Schematic Representation of Case Study Research Designs

Aim. The paper is a report of a study to demonstrate how the use of schematics can provide procedural clarity and promote rigour in the conduct of case study research. Background. Case study research is a methodologically flexible approach to research design that focuses on a particular case – whether an individual, a collective or a phenomenon of interest. It is known as the 'study of the particular' for its thorough investigation of particular, real-life situations and is gaining increased attention in nursing and social research. However, the methodological flexibility it offers can leave the novice researcher uncertain of suitable procedural steps required to ensure methodological rigour. Method. This article provides a real example of a case study research design that utilizes schematic representation drawn from a doctoral study of the integration of health promotion principles and practices into a palliative care organization. Discussion. The issues discussed are: (1) the definition and application of case study research design; (2) the application of schematics in research; (3) the procedural steps and their contribution to the maintenance of rigour; and (4) the benefits and risks of schematics in case study research. Conclusion. The inclusion of visual representations of design with accompanying explanatory text is recommended in reporting case study research methods.

Teachers’ understanding of school connectedness : implications for the development and implementation of school based injury prevention strategies

Aim: Worldwide, injury is the leading cause of death and disability for young people. Injuries among young people are commonly associated with risk taking behaviour, including violence and transport risks, which often occur in the context of alcohol use. The school environment has been identified as having a significant role in shaping adolescent behaviour. In particular, school connectedness, the degree to which adolescents feel that they belong and are accepted at school, has been shown to be an important protective factor. Strategies for increasing school connectedness may therefore be effective in reducing risk taking and associated injury. Prior to developing connectedness strategies, it is important to understand the perspectives of those in the school regarding the construct and how it is realised in the school context. The aim of this research was to understand teachers’ perspectives of school connectedness, the strategies they employ to connect with students, and their perceptions of school connectedness as a strategy for risk taking and injury prevention. Method: In depth interviews of approximately 45 minutes duration were conducted with 13 Health and PE teachers and support staff from 2 high schools in Southeast Queensland, Australia. Additionally, 6 focus group workshop discussions were held with 35 Education department employees (5-6 per group), including teachers from 15 Southeast Queensland high schools. Results: Participants were found to place strong importance on the development of connectedness among students, including those at risk for problem behaviour. Strategies used to promote connectedness included building trust, taking an interest in each student and being available to talk to, and finding something positive for students to succeed at. Teachers identified strategies as being related to decreased risk taking behavior. Teacher training on school connectedness was perceived as an important and useful inclusion in a school based injury prevention program. Conclusions: The established link between increased school connectedness and decreased problem behaviour has implications for school based strategies designed to decrease adolescent risk taking behaviour and associated injury. Targeting school connectedness as a point of intervention, in conjunction with individual attitude and behaviour change programs, may be an effective injury prevention strategy.

Modeling factors that influence exercise and dietary change among midlife Australian women: results from the Healthy Aging of Women Study

The objective of this study was to investigate the factors that influence midlife women to make positive exercise and dietary changes. In late 2005 questionnaires were mailed to 866 women aged 51–66 years from rural and urban locations in Queensland, Australia and participating in Stage 2 of the Healthy Aging of Women Study. The questionnaires sought data on socio-demographics, body mass index (BMI), chronic health conditions, self-efficacy, exercise and dietary behavior change since age 40, and health-related quality of life. Five hundred and sixty four (69%) were completed and returned by early 2006. Data analysis comprised descriptive and bivariate statistics and structural equation modeling. The results showed that midlife is a significant time for women to make positive health behavior changes. Approximately one-third of the sample (34.6%) indicated that they had increased their exercise and around 60% had made an effort to eat more healthily since age 40. Modeling showed self-efficacy to be important in making both exercise and dietary changes. Although education appeared to influence self-efficacy in relation to exercise change, this was not the case for dietary change. The study has application for programs promoting healthy aging among women, and implies that those with low education, high BMI and poor mental health may need considerable support to improve their lifestyles.

The domestic kitchen : the weak link in the food chain : is convenience leading to apathy?

