Cost-effectiveness analysis of a kidney and cardiovascular disease treatment program in an Australian Aboriginal population

The objective of the study was to assess, from a health service perspective, whether a systematic program to modify kidney and cardiovascular disease reduced the costs of treating end-stage kidney failure. The participants in the study were 1,800 aboriginal adults with hypertension, diabetes with microalbuminuria or overt albuminuria, and overt albuminuria, living on two islands in the Northern Territory of Australia during 1995 to 2000. Perindopril was the primary treatment agent, and other medications were also used to control blood pressure. Control of glucose and lipid levels were attempted, and health education was offered. Evaluation of program resource use and costs for follow-up periods was done at 3 and 4.7 years. On an intention-to-treat basis, the number of dialysis starts and dialysis-years avoided were estimated by comparing the fate of the treatment group with that of historical control subjects, matched for disease severity, who were followed in the before the treatment program began. For the first three years, an estimated 11.6 person-years of dialysis were avoided, and over 4.7 years, 27.7 person-years of dialysis were avoided. The net cost of the program was 1,210 dollars more per person per year than status quo care, and dialyses avoided gave net savings of 1.0 million dollars at 3 years and 3.4 million dollars at 4.6 years. The treatment program provided significant health benefit and impressive cost savings in dialysis avoided.

Assessing Cardiovascular Risk in Regional Areas: The Healthy Hearts – Beyond City Limits Program

Background: Cardiovascular disease (CVD) is more prevalent in regional and remote Australia compared to metropolitan areas. The aim of Healthy Hearts was to determine age and sex specific CVD risk factor levels and the potential value of national risk clinics. Methods: Healthy Hearts was an observational research study conducted in four purposefully selected higher risk communities in regional Victoria, Australia. The main outcome measures were the proportion of participants with CVD risk factors with group comparisons to determine the adjusted likelihood of elevated risk factor levels. Trained personnel used a standardized protocol over four weeks per community to measure CVD risk factor levels, estimate absolute CVD risk and provide feedback and advice. Results: A total of 2125 self-selected participants were assessed (mean age 58 ± 15 years, 57% women). Overall, CVD risk factors were highly prevalent. More men than women had ≥ 2 modifiable CVD risk factors (76% vs. 68%, p < .001), pre-existing CVD (20 vs. 15%, p < .01) and a major ECG abnormality requiring follow-up (15% vs. 7%, p < .001) . Less men reported depressive symptoms compared to women (28% vs. 22%, p < .01). A higher proportion of women were obese (adjusted OR 1.36, 95% CI 1.13 to 1.63), and physically inactive (adjusted OR 1.32, 95% CI 1.07 to 1.63). Conclusions: High CVD risk factor levels were confirmed for regional Victoria. Close engagement with individuals and communities provides scope for the application of regional risk management clinics to reduce the burden of CVD risk in regional Australia.

Flexing some muscle: strategy and outcomes in the Queensland health and fitness industry

In 1993, contrary to the trend towards enterprise bargaining, and despite an employment environment favouring strong managerial prerogative, a small group of employers in the Queensland commercial health and fitness industry sought industrial regulation through an industry-specific award. A range of factors, including increased competition and unscrupulous profiteers damaging the industry’s reputation, triggered the actions as a business strategy. The strategic choices of the employer group, to approach a union to initiate a consent award, are the inverse of behaviours expected under strategic choice theory. This article argues that organizational size, collective employer action, focus on industry rather than organizational outcomes and the traditional industrial relations system providing broader impacts explain their atypical behaviour.

Early evidence for direct and indirect effects of the infant rotavirus vaccine program in Queensland

Objective: To assess the impact of introducing a publicly funded infant rotavirus vaccination program on disease notifications and on laboratory testing and results. Design and setting: Retrospective analysis of routinely collected data (rotavirus notifications [2006–2008] and laboratory rotavirus testing data from Queensland Health laboratories [2000–2008]) to monitor rotavirus trends before and after the introduction of a publicly funded infant rotavirus vaccination program in Queensland in July 2007. Main outcome measures: Age group-specific rotavirus notification trends; number of rotavirus tests performed and the proportion positive. Results: In the less than 2 years age group, rotavirus notifications declined by 53% (2007) and 65% (2008); the number of laboratory tests performed declined by 3% (2007) and 15% (2008); and the proportion of tests positive declined by 45% (2007) and 43% (2008) compared with data collected before introduction of the vaccination program. An indirect effect of infant vaccination was seen: notifications and the proportion of tests positive for rotavirus declined in older age groups as well. Conclusions: The publicly funded rotavirus vaccination program in Queensland is having an early impact, direct and indirect, on rotavirus disease as assessed using routinely collected data. Further observational studies are required to assess vaccine effectiveness. Parents and immunisation providers should ensure that all Australian children receive the recommended rotavirus vaccine doses in the required timeframe.

