Dissemination and implementation of national physical activity, sedentary behaviour, and/or sleep guidelines among community-dwelling adults aged 18 years and older: a systematic scoping review and suggestions for future reporting and research

Strategies for dissemination (purposive distribution of a guideline to specific audiences) and implementation (actions to support the general public in meeting guideline recommendations/behavioural benchmarks) of national movement guidelines (physical activity (PA), sedentary behaviour, and sleep) have yet to be synthesized. The purpose of this systematic scoping review was to identify strategies for dissemination and implementation of national PA, sedentary behaviour, and/or sleep guidelines among community-dwelling adults (aged >18 years) and/or stakeholders in Canada and analogous countries. Five search approaches (e.g., published literature, grey literature, targeted web-based, custom Google, and content expert consultation) identified records (e.g., empirical studies, organizational reports, website pages, or guideline messages) that discussed and/or evaluated dissemination or implementation strategies for a prespecified list of guidelines. A modified strategy classification system was developed to chart the data. Forty-seven reports met inclusion criteria. Dissemination strategies (n = 42) were more frequently reported than implementation strategies (n = 24). Implementation strategies were more frequently evaluated (n = 13 vs. 7 dissemination strategies) and associated with positive outcomes. The 13 studies that evaluated strategies were at high or serious risk of bias. We identified limited information about the dissemination and implementation of national movement guidelines and identified strategies were rarely evaluated. Greater efforts are required to increase the impact of guidelines among the general public and stakeholders and to build the evidence base in this field. (Open Science Framework registration: https://osf.io/4tyw3.) Novelty An adapted movement guideline dissemination and implementation strategy classification framework is provided. Knowledge translation efforts should be documented and evaluated to advance science and practice in the movement guideline field.

Self-Compassion, Adaptive Reactions and Health Behaviours Among Adults With Prediabetes and Type 1, Type 2 and Gestational Diabetes: A Scoping Review

Engaging in health-promoting behaviours has health benefits for people with prediabetes or diabetes. People experience negative affect after diagnoses, which can impede self-regulation of health behaviours. Self-compassion, extending care to oneself in difficult times, can mitigate negative affect and promote self-regulation. This scoping review explored the relationship between self-compassion and adaptive affect, self-regulation and engagement in health-promoting/management behaviours among people with prediabetes or diabetes. We conducted a scoping literature search from 6 databases for studies and conference abstracts. Randomized controlled trials and cross-sectional, longitudinal, observational and qualitative designs focused on self-compassion were included. Eligible studies included adults with diabetes (prediabetes, type 1, type 2 and gestational), measured self-compassion using a validated Self-Compassion Scale (quantitative) or included the 3 components (qualitative) and investigated: negative affect, health promoting/management behaviours and/or self-regulation. After deduplication, 5,338 quantitative and 953 qualitative abstracts, and 18 conference proceedings were screened leaving 35 articles. Full-text screening retained 11 eligible studies (6 cross-sectional studies, 2 randomized controlled trials, 2 longitudinal studies and 1 qualitative study). Higher self-compassion was associated with decreased negative affect in 9 studies and was positively associated with well-being in 1 cross-sectional study. Self-compassion led to decreased negative affect and improved blood glucose in 2 interventions. Five studies found positive associations between self-compassion and health-promoting/management behaviours. One qualitative study found self-compassion to benefit affective reactions, health-promoting behaviours and self-regulation. This review shows that self-compassion is linked to adaptive behavioural and affective responding among people with prediabetes and diabetes, and the need for more research on self-compassion and self-regulation in these populations.

Subclinical disease revisited

It has become commonplace to treat postoperative patients with adjuvant radiotherapy to increase local control. The reduction in local recurrences seen in patients with head and neck cancer following radiotherapy led to coining of the term "subclinical disease" to describe the presumed presence of small, clinically undetectable, nests of tumor cells which remain even after the most aggressive of surgeries. The basic assumption fundamental to the concept of subclinical disease is that any patient with residual disease will suffer a local failure if left untreated. For example, lymph node involvement, either clinically evident or pathologically proven, is considered an absolute indication for adjuvant therapy. A positive or "close" or "microscopically positive" margin is also considered grounds for further treatment. The purpose of this communication is to critically discuss recent reports that challenge this assumption.

