The purpose of this study was to explore HCPs’ perceptions of what influences physical activity for children with T1DM in an effort to inform those working with children who have T1DM. Factors believed to influence participation are presented as five major themes and eleven corresponding sub-themes. Verbatim quotes are provided to demonstrate themes, labelled with the participant’s professional role.
Theme 1 Social support is a positive influence on children’s participation in physical activity
Social support was the most commonly identified influence on children’s physical activity, with parents and peers being perceived as important sources of practical and emotional support.
Parental responsibility and support is believed to be the key to children’s participation in physical activity
The majority of HCPs perceived parents as a powerful source of support for their child’s physical activity. Parental support encompassed parents being encouraging and demonstrating a positive attitude toward physical activity, for example:
“I think parental responsibility, so communicating with their children to say look, [physical activity] is important for you, for your development, to continue being social with your friends, obviously good for your health. So I think that parental role is extremely important, that supportive structure around them” (P09, Dietician)
Parental support was believed to be emotional (e.g., encouragement) and/or logistical (e.g., providing transport, “they would need their parents to take them to the activity, Mum to drive them” (P02, Consultant)). Some HCPs believed that it helped if parents were active and others believed an active parental role model was not necessary, for example, “I don’t think necessarily that parents have to be really sporty to get the children to be sporty, but they encourage them to be sporty and take them to their hobbies and support them” (P01, Dietician). Overall, parents were perceived as the key to children being provided the opportunity to be active.
“I suppose parents’ lifestyle influences…whether they have those opportunities to be active or whether their parents want to get on with other things and leave them to watch TV or play on the PlayStation” (P11, Dietician).
The parents believed to be less engaged and supportive were perceived as “likely to be the most reluctant” (P01, Dietician) to encourage their child to be physically active and less likely to prioritise the importance of physical activity:
“The main problem you're likely to face is not diabetes, it’s just, when are we [the family] going to fit this [physical activity] into our busy lives and is it really a priority?” (P03, Consultant).
Active friends are a positive influence on children’s physical activity
Active friends were deemed an influential support network for providing socialisation opportunities and modelling active behaviour. One HCP believed that participation in physical activity depended on, “who they make friends with and whether they are into [physical activity], if they’ve got friends who play football they’ll go join them and play football after school” (P11, Dietician).
Theme 2 Characteristics of the child that enable participation
Specific characteristics of the child were thought to facilitate participation in physical activity. Whilst some biological factors were cited, such as age and gender, the most pertinent characteristic referred to the child’s motivation.
Individual motivation to be physically active is the main influence on children’s level of physical activity
Around half of the HCPs identified the child’s motivation to be physically active as the main influence on children’s participation in physical activity. Some HCPs believed that children are driven by “what they’re interested in and what they feel they’re good at” (P08, Dietician), implying that the motivation is intrinsic and participation in physical activity is likely to be for enjoyment and satisfaction. Others conceded that it is difficult to know what motivates some children: “We don’t really know what it is that drives some people into it [physical activity] and others into couch potatoes” (P11, Dietician).
Children involved in structured activity or organised sports were described as being the most motivated and committed, e.g., “Taking part in competitive sport requires discipline anyway so you find that the patient and the family tend to be quite motivated and disciplined and that reflects on their diabetes control” (P02, Consultant). Being active prior to T1DM diagnosis was perceived to coincide with the perceived ability of children to overcome barriers to physical activity, e.g., “The ones that have always been active carry on and find a way to do that with the diabetes” (P04, Nurse). The same nurse went on to say that these active children, “know what they get out of the exercise already” (P04, Nurse), which implies that experiencing some reward from previous participation can motivate children to be active after diagnosis.
Theme 3 Formal organisations have the potential to support physical activity
The child’s school and healthcare team were identified as having the potential to influence children’s participation in physical activity.
Schools are believed to have a “wonderful opportunity” (P10, Consultant) to promote physical activity
School teachers were believed to have an important role in the facilitation of physical activity for children with T1DM. As a mandatory part of the school curriculum, Physical Education (PE) was believed to be an accessible opportunity for all children to be active “whether they like it or not” (P09, Dietician). For teachers supervising children with T1DM, “the priority is safety” (P09, Dietician) and HCPs perceived that it is the role of the diabetes team to ensure that schools are adequately informed and prepared to supervise and support pupils with T1DM via training and school visits.
“That has occasionally been an issue, where teachers haven’t understood or are frightened about what might happen and children are prevented from participating…well often the diabetes nurses can be quite helpful in those situations, going out to the school and talking to teachers, finding out their concerns and addressing those issues” (P03, Consultant).