To investigate the meaning and understanding of domestic food preparation within the lived experience of the household's main food preparer this ethnographic study used a combination of qualitative and quantitative methodologies. Data were collected from three sources: the literature; an in-store survey of251 food shoppers chosen at random while shopping during both peak and off peak shopping periods at metropolitan supermarkets; and semi-structured interviews with the principal food shopper and food preparer of 15 different Brisbane households. Male and female respondents representing a cross section of socio-economic groupings, ranged in age from 19-79 years and were all from English speaking backgrounds. Changes in paid labour force participation, income and education have increased the value of the respondents' time, instigating massive changes in the way they shop, cook and eat. Much of their food preparation has moved from the domestic kitchen into the kitchens of other food establishments. For both sexes, the dominant motivating force behind these changes is a combination of the their self perceived lack of culinary skill; lack of enjoyment of cooking and lack of motivation to cook. The females in paid employment emphasise all factors, particularly the latter two, significantly more than the non-employed females. All factors are of increasing importance for individuals aged less than 35 years and conversely, of significantly diminished importance to older respondents. Overall, it is the respondents aged less than 25 years who indicate the lowest cooking frequency and/or least cooking ability. Inherent in this latter group is an indifference to the art/practice of preparing food. Increasingly, all respondents want to do less cooking and/or get the cooking over with as quickly as possible. Convenience is a powerful lure by which to spend less time in the kitchen. As well, there is an apparent willingness to pay a premium for convenience. Because children today are increasingly unlikely to be taught to cook, addressing the food skills deficit and encouraging individuals to cook for themselves are significant issues confronting health educators. These issues are suggested as appropriate subjects of future research.

Road safety messages tailored for young adults : Using the Internet and encouraging protective passenger behaviour

Young drivers are at higher risk of crashes than other drivers when carrying passengers. Graduated Driver Licensing has demonstrated effectiveness in reducing fatalities however there is considerable potential for additional strategies to complement the approach. A survey with 276 young adults (aged 17-25 years, 64% females) was conducted to examine the potential and importance of strategies that are delivered via the Internet and potential strategies for passengers. Strategies delivered via the Internet represent opportunity for widespread dissemination and greater reach to young people at times convenient to them. The current study found some significant differences between males and females with regard to ways the Internet is used to obtain road safety information and the components valued in trusted road safety sites. There were also significant differences between males and females on the kinds of strategies used as passengers to promote driver safety and the context in which it occurred, with females tending to take more proactive strategies than males. In sum, young people see value in Internet delivery for passenger safety information (80% agreed/ strongly agreed) and more than 90% thought it was important to intervene while a passenger of a risky driver. Thus tailoring Internet road safety strategies to young people may differ for males and females however there is considerable potential for a passenger focus in strategies aimed at reducing young driver crashes.

A systematic review of the association between physical activity and colorectal cancer risk

This review evaluated the strength of the evidence for a causal relationship between physical activity (PA) and colorectal cancer (CRC). A systematic review of databases through February 2008 was conducted to identify studies that assessed the association between total or recreational PA and incidence or mortality of CRC (including CRC, rectal cancer, colon cancer, and proximal or distal colon cancer). Studies were evaluated for significant associations between PA and risk of CRC endpoints and for evidence of dose–response relationships in the highest quality studies. Twenty cohort studies were evaluated; 11 were high-quality. Fifty percent of all studies and 64%of highest quality studies reported at least one significant association between PA and risk of a CRC endpoint (Po0.05).However, only 28%of all analyses (31% of analyses of highest quality studies) were significant (Po0.05). Only 40% of analyses of highest quality studies resulted in a significant P for trend (Po0.05); however, a non-significant inverse linear association between PA and colon cancer riskwas apparent.Heterogeneity in the evidence from all studies and from the highest quality studies was evident. Evidence from cohort studies is not sufficient to claim a convincing relationship exists between PA and CRC risk.

Do walking and leisure-time physical activity protect against arthritis in older women?