Apoptosis may be either suppressed or enhanced with strategic combinations of antineoplastic drugs or anti-IgM

A variety of drugs have been used to treat B-lymphocyte neoplasms, including both cell cycle-specific (CCS) and non-cell-cycle-specific drugs. Although the therapy for such cancers is complex and can include both types of drugs, the efficacy of these drugs in inducing cell death remains unclear. In this paper we have concentrated on specific CCS drugs and have examined their ability to induce programmed cell death (apoptosis) in Burkitt's lymphoma cell lines derived from patients. The CCS drugs chosen were hydroxyurea and aphidicolin (active in late G1, early S phase), the topoisomerase poisons camptothecin and etoposide (S, early G2 phase) and vincristine and Taxol (late G2, M phase). These choices allow comparison of two drugs with differing modes of action for each of the various phases of the cell cycle. Our results indicate that the variation in apoptosis between drugs that act at the same phase of the cell cycle is negligible. Both S/G2 and G2/M blockers are very potent at inducing apoptosis whereas G1/S blockers are ineffective in the induction of apoptosis. In addition, marked kinetic variations in the rate of apoptosis induction were observed, etoposide and camptothecin being more rapid in their action than the other agents. The order of effectiveness in inducing apoptosis on a kinetic basis was S/G2 agents >> G2/M agents >> G1/S agents. In this study we have also found that growth inhibition was induced by all the CCS agents chosen and by anti-IgM in various Burkitt's lymphoma lines. Furthermore c-myc was down-regulated under similar conditions. Since apoptosis was only selectively induced by some of the CCS agents, it implies c-myc expression is associated with growth regulation and c-myc down-regulation is an insufficient condition for the induction of apoptosis. In addition, cotreatments using the CCS and other agents revealed the following: Cotreatment using two CCS drugs which act at the same stage in the cell cycle showed either no change or only additivity to the effects seen with either agent alone. However, cotreatment with CCS drugs showed that an inhibitory effect is found between G1/S and G2/M drugs or S/G2 and G2/M drugs. No effect was found between G1/S and S/G2 drugs. Anti-IgM, which by itself was capable of inducing apoptosis, was observed to augment apoptosis induced by very low concentrations of G2/M-acting drugs but it has little effect on G1/S or the S/G2 drugs. The inhibitory effect of anti-CD40 or TNF-alpha on anti-IgM-induced apoptosis did not carry over to an effect on apoptosis induction by the CCS agents. Thus specific combinations of agents may lead to either enhancement, inhibition, or no interactive effect on apoptosis.

Radiation therapy port films: a quality assurance study

PURPOSE

The purpose of this study was to assess the port film acceptance rate in a large community practice setting and to catalog the reasons for rejection.

METHODS

Between December 1993 and July 1996, a quality assurance monitor log was maintained on 4,150 patients who underwent a total of 4,450 treatment courses. Port films were taken at the beginning and at the half way point in the treatment course. A total of 20,735 port films were compared with the matching simulation films. We recorded the site being treated, the radiation oncologist who reviewed the films and the reason for rejection.

RESULTS

The monthly acceptance rate varied from a low of 67% to a high of 83%, with a gradual upward trend. The single most common reason for rejecting films was a centering problem-12% of all films taken were rejected for this reason. The next most common problems were block placement or body setup errors that caused 3.4% and 2.7% of the films to be rejected, respectively. Average acceptance rates between 10 different sites (abdomen, brain, breast, chest, extremities, head and neck, pelvis, prostate, rectum and spine) varied from 68% to 80%. Individual differences between 12 radiation oncologists reviewing the films varied from 67% to 87%.

CONCLUSIONS

A detailed analysis of field localization errors allowed us to identify areas where improvement was needed and suggested that specific guidelines for acceptance would help reduce the variability noted in the acceptance rate between sites and physicians.

A comparison of single-dose and fractionated total-body irradiation on the development of pneumonitis following bone marrow transplantation

PURPOSE

A review of 132 consecutive patients who received bone marrow transplant for various malignancies was conducted to determine factors associated with increased risk in developing interstitial pneumonitis (IP) as the result of total body irradiation (TBI). Twenty-four patients were excluded because 22 did not receive TBI and two had insufficient records.