Healthcare professionals’ role to educate and advise around physical activity
The majority of HCPs believed that it was their role to educate and support children with advice and guidance around physical activity; “to give them the skills to be able to manage their diabetes to the best of their ability and perform that activity” (P07, Dietician). They believed they should reassure parents that physical activity is safe when diabetes management plans are in place e.g., “it’s important that we have a role …we reassure them that anything is possible as long as they’re willing to commit to what we say” (P09, Dietician). And believed they were in a position to normalise the experience of hypoglycaemic episodes:
“We do tell the parents that having a couple of hypos a week is actually a sign of good control, as long as the child can recognise hypo symptoms…so it is normal as long as they’re just checking blood sugars and know how to treat them” (P01, Dietician).
Healthcare professionals described their tendency to discuss physical activity with specific children; overweight children e.g., “if it’s a child who’s got a weight problem as well then we might address it” (P02, Consultant) and children who were regularly active prior to diagnosis e.g., “We talk about exercise if they’re sporty” (P01, Dietician). Furthermore, some HCPs identified themselves or specific colleagues as being more inclined or suitable to give advice around physical activity. One HCP described their centre as being proactive in offering exercise advice to children; “I think compared to other centres we are probably quite proactive in advising on exercise in diabetes” (P04, Dietician) and a colleague in the same centre explained, “I think it’s driven more by our personal interests as much as anything else” (P03, Consultant).
Professional expertise supports the child’s existing lifestyle rather than promoting increased physical activity
The HCPs perceived that they were better placed to support the management of existing structured activities rather than promoting an increase in day-to-day physical activity. The management strategies described were individualised management plans, activity diaries and ongoing clinic discussions:
“With most patients you can find a pattern to say look the child tends to go a bit hypo maybe two hours after the activity, so we need to make sure that we give them a good carbohydrate meal, we cut down the insulin or work out a strategy that works” (P02, Consultant).
A minority of HCPs did promote lifestyle physical activity, describing how they encourage day-to-day activities such as walking to school and playing outside. One dietician perceived it easier to discuss physical activity with children who already had an interest being active, because then the HCP’s role was “to support [the child’s] chosen lifestyle, but it’s very different to actively promoting physical activity in a group of people that you know will have problems” (P11, Dietician). Another dietician acknowledged; “people forget about anything that may just be sort of everyday activities…, walking to school say, and we concentrate a lot more on what we call ‘exercise’” (P07, Dietician).
Theme 4 Type 1 Diabetes presents specific challenges to physical activity
There was consensus among HCPs that T1DM “shouldn’t really interfere” (P01, Dietician) with day-to-day physical activities, but that structured, prolonged exercise and competitive sport participation need a diabetes management plan in place to ensure that participation is safe and performance is optimal. The current level of activity in children with T1DM was believed to be similar to their peers without diabetes. Nevertheless, HCPs recognised that diabetes presents unique challenges to children with T1DM engaging in active lifestyles.
Problems maintaining stable blood glucose control
Blood glucose control was perceived as a challenge for children with T1DM and their parents due to the extra demands of monitoring and managing fluctuating blood glucose levels around times of physical activity. The majority of HCPs perceived one of the main challenges to be the frequent testing of blood glucose level, which they sympathised as being “difficult” (P07, Dietician), “boring” (P04, Dietician), “interfering” (P01, Dietician) and “a lot of effort” (P01, Dietician). One HCP acknowledged that, “I think our expectations of testing so frequently during physical activity are very difficult for people to keep up” (P07, Dietician). Swimming and spontaneous activities were specific situations perceived to be problematic for maintaining a stable blood glucose level. Spontaneous activities are sporadic and typically unplanned, making it difficult for families or HCPs to pre-empt changes in blood glucose level:
“You’ve got a child…who suddenly decides to go out and bounce on the trampoline for half an hour and then their blood sugars go low and then it’s the parents that worry about sudden unpredicted exercise because that can make their sugars drop quickly” (P03, Consultant).
Parental concern regarding hypoglycaemia limits children’s physical activity
Every HCP interviewed accepted the negative impact that hypoglycaemia had on participation in physical activity for children with T1DM and agreed that the main challenge was the worry of hypoglycaemia, rather than its actual occurrence. Parental concern and worry about hypoglycaemia was the most commonly cited barrier to physical activity. One Consultant referred to parental worry as a normal response and “part and parcel” of being a parent of a child with T1DM, rather than a “pathological worrying state” (P02, Consultant). However, the same Consultant acknowledged; “that [parental concerns about hypoglycaemia] will definitely limit the child’s participation” (P02, Consultant). Nocturnal hypoglycaemia was identified as a specific cause of worry for parents:
“When they do become a bit sporty, they do struggle, especially with getting hypos, their blood sugars drop at some point in the evening after the activity and parents worry a lot about hypos in the evening or at night and that can be something that deters them from doing activities” (P02, Consultant).