Objective: To examine the prospective dose–response relationships between both leisure-time physical activity (LTPA) and walking with self-reported arthritis in older women. Design, setting and participants: Data came from women aged 73–78 years who completed mailed surveys in 1999, 2002 and 2005 for the Australian Longitudinal Study on Women’s Health. Women reported their weekly minutes of walking and moderate to vigorous physical activities. They also reported on whether they had been diagnosed with, or treated for, arthritis since the previous survey. General estimating equation analyses were performed to examine the longitudinal relationship between LTPA and arthritis and, for women who reported walking as their only physical activity, the longitudinal relationship between walking and arthritis. Women who reported arthritis or a limited ability to walk in 1999 were excluded, resulting in data from 3613 women eligible for inclusion in these analyses. Main results: ORs for self-reported arthritis were lowest for women who reported “moderate” levels of LTPA (OR 0.78; 95% CI 0.67 to 0.92), equivalent to 75 to <150 minutes of moderate-intensity LTPA per week. Slightly higher odds ratios were found for women who reported “high” (OR 0.81; 95% CI 0.69 to 0.95) or “very high” (OR 0.84; 95% CI 0.72 to 0.98) LTPA levels, indicating no further benefit from increased activity. For women whose only activity was walking, an inverse dose–response relationship between walking and arthritis was seen. Conclusions: The results support an inverse association between both LTPA and walking with self-reported arthritis over 6 years in older women who are able to walk.

Effect of the Summer Months on Body Weight and Composition in College Women

BACKGROUND AND OBJECTIVES: College students and young adults are experiencing the greatest increases in rates of obesity, and 20% of college students are classified as obese. The objective of this study was to compare changes and rates of change in body weight and body composition between the freshman academic year and the summer after the freshman year among female college students. METHODS: Participants were recruited early in their freshman year of college to participate in a prospective longitudinal study examining changes in body weight and composition over the college years. Height and weight were measured, and body composition was assessed using dual energy x-ray absorptiometry (DEXA) at the beginning and end of the freshman year. Upon return from the summer for their sophomore year, participants returned to have all measurements repeated. Sixty-nine female participants completed all three visits. RESULTS: Body weight increased 1.3 kg during the academic period and an additional 0.1 kg during the summer period. Body mass index (BMI) increased between the first two visits but did not change between the last two visits. However, percent fat increased at each visit. Fat-free mass significantly increased 0.5 kg over the academic year but decreased by 1.1 kg over the summer (p<0.05). Greater rates of change were detected in percent fat, fat-free mass, and BMI during the summer compared with the academic year (p<0.05). CONCLUSIONS: Differences in body composition between the academic and summer periods may reflect changes in living situations between these periods. Unfavorable changes during the summer suggest the need to promote healthy lifestyles to freshman women before they leave campus for the summer

Exercise and cancer rehabilitation : a systematic review

Introduction: Cancer is increasingly being viewed as a chronic illness requiring long-term management, and there is a growing need for evidence-based rehabilitation interventions for cancer survivors. Previous reviews have evaluated the benefits of exercise interventions for patients undergoing cancer treatment and long-term survivors, but none have investigated the role of exercise during cancer rehabilitation, the period immediately following cancer treatment completion. This systematic review summarises the literature on the health effects of exercise during cancer rehabilitation and evaluates the methodological rigour of studies in this area to date.----------- Methods: Relevant studies were identified through a systematic search of PubMed and Embase to April 2009. Data on study design, recruitment strategy, participants, exercise intervention, adherence rates, and outcomes were extracted. Methodological rigour was assessed using a structured rating system.---------- Results: Ten studies were included. Breast cancer patients were the predominate patient group represented. Most interventions were aerobic or resistance-training exercise programmes, and exercise type, frequency, duration and intensity varied across studies. Improvements in physical functioning, strength, physical activity levels, quality of life, fatigue, immune function, haemoglobin concentrations, potential markers of recurrence, and body composition were reported. However, all studies were limited by incomplete reporting and methodological limitations.---------- Conclusions: Although the methodological limitations of studies in this new field must be acknowledged, initial evidence indicates that exercise is feasible and may provide physiological and psychological benefits for cancer survivors during the rehabilitation period. Future studies with rigorous study designs are now required to advance the field.

