What are the barriers and facilitators to effective health promotion in urgent and emergency care? A systematic review

Background

There are potential health gains such as reducing early deaths, years spent in ill-health and costs to society and the health and care system by encouraging NHS staff to use encounters with patients to help individuals significantly reduce their risk of disease. Emergency department staff and paramedics are in a unique position to engage with a wide range of the population and to use these contacts as opportunities to help people improve their health. The aim of this research was to examine barriers and facilitators to effective health promotion by urgent and emergency care staff.

Methods

A systematic search of the literature was performed to review and synthesise published evidence relating to barriers and facilitators to effective health promotion by urgent and emergency care staff. Medical and social science databases were searched for articles published between January 2000 and December 2021 and the reference lists of included articles were hand searched. Two reviewers independently screened the studies and assessed risk of bias. Data was extracted using a bespoke form created for the study.

Results

A total of 19 papers were included in the study. Four themes capture the narratives of the included research papers: 1) should it be part of our job?; 2) staff comfort in broaching the topic; 3) format of health education; 4) competency and training needs. Whilst urgent and emergency care staff view health promotion as part of their job, time restraints and a lack of knowledge and experience are identified as barriers to undertaking health promotion interventions. Staff and patients have different priorities in terms of the health topics they feel should be addressed. Patients reported receiving books and leaflets as well as speaking with a knowledgeable person as their preferred health promotion approach. Staff often stated the need for more training.

Conclusions

Few studies have investigated the barriers to health promotion interventions in urgent and emergency care settings and there is a lack of evidence about the acceptability of health promotion activity. Additional research is needed to determine whether extending the role of paramedics and emergency nurses to include health promotion interventions will be acceptable to staff and patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00651-3.

Controlled before-after intervention study of suburb-wide street changes to increase walking and cycling: Te Ara Mua-Future Streets study design

BACKGROUND

Achieving a shift from car use to walking, cycling and public transport in cities is a crucial part of healthier, more environmentally sustainable human habitats. Creating supportive active travel environments is an important precursor to this shift. The longevity of urban infrastructure necessitates retrofitting existing suburban neighbourhoods. Previous studies of the effects of street changes have generally relied on natural experiments, have included few outcomes, and have seldom attempted to understand the equity impacts of such interventions.

METHODS

In this paper we describe the design of Te Ara Mua - Future Streets, a mixed-methods, controlled before-after intervention study to assess the effect of retrofitting street changes at the suburb scale on multiple health, social and environmental outcomes. The study has a particular focus on identifying factors that improve walking and cycling to local destinations in low-income neighbourhoods and on reducing social and health inequities experienced by Māori (Indigenous New Zealanders) and Pacific people. Qualitative system dynamics modelling was used to develop a causal theory for the relationships between active travel, and walking and cycling infrastructure. On this basis we selected outcomes of interest. Together with the transport funder, we triangulated best evidence from the literature, transport policy makers, urban design professionals and community knowledge to develop interventions that were contextually and culturally appropriate. Using a combination of direct observation and random sample face to face surveys, we are measuring outcomes in these domains of wellbeing: road-user behaviour, changes to travel mode for short trips, physical activity, air quality, road traffic injuries, greenhouse gas emissions, and perceptions of neighbourhood social connection, safety, and walking and cycling infrastructure .

DISCUSSION

While building on previous natural experiments, Te Ara Mua - Future Streets is unique in testing an intervention designed by the research team, community and transport investors together; including a wide range of objective outcome measures; and having an equity focus. When undertaking integrated intervention studies of this kind, a careful balance is needed between epidemiological imperatives, the constraints of transport funding and implementation and community priorities, while retaining the ability to contribute new evidence for healthy, equitable transport policy. The study was retrospectively registered as a clinical trial on 21 June 2018 in the ISCRTN registry: ISRCTN89845334 http://www.isrctn.com/ISRCTN89845334.