A small number of HCPs perceived the child’s concerns about hypoglycaemia to be a potential barrier to physical activity; “maybe it is that some of them are less confident because of the fear of hypos” (P01, Dietician), but the general consensus was that “it’s the parents that worry a lot more than the children” (P08, Dietician). Some HCPs offered hypotheses for the cause of parental concerns about hypoglycaemia; parental worries due to a historical emphasis on the risk of exercise-induced hypoglycaemia, negative past experiences of hypoglycaemia, being newly diagnosed or parents worrying instead of the child; “the younger kids, they probably just don’t have the awareness to worry about it [hypoglycaemia], so their parents worry on their behalf“(P02, Consultant). No consistent reason was offered, but there was some agreement that most concerns are likely to follow an episode of hypoglycaemia, with the consequences for children being embarrassment or losing confidence and for parents having the lasting memory of the episode; “[parents] have got the real scary situation in their head” (P04, Specialist Nurse) and “haunted them a long time later” (P05, Dietician).
Four HCPs indicated that parents might avoid hypoglycaemia during or after physical activity by keeping blood glucose higher than is recommended, termed ‘maladaptive hypoglycaemia avoidance behaviour’. Amongst these HCPs, there was consensus that it was the role of the HCP to promote adequate levels of blood glucose rather than high levels:
“Often parents like to have their children have relatively high blood glucose levels and we try to listen to those concerns and empathise with them, but at the same time, we try to have them, rather than highs, we try to promote adequate levels” (P09, Dietician).
Concerns about diabetes being used as an excuse not to be active
Five HCPs believed that the extra effort required when a child with T1DM participates in physical activity could be used as an excuse not to participate, particularly by children who do not have a keen interest in being active; “Sometimes the diabetes can be used as a nice convenient excuse but you usually find out that these were children who never did anything beforehand” (P03, Consultant).
Theme 5 Perceived barriers to healthcare professionals fulfilling their role to promote physical activity
The majority of HCPs could readily identify barriers to the successful promotion of physical activity in children with T1DM.
Healthcare professionals perceive difficulty implementing physical activity guidelines
Healthcare professionals confided that physical activity was not always a priority for discussion during clinic appointments, where time was prioritised to other aspects of diabetes care. The reasons suggested for not prioritising physical activity included; “there’s quite a bit to it” (P10, Consultant), and “you only get a small amount of time” (P09, Dietician). Healthcare professionals found it difficult to translate physical activity information into a comprehensible format e.g., “difficult trying to translate that information into a digestible form for children” (P11, Dietician). Two HCPs suggested that the limited time available during routine clinic appointments meant that details around physical activity promotion and management were often omitted. Also, it was acknowledged that the effective implementation of guidelines was dependent on there being commitment from the child and family:
“If people are really going to manage their diabetes well during exercise that takes a lot of commitment in terms of what we may ask people to do. We might ask them to take blood glucose before and then every 20-30 minutes during activity and every hour afterwards” (P07, Dietician).
Healthcare professionals acknowledge the need for further training and resources
Healthcare professionals believed that standardised guidelines for physical activity participation would be beneficial to educate children with T1DM and their families, however conceded that “there's not an off-the-peg solution to anything” (P11, Dietician). Instead, because advice needs to be tailored to the individual child, its effectiveness depends on the ability of parents to understand how blood glucose levels respond to physical activity; “It can be quite individual for the patient and that can be quite overwhelming” (P07, Dietician).
There was general agreement that resources or referrals were available for children participating in structured or high level exercise and sport, however a gap was perceived in the availability of resources to promote and manage everyday lifestyle physical activities.
“It would be useful to get better resources…a nice hand-out that we could actually give out UK-wide would help families get the right support and education they need and make sure all centres are giving the same advice” (P05, Dietician).
Another HCP suggested that a curriculum or resource aimed at school teachers would be useful, especially PE teachers, who are “ideally placed to understand” (P10, Consultant) exercise:
“It might be useful to have a bit of a curriculum that is clear, directed at teachers for example, with a bit more for those that do sporting activities…they will be the ones to have a child go hypo if that’s not properly planned or monitored” (P10, Consultant).
Two HCPs described initiatives that had been developed in their respective centres to address this need for resources and facilitate the discussion and management of physical activity; i) an algorithm (not yet evaluated) giving instructions to children depending on their blood glucose level prior to physical activity and ii) an education programme for adolescents making the transition from paediatric to adult care .
A small number of HCPs lacked confidence in their ability to implement physical activity guidelines and questioned the effectiveness of the guidelines they were implementing: “I’m not quite sure how effective that education is” (P10, Consultant). Some suggested that further training might facilitate the promotion and management of physical activity in the clinic setting; “I don’t always feel I know all I need to know about it…and so I think educating health professionals is a starting point” (P07, Dietician), and; “I don’t feel adequately informed, probably because I haven’t studied [physical] activity” (P11, Dietician). One dietician described a self-initiated solution to this lack of mainstream physical activity training was to attend physical activity conferences:
“We don’t get enough training as a dietician you don’t get any training in Type 1 Diabetes particularly until you start doing it let alone on sports and exercise. So the way I’ve been trained is because I’ve gone to conferences on specific days and I’ve gone out my way to do that; it’s not an essential part of the training” (P05, Dietician).