Feasibility of using telecommunications technology in a Cardiac-Diabetes Self-Management Program

Background: Evidence demonstrates self-management programs are an effective approach to assist patients with chronic diseases such as type 2 diabetes or cardiac conditions to modify their lifestyle for better managing their conditions. Using information technology (IT) has great potential to support self-management programs and assist patients to fulfill their goals in managing their conditions more efficiently and effectively. Examples of different types of technology used in self-management programs that have limited research support include: text messages, telephone followup, web-based programs, and other internet-assisted education. But little is known about the applicability and feasiability of different forms of technology for patients with chronic diseases such as those with type 2 diabetes and critical cardiac conditions. Furthermore, although there is some evidence of the benefits of using IT in supporting self-management programs, further research on the use of IT in such programs is recommended. Objective: To develop and pilot test an integrated Cardiac- Diabetes Self-Management Program (CDSMP) incorporating telephone and text-message follow-up. Methods: A pilot study using randomised controlled trial is conducted in the coronary care unit (CCU) in a Brisbane metropolitan hospital in Australia to collect data on patients with type 2 diabetes admitted to CCU. The main outcomes included self-efficacy levels, knowledge, and quality of life. Results: Initial results reveal that patients with diabetes admitted to the CCU in the experimental group did improve their self-efficacy, and knowledge levels. Acknowledgements: This Project is funded by QUT Early Career Researcher Research Grant

Diabetes health program development for Aboriginal and Torres Strait Islander women

According to Australian Health (2008), the area of endocrine, nutritional and metabolic disorders (mainly diabetes) yields the highest cause of death for Indigenous Australian women at 10.1%. Indigenous Brisbane North women’s results reiterate this with slightly higher percentages and are a cause for concern and action due to the noted levels of undiagnosed/unaware Indigenous Brisbane North women with abnormal blood glucose levels, whom participated in the research. A sub-sample of the group (N=17) were piloted to test the feasibility of method of eliciting health information on Indigenous Women within this community. This pilot study revealed the following health information regarding this group of women. 41.2% of Indigenous Brisbane North women were found to have blood glucose levels that were outside normal ranges, however only 29.4% had been diagnosed with diabetes and or endocrine abnormalities. These findings highlight that 11.8% of participants have signs indicating that they may have undiagnosed diabetes or/and pre diabetes juxtaposed to unacceptable endocrine levels compatible with health and wellness. The percentages of Indigenous Brisbane North Women whom have indicated that they have a diagnosis of diabetes have been compared to both National Indigenous peoples percentages and the national percentages for the wider Australian community (all Australians). The rate of diabetes within this population is 9 times that of the wider Australian community and 5 times that of the wider Australian Indigenous community. Data was collected from Indigenous participants on arrival and the attendance numbers of 112 women was recorded for comparison with other current health prevention wellness programs being delivered. Data was also collected through the use of specially designed culturally safe questionnaires undertaken in conjunction with health checks and health service information given to participants.

Comprehensive assessment of the fitness of older people for chemotherapy

Purpose: To present the results of a mixed-method study comparing the level of agreement of a two-phased, nurse-administered Comprehensive Geriatric Assessment (CGA) with current methods that assess the fitness for chemotherapy of older cancer patients. A nurse-led model of multidisciplinary cancer care based on the results is also described. Methods: The two phases comprised initial screening by a nurse with the Vulnerable Elders Survey-13 [VES-13], followed by nurse administration of a detailed CGA. Both phases were linked to a computerised algorithm categorising the patient as ‘fit’, ‘vulnerable’ or ‘frail’. The study determined the level of agreement between VES-13- and CGA-determined categories; and between the CGA and the physicians’ assessments. It also compared the CGA’s predictive abilities in terms of subsequent treatment toxicity; while interviews determined the acceptability of the nurse-led procedure from key stakeholders' perspectives. Results: Data collection was completed in December 2011. The results will be presented at the conference. A consecutive-series n=170 will be enrolled, 33% of whom are ‘fit’; 33% ‘vulnerable’; and 33% ‘too frail’ for treatment. This sample can detect, with 90% power, kappa coefficients of agreement of ≥ 0.70 or higher (“substantial agreement”). Fitness sub-group comparisons of agreement between the medical oncologist and the nurse assessments can detect kappa estimates of Κ ≥ 0.80 with the same power. Conclusion: The results have informed a nurse-led model of cancer care. It meets a clear need to develop, implement and test a nurse-led, robust, evidence-based, clinically-justifiable and economically-feasible CGA process that has relevance in national and international contexts.