Information preferences of women receiving chemotherapy for breast cancer

The aim of this cross-sectional survey was to identify a possible relationship between the information-seeking behaviour of patients receiving chemotherapy for breast cancer with source, type, amount and satisfaction of health information accessed. The sample (n = 36) were drawn from the medical oncology department of a large city centre teaching hospital. Participants were recruited through consecutive attendance to the medical oncology department. Eighty-six patients were invited to participate (response rate 42%). An anonymous self-report questionnaire and the Miller Behavioural Style Scale were used to measure attitudes towards 10 different sources of information and identify information-seeking behaviour. The study found that high information-seeking behaviour influenced the type of information sources used to find out about chemotherapy, but did not influence the level of satisfaction with the information sources used. Healthcare professionals were the most frequently used sources of information, but the majority of the sample used a variety of information sources. The Internet was the most frequently used mass media source of information (50% of the sample), especially by those under 50 years old (P = 0.033). Patients' behavioural signature needs to be considered when addressing their information needs. Oncology services need to provide patients with details of recommended high-quality websites to access for information about their chemotherapy.

Prevalence and healthcare burden of illegal drug use among emergency department patients

OBJECTIVES

Illegal drug use is common in emergency department (ED) patients, but previous prevalence studies have relied upon approaches that may underestimate the true extent of the problem. The aim of this study was to examine illegal drug use in a typical adult ED.

METHODS

We employed an independent researcher to prospectively and anonymously interview patients attending an inner city adult ED throughout all 168 hours of a typical week. Additional information collected from the treating clinician indicated whether each presentation was directly or indirectly related to illegal drug use.

RESULTS

We found that 6.9% of all patient attendances were directly or indirectly related to illegal drug use, and hospital admission was required in nearly half of these. The majority of drug related problems were acute injuries, overdose, and the medical complications of drug use.

CONCLUSIONS

This suggests that the emergency healthcare burden related to illegal drug use is substantial, and higher than previously reported.

Roll-out of a nurse-led welfare benefits screening service throughout the largest Local Health Care Co-operative in Glasgow: an evaluation study

OBJECTIVE

To evaluate the roll-out of a nurse-led Attendance Allowance (AA) screening programme in 24 general practices located within the largest Local Health Care Co-operative in Glasgow.

STUDY DESIGN

Evaluation study

METHODS

Six hundred and thirty participants aged over 64 years who, in the nurses' clinical judgement, appeared to have care needs were recruited opportunistically by community nurses over a 15-month period. A money advice worker contacted all potential underclaimers offering a home visit to assess for unclaimed benefits. The main outcome measured was the total amount of unclaimed AA, linked benefits and grants.

RESULTS

Three hundred and sixty-three participants and 13 relatives were awarded a total of 1,136,424.10 pounds. Of this, 1,016,908.70 pounds was on a recurrent annual basis and 119,515.44 pounds was awarded as lump sums.

CONCLUSIONS

This method of benefits assessment (community-nurse-led pre-AA screening followed by a home visit from a money advice worker) would appear to be an efficient and effective method of income maximization that could be rolled out nationally within primary care settings located in deprived areas.

The use of childhood injury surveillance within a general accident and emergency department

The prevention of accidental injury is a government priority in the United Kingdom. Following the recent Government White Paper, towards a Healthier Scotland (Scottish Office 1999), the issue of poverty and inequalities in health has come to prominence. This study, at Glasgow Royal Infirmary, looked at the socio-economic context of injuries and aimed to identify if there was a relationship between the frequency of injuries and the deprivation status of the patient. This paper examines one method of data collection, the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) which is currently being used at the local children's hospital. The practical difficulties of collecting this data within a busy, general Accident and Emergency (A&E) department are examined. The questionnaire uses narrative and sequence text to provide descriptive information relating to the injury and the events leading up to it. Findings demonstrated that a large percentage of children's injuries were treated at the child's local general hospital. Differences between the two hospitals were also found relating to the children's ages and where the injuries took place. Results also showed that the socio-economic distribution of childhood accidents is still a major problem in this city. Therefore, this study recommends that injury data should be collected at all A&E departments to establish an accurate picture of the pattern of injuries within the city.