METHODS AND MATERIALS

Patients were conditioned with TBI and various drug regimens. Eighteen patients received a single 6.0 Gy dose of x-rays. The remaining 90 were treated with three doses of 3.33 Gy separated by 24 h. All patients were followed for at least 18 months for the purposes of determining the IP incidence.

RESULTS

Twenty-seven of these 108 (25%) patients developed IP; 19 (17.6%) died. The 2-year estimated incidence of IP was 24 and 18.6% for fatal IP. The etiology was determined to be idiopathic in 12 patients, the result of cytomegalovirus in 6 patients, and caused by a variety of other infectious organisms in 9 patients. We were unable to demonstrate a statistically significant increase in IP with age (adults vs. children), dose regimen, use of methotrexate for graft-vs.-host disease prophylaxis, the presence of acute graft-vs.-host disease, time from diagnosis to transplant, or transplant type (allogeneic vs. autologous).

CONCLUSIONS

The incidence of fatal IP reported here is similar to that reported by other institutions utilizing hyperfractionated TBI protocols. Our data do not support the need for hyperfractionation to reduce the risk of IP.

Growth rates of hprt and tk mutant CHO cell lines

The growth rates of 31 X-ray-induced hypoxanthine phosphoribosyl transferase (hprt) deficient mutants of CHO-K1 cells were measured. Mutants had been classified as (1) full-deletion, (2) partial deletion or rearrangement, or (3) unchanged by Southern blot analyses. No relationship between growth rate and deletion type was observed. Even where all hprt-specific bands were missing, proliferation rates in culture were normal. Additionally, in CHO-AT3-2 cells, which are heterozygous at the tk locus, no difference in growth rates between a spontaneous hprt mutant and its parent was observed, although double hprt-tk-/- mutants grew more slowly.

Southern blot and polymerase chain reaction exon analyses of HPRT- mutations induced by radon and radon progeny

A linear dose response was observed for radon-induced mutations at the CHO-hprt locus with an induction frequency of 1.4 x 10(-4) mutants per viable cell per gray. Mutants isolated after two levels of radon exposure were evaluated using Southern blot techniques and polymerase chain reaction (PCR) exon amplification. No significant differences in mutational spectra were detected at these two exposure levels. Of 52 radon-induced mutations, 48% sustained a gene deletion, 23% underwent a rearrangement of the banding patterns or loss of one or more exons, and 29% showed no change from the parental line. These mutants were compared with mutants produced after X irradiation (3 Gy) and with spontaneous mutants from untreated cells. The spectra of mutation types in cells treated with radon and X rays were not significantly different. In contrast, 31 spontaneous mutations exhibited a low percentage of gene deletion events (16%); most spontaneous mutants showed no change (74%); the remaining 10% were classified as alterations. In conclusion, the principal lesion seen at the CHO-hprt locus after radiation exposure is gene deletion, while the predominant class of spontaneous mutations is composed of smaller events not detectable by Southern blot or PCR exon analysis.

Characteristics of an infinite life span diploid human fibroblast cell strain and a near-diploid strain arising from a clone of cells expressing a transfected v-myc oncogene

Diploid human fibroblasts were transfected with a plasmid carrying a v-myc oncogene linked to the neo gene or with a vector control carrying a neo gene. Drug-resistant clones were isolated and subcultured as needed. All populations went into crisis and eventually senesced. But while they were senescing, viable-appearing clones were noted among the progeny of a transfected population that expressed the v-myc oncogene. After several months, these cells began replicating more rapidly. Karyotype analysis indicated that they were clonally derived since all of them had 45 chromosomes, including 2 marker chromosomes. This cell strain was designated MSU-1.1. Similar analysis showed that cells from an earlier passage were diploid. These cells were designated MSU-1.0. Both strains have undergone more than 200 population doublings since their siblings senesced, without any change in chromosome complement. Both strains express the v-myc protein and have the same integration site for the transfected v-myc and neo genes. The MSU-1.0 cells cannot grow without exogenously added growth factors. The MSU-1.1 cells grow moderately well under the same conditions and grow to a higher saturation density than MSU-1.0 cells. Since the chance of human cells acquiring an infinite life span in culture is very rare, the data suggest that MSU-1.1 cells are derived from MSU-1.0 cells. The expression of v-myc is probably required for acquisition of an infinite life span, since this phenotype did not develop in populations not expressing this oncogene. However, expression of v-myc is clearly not sufficient, since all of the progeny of the clone that gave rise to the MSU-1.0 cells expressed this oncogene, but the vast majority of them senesced.