Factors associated with physical activity in Australians with hip or knee osteoarthritis

Background: Physical activity (PA) is recommended for managing osteoarthritis (OA). However, few people with OA are physically active. Understanding the factors associated with PA is necessary to increase PA in this population. This cross-sectional study examined factors associated with leisure-time PA, stretching exercises, and strengthening exercises in people with OA. Methods: For a mail survey, 485 individuals, aged 68.0 y (SD=10.6) with hip or knee OA, were asked about factors that may influence PA participation, including use of non-PA OA management strategies and both psychological and physical health-related factors. Associations between factors and each PA outcome were examined in multivariable logistic regression models. Results: Non-PA management strategies were the main factors associated with the outcomes. Information/education courses, heat/cold treatments, and paracetamol were associated with stretching and strengthening exercises (P<0.05). Hydrotherapy and magnet therapy were associated with leisure-time PA; using orthotics and massage therapy, with stretching exercises; and occupational therapy, with strengthening exercises (P<0.05). Few psychological or health15 related factors were associated with the outcomes. Conclusions: Some management strategies may make it easier for people with OA to be physically active, and could be promoted to encourage PA. Providers of strategies are potential avenues for recruiting people with OA into PA programs.

Colorectal cancer survivors’ exercise experiences and preferences : qualitative findings from an exercise rehabilitation programme immediately after chemotherapy

Little is known about cancer survivors’ experiences with and preferences for exercise programmes offered during rehabilitation (immediately after cancer treatment). This study documented colorectal cancer survivors’ experiences in an exercise rehabilitation programme and their preferences for programme content and delivery. At the completion of 12-weeks of supervised exercise, 10 participants took part in one-on-one semi-structured interviews. Data from these interviews were coded, and themes were identified using qualitative software. Key findings were that most participants experienced improvements in treatment symptoms, including reduced fatigue and increased energy and confidence to do activities of daily living. They also reported that interactions with the exercise trainer and a flexible programme delivery were important aspects of the intervention. Most participants reported that they preferred having a choice of exercise, starting to exercise within a month after completing treatment, having supervision and maintaining a one-on-one format. Frustrations included scheduling conflicts and a lack of a transition out of the programme. The findings indicate that colorectal cancers experience benefits from exercise offered immediately after treatment and prefer individual attention from exercise staff. They further indicate directions for the implementation of future exercise programmes with this population.

The Eat Smart Study : a randomised controlled trial of a reduced carbohydrate versus a low fat diet for weight loss in obese adolescents

Background Despite the recognition of obesity in young people as a key health issue, there is limited evidence to inform health professionals regarding the most appropriate treatment options. The Eat Smart study aims to contribute to the knowledge base of effective dietary strategies for the clinical management of the obese adolescent and examine the cardiometablic effects of a reduced carbohydrate diet versus a low fat diet. Methods and design Eat Smart is a randomised controlled trial and aims to recruit 100 adolescents over a 2½ year period. Families will be invited to participate following referral by their health professional who has recommended weight management. Participants will be overweight as defined by a body mass index (BMI) greater than the 90th percentile, using CDC 2000 growth charts. An accredited 6-week psychological life skills program ‘FRIENDS for Life’, which is designed to provide behaviour change and coping skills will be undertaken prior to volunteers being randomised to group. The intervention arms include a structured reduced carbohydrate or a structured low fat dietary program based on an individualised energy prescription. The intervention will involve a series of dietetic appointments over 24 weeks. The control group will commence the dietary program of their choice after a 12 week period. Outcome measures will be assessed at baseline, week 12 and week 24. The primary outcome measure will be change in BMI z-score. A range of secondary outcome measures including body composition, lipid fractions, inflammatory markers, social and psychological measures will be measured. Discussion The chronic and difficult nature of treating the obese adolescent is increasingly recognised by clinicians and has highlighted the need for research aimed at providing effective intervention strategies, particularly for use in the tertiary setting. A structured reduced carbohydrate approach may provide a dietary pattern that some families will find more sustainable and effective than the conventional low fat dietary approach currently advocated. This study aims to investigate the acceptability and effectiveness of a structured reduced dietary carbohydrate intervention and will compare the outcomes of this approach with a structured low fat eating plan. Trial Registration: The protocol for this study is registered with the International Clinical Trials Registry (ISRCTN49438757).