Neuronal density in the human retinal ganglion cell layer from 16-77 years

Literature assessing whether or not neurons (retinal ganglion cells and displaced amacrine cells) are lost from the retinal ganglion cell layer in mammals with age is still controversial, some studies finding a decrease in cell density and others not. To date there have been no studies estimating the total number of neurons in the retinal ganglion cell layer of humans throughout life. Recent studies have concentrated on the macular region and examined cell densities, which are reported to decrease during aging. In a study of the human retinal pigment epithelium (RPE), we showed that, while RPE cell number does not change, cell density increases significantly in central temporal retina (macular region) as the retina ages. We speculated that the increase in density represents a "drawing together" of the retinal sheet to maintain high cell densities, in this region of the neural retina, in the face of presumed cell loss from the ganglion cell layer due to aging. Here, therefore, we have sampled the entire ganglion cell layer of the human retina and estimated total neuron numbers in 12 retinae aged from 16 to 77 years. Human retinae, fixed in formalin, were obtained from the Queensland Eye Bank and whole-mounted, ganglion cell layer uppermost. The total number of neurons was lower in the older than younger retinae and neuronal density was lower in most retinal regions in older retinae. Retinal area increased with age and neuronal density fell throughout the retina with a mean reduction of 0.53% per year. However, the percentage reduction in density was much lower for the macular region, with a value of 0.29% per year. It is possible that this lesser reduction in cell density in the macula is a result of the drawing together of the retinal sheet in this region as we speculated from RPE data.

Public health: a new nursing role for community practitioners

This article discusses the six key activities identified by the Royal College of Nursing (1994) as essential ingredients for public health nursing. Examples of public health practice and community nurse involvement are given to illustrate each activity. Public health skills such as health profiling, building healthy alliances and policy development are outlined. Current barriers to community nurses participating in these activities are identified and models of public health practice are reviewed. The potential for a radical transformation of community nursing practice is discussed in the context of an expanding public health role of community nurses in Scotland. Options for future practice are presented and discussed.

Haplotype dimorphism in a SNP collection from Drosophila melanogaster

A moderate resolution single nucleotide polymorphism (SNP) map of the genome of Drosophila melanogaster that is designed for use in quantitative genetic mapping is described. Seventeen approximately 500 nucleotide gene sequences spaced at 10 to 20 centimorgan intervals were combined with 49 shorter sequence tag sites (STSs) at 5 to 10 centimorgan intervals to generate a map that should not leave any gaps greater than one half of a chromosome arm when any two wild type lines are compared. Of 20 markers with sufficient polymorphism to construct haplotype cladograms, 13 showed evidence for two divergent classes of haplotype. The possible mechanisms for and implications of the unexpected finding that two thirds of all short gene sequences in D. melanogaster may be dimorphic are discussed, including the suggestion that admixture between two separate lineages may have been a major event in the history of the species.

An exploration of the sequence of a 2.9-Mb region of the genome of Drosophila melanogaster: the Adh region

A contiguous sequence of nearly 3 Mb from the genome of Drosophila melanogaster has been sequenced from a series of overlapping P1 and BAC clones. This region covers 69 chromosome polytene bands on chromosome arm 2L, including the genetically well-characterized "Adh region." A computational analysis of the sequence predicts 218 protein-coding genes, 11 tRNAs, and 17 transposable element sequences. At least 38 of the protein-coding genes are arranged in clusters of from 2 to 6 closely related genes, suggesting extensive tandem duplication. The gene density is one protein-coding gene every 13 kb; the transposable element density is one element every 171 kb. Of 73 genes in this region identified by genetic analysis, 49 have been located on the sequence; P-element insertions have been mapped to 43 genes. Ninety-five (44%) of the known and predicted genes match a Drosophila EST, and 144 (66%) have clear similarities to proteins in other organisms. Genes known to have mutant phenotypes are more likely to be represented in cDNA libraries, and far more likely to have products similar to proteins of other organisms, than are genes with no known mutant phenotype. Over 650 chromosome aberration breakpoints map to this chromosome region, and their nonrandom distribution on the genetic map reflects variation in gene spacing on the DNA. This is the first large-scale analysis of the genome of D. melanogaster at the sequence level. In addition to the direct results obtained, this analysis has allowed us to develop and test methods that will be needed to interpret the complete sequence of the genome of this species. Before beginning a Hunt, it is wise to ask someone what you are looking for before you begin looking for it. Milne 1926