Molecular characterization of X-ray-induced mutations at the HPRT locus in plateau-phase Chinese hamster ovary cells

CHO-K1 cells were irradiated in plateau phase to determine the effect of dose, dose fractionation, and delayed replating on the type, location and frequency of mutations induced by 250 kVp X-rays at the hypoxanthine-guanine phosphoribosyl transferase (HPRT) locus. Independent HPRT-deficient cell lines were isolated from each group for Southern blot analysis using a hamster HPRT cDNA probe. When compared with irradiation with 4 Gy and immediate replating, dose fractionation (2 Gy + 24 h + 2 Gy) the entire gene. Since an increase in survival was noted under these conditions, these data suggest that repair of sublethal and potentially lethal damage acts equally on all premutagenic lesions, regardless of type or location. Differences in the mutation spectrum were noted when cells were irradiated at 2 Gy and replated immediately. The location of the deletion breakpoints was determined in 15 mutants showing partial loss of the HPRT locus. In 12 of these cell lines one or both of the breakpoints appeared to be located near the center of the gene, indicating a nonrandom distribution of mutations. These results indicate that damage induced by ionizing radiation results in a nonrandom distribution of genetic damage, suggesting that certain regions of the genome may be acutely sensitive to the mutagenic effects of ionizing radiation.

Localization of deletion breakpoints in radiation-induced mutants of the hprt gene in hamster cells

DNA was analysed from a large set of hamster hprt gene mutants, some induced by ionising radiations and others occurring naturally, to identify those with large alterations in part of the gene. DNA from these mutants was restricted further with different endonucleases and probed to establish the patterns of restriction fragments remaining. Of 15 mutants characterized, one showed a duplication of part of the 5' end of the gene, and the remainder showed deletions of various sizes. It was possible to approximately locate the breakpoints of the deletions by comparison of fragment patterns to a recently-established map of the hamster gene. The relatively small number of mutants examined precludes rigorous analysis of the distribution of breakpoints in the hprt gene, but taken with other recent studies of deletion mutagenesis it is suggested that non-random induction or selection of this type of mutation may occur.

Optimal parameters for the polybrene-induced DNA transfection of diploid human fibroblasts

Recently it has been shown that Polybrene, in conjunction with dimethyl sulfoxide (DMSO) shock, can markedly increase frequency of DNA transfection of chicken embryo fibroblasts as compared with the frequency obtained with the standard calcium phosphate protocol. We have adapted this procedure for use with diploid human fibroblasts. Using plasmid DNA containing a dominant selectable marker gene (resistance to Geneticin), we have determined that treatment of the cells for 6 h in culture medium containing Polybrene at a concentration of 2 to 5 micrograms/ml, followed by a 4-min shock with 30% DMSO, resulted in the highest yield of transfectants, ca. 400/10(6) cells treated with as little as 100 ng of plasmid DNA. The selective agent could be added immediately after the DMSO shock. This allows transfection and selection to be carried out in the same dishes and ensures that each clone represents a unique event.

Pyrimidine dimer induction in E. coli DNA by Cerenkov emission associated with high energy X-irradiation

The induction of pyrimidine dimers in E. coli DNA by secondary ultraviolet light associated with 6 MVp X-rays in the dose range 20-90 Gy has been demonstrated using T4 endonuclease V. Under the experimental conditions used in these experiments the major component of this secondary U.V. light is Cerenkov emission.

Induction of lethal damage in E. coli by Cerenkov emission associated with high-energy X-rays: the effect of bromouracil substitution

5.1. The damages induced in E. coli AB2487 recA by Cerenkov emission and ionizing radiation contribute in an additive fashion to the overall lethality, and do not interact in a synergistic fashion. 5.2. BU substitution enhances the lethal action of high energy X-irradiation on E. coli AB2487 recA by a mechanism involving enhanced radiosensitivity and enhanced photosensitivity.