Correlates of sitting time in working age Australian women : who should be targeted with interventions to decrease sitting time?

Background: While there is emerging evidence that sedentary behavior is negatively associated with health risk, research on the correlates of sitting time in adults is scarce. Methods: Self-report data from 7,724 women born between 1973-1978 and 8,198 women born between 1946-1951 were collected as part of the Australian Longitudinal Study on Women’s Health. Linear regression models were computed to examine whether demographic, family and caring duties, time use, health and health behavior variables were associated with weekday sitting time. Results: Mean sitting time (SD) was 6.60 (3.32) hours/day for the 1973-1978 cohort and 5.70 (3.04) hours/day for the 1946-1951 cohort. Indicators of socio-economic advantage, such as full11 time work and skilled occupations in both cohorts and university education in the mid-age cohort, were associated with high sitting time. A cluster of ‘healthy behaviours’ was associated with lower sitting time in the mid-aged women (moderate/high physical activity levels, non-smoking, non-drinking). For both cohorts, sitting time was highest in women in full-time work, in skilled occupations and in those who spent the most time in passive leisure. Conclusions: The results suggest that, in young and mid-aged women, interventions for reducing sitting time should focus on both occupational and leisure-time sitting.

Music is a Wordless Knowing of Others : Resilience in Virtual Ensembles

Music making affects relationships with self and others by generating a sense of belonging to a culture or ideology (Bamford, 2006; Barovick, 2001; Dillon & Stewart, 2006; Fiske, 2000; Hallam, 2001). Whilst studies from arts education research present compelling examples of these relationships, others argue that they do not present sufficiently validated evidence of a causal link between music making experiences and cognitive or social change (Winner & Cooper, 2000; Winner & Hetland, 2000a, 2000b, 2001). I have suggested elsewhere that this disconnection between compelling evidence and observations of the effects of music making are in part due to the lack of rigor in research and the incapacity of many methods to capture these experiences in meaningful ways (Dillon, 2006). Part of the answer to these questions about rigor and causality lay in the creative use of new media technologies that capture the results of relationships in music artefacts. Crucially, it is the effective management of these artefacts within computer systems that allows researchers and practitioners to collect, organize, analyse and then theorise such music making experiences.

Voices of the Unheard

Adversity has the effect of eliciting talents, which, in prosperous circumstances, would have lain dormant. Horace - Roman lyric poet and satirist 65BC – 8 BC This quotation from Horace could well be the chorus to a medley of songs sung by people who face extraordinary adversity and have gained emotional resilience through music making. In this chapter we present three composition ventures that are stories or verses in a new song and whose chorus summarises the nature of the resilience factors present in the narratives. We are aware that words on a page like this can have the effect of filtering out the engaging nature of musical experience and reduce music to a critique or an evaluation of its aesthetic value. This disjuncture between language and the ephemeral, embodied experience is a problem for those who use these creative processes in therapeutic and salutogenic ways (Antonovsky, 1996) for public health. The notion of salutogenic health, put simply, delineates it from therapy in that the processes focus upon wellness rather than therapy. Whilst we include evidence from the fields of community music therapy (Pavlicevic, 2004; Leitschuh et al., 1991), neuroscience (Bittman et al., 2001) and community music (Bartleet et al., 2009) the framework for a salutogenic health outcome in community music is one which seeks to employ music practices and the qualities of music making that provide positive health benefit to communities –to enhance health and well being rather than the “treatment” of disorders. It is essentially a holistic and interdisciplinary study. Therapy and salutogenic health are not mutually exclusive as both depend upon the qualities of music experience to affect change. Collecting, analysing and presenting evidence of change in human behaviour that can be directly attributed to creative music making is a problem of evaluation.