Horse vision and an explanation for the visual behaviour originally explained by the 'ramp retina'

Here we provide confirmation that the 'ramp retina' of the horse, once thought to result in head rotating visual behaviour, does not exist. We found a 9% variation in axial length of the eye between the streak region and the dorsal periphery. However, the difference was in the opposite direction to that proposed for the 'ramp retina'. Furthermore, acuity in the narrow, intense visual streak in the inferior retina is 16.5 cycles per degree compared with 2.7 cycles per degree in the periphery. Therefore, it is improbable that the horse rotates its head to focus onto the peripheral retina. Rather, the horse rotates the nose up high to observe distant objects because binocular overlap is oriented down the nose, with a blind area directly in front of the forehead.

Experimental eye enlargement in mature animals changes the retinal pigment epithelium

Form deprivation has been shown to result in myopia in a number of species such that the eye enlarges if one eye is permanently closed at the time of eye opening. In the quokka wallaby, the eye grows slowly throughout life. After form deprivation, the eye enlarges by 1-1.5 years of age to the size of that in a 4-6-year-old animal and the number of multinucleated retinal pigment epithelial (RPE) cells in the enlarged retina remains much lower than would be expected in eyes of comparable size. Here we have repeated the experiment but examined animals at 4 years of age. The sutured eye grew significantly larger than did its partner. Numbers of RPE cells were comparable between sutured and partner eyes but were lower than in normal animals of similar age. Reductions in RPE cell density were greater in nasal than in dorsal or ventral retina and were not seen in temporal retina. The distribution of multinucleated cells was quite different in the sutured and open eyes. As in normal eyes, partner eyes had most multinucleated cells in ventral retina, while in the sutured eyes such cells were located mainly in the far periphery. In conclusion, the RPE is significantly changed by the eye enlargement process. However, it is not known whether this change results from an active part played by the RPE in the retinal expansion process or whether the changes are simply a result of a passive increase in area of the RPE.

The C. elegans vulval induction gene lin-2 encodes a member of the MAGUK family of cell junction proteins

The lin-2 gene is required for the induction of the Caenorhabditis elegans vulva. Vulval development is initiated by a signal from the anchor cell that is transduced by a receptor tyrosine kinase/Ras pathway. We show that lin-2 acts in the vulval precursor cell P6.p, downstream of lin-3 EGF and upstream of let-60 ras, to allow expression of the 1 degrees cell fate. lin-2 encodes a protein of relative molecular mass 109,000 (LIN-2A) with regions of similarity to CaM kinase II and membrane-associated guanylate kinases. Mutant lin-2 transgenes designed to lack either protein kinase or guanylate kinase activity are functional, indicating that LIN-2A has a structural rather than an enzymatic role in vulval induction. Most or all identified membrane-associated guanylate kinases are components of cell junctions, including vertebrate tight junctions and arthropod septate junctions in epithelia. Thus, LIN-2A may be a component of the cell junctions of the epithelial vulval precursor cells that is required for signaling by the receptor tyrosine kinase LET-23. We propose that LIN-2A is required for the localization of one or more signal transduction proteins (such as LET-23) to either the basal membrane domain or the cell junctions, and that mislocalization of signal transduction proteins in lin-2 mutants interferes with vulval induction.

Control of type-D GABAergic neuron differentiation by C. elegans UNC-30 homeodomain protein

The Caenorhabditis elegans gene unc-30 is required for the development and functioning of the 19 inhibitory GABAergic (gamma-aminobutyric-acid-secreting) type D motor neurons, which control locomotion. In unc-30 mutants the D neurons lack GABA and have defects in axonal pathfinding and synaptic connections (J. White, personal communication). We report here that unc-30 encodes a homeodomain protein that is present in the nuclei of the D neurons at high levels in young larvae, in which the motor circuitry is formed, and at low levels in older animals. The UNC-30 protein is also present in six non-GABAergic neurons and is absent from the seven non-D-type GABAergic neurons. Ectopic expression of unc-30 induced GABA expression in cells that are normally not GABAergic. We propose that unc-30 functions as a transcriptional regulator within the type D neurons to control their terminal differentiation and that unc-30 is sufficient in some but not all cell types to induce GABA expression.