Moving MobileMums forward: protocol for a larger randomized controlled trial of an improved physical activity program for women with young children

Background: Women with young children (under 5 years) are a key population group for physical activity intervention. Previous evidence highlights the need for individually tailored programs with flexible delivery mechanisms for this group. Our previous pilot study suggested that an intervention primarily delivered via mobile phone text messaging (MobileMums) increased self-reported physical activity in women with young children. An improved version of the MobileMums program is being compared with a minimal contact control group in a large randomised controlled trial (RCT). Methods/design: This RCT will evaluate the efficacy, feasibility and acceptability, cost-effectiveness, mediators and moderators of the MobileMums program. Primary (moderate-vigorous physical activity) and secondary (intervention implementation data, health service use costs, intervention costs, health benefits, theoretical constructs) outcomes are assessed at baseline, 3-months (end of intervention) and 9-months (following 6-month no contact: maintenance period). The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000481976; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336109).The intervention commences with a face-to-face session with a behavioural counsellor to initiate rapport and gather information for tailoring the 12-week text message program. During the program participants also have access to a: MobileMums Participant Handbook, MobileMums refrigerator magnet, MobileMums Facebook(C) group, and a MobileMums website with a searchable, on-line exercise directory. A nominated support person also receives text messages for 12-weeks encouraging them to offer their MobileMum social support for physical activity. Discussion: Results of this trial will determine the efficacy and cost-effectiveness of the MobileMums program, and the feasibility of delivering it in a community setting. It will inform the broader literature of physical activity interventions for women with young children and determine whether further investment in the translation of the program is warranted.

Investigating the impact of a leadership development program for nurse unit managers on the satisfaction of nursing staff

Background and significance: Nurses' job dissatisfaction is associated with negative nursing and patient outcomes. One of the most powerful reasons for nurses to stay in an organisation is satisfaction with leadership. However, nurses are frequently promoted to leadership positions without appropriate preparation for the role. Although a number of leadership programs have been described, none have been tested for effectiveness, using a randomised control trial methodology. Aims: The aims of this research were to develop an evidence based leadership program and to test its effectiveness on nurse unit managers' (NUMs') and nursing staff's (NS's) job satisfaction, and on the leader behaviour scores of nurse unit managers. Methods: First, the study used a comprehensive literature review to examine the evidence on job satisfaction, leadership and front-line manager competencies. From this evidence a summary of leadership practices was developed to construct a two component leadership model. The components of this model were then combined with the evidence distilled from previous leadership development programs to develop a Leadership Development Program (LDP). This evidence integrated the program's design, its contents, teaching strategies and learning environment. Central to the LDP were the evidence-based leadership practices associated with increasing nurses' job satisfaction. A randomised controlled trial (RCT) design was employed for this research to test the effectiveness of the LDP. A RCT is one of the most powerful tools of research and the use of this method makes this study unique, as a RCT has never been used previously to evaluate any leadership program for front-line nurse managers. Thirty-nine consenting nurse unit managers from a large tertiary hospital were randomly allocated to receive either the leadership program or only the program's written information about leadership. Demographic baseline data were collected from participants in the NUM groups and the nursing staff who reported to them. Validated questionnaires measuring job satisfaction and leader behaviours were administered at baseline, at three months after the commencement of the intervention and at six months after the commencement of the intervention, to the nurse unit managers and to the NS. Independent and paired t-tests were used to analyse continuous outcome variables and Chi Square tests were used for categorical data. Results: The study found that the nurse unit managers' overall job satisfaction score was higher at 3-months (p = 0.016) and at 6-months p = 0.027) post commencement of the intervention in the intervention group compared with the control group. Similarly, at 3-months testing, mean scores in the intervention group were higher in five of the six "positive" sub-categories of the leader behaviour scale when compared to the control group. There was a significant difference in one sub-category; effectiveness, p = 0.015. No differences were observed in leadership behaviour scores between groups by 6-months post commencement of the intervention. Over time, at three month and six month testing there were significant increases in four transformational leader behaviour scores and in one positive transactional leader behaviour scores in the intervention group. Over time at 3-month testing, there were significant increases in the three leader behaviour outcome scores, however at 6-months testing; only one of these leader behaviour outcome scores remained significantly increased. Job satisfaction scores were not significantly increased between the NS groups at three months and at six months post commencement of the intervention. However, over time within the intervention group at 6-month testing there was a significant increase in job satisfaction scores of NS. There were no significant increases in NUM leader behaviour scores in the intervention group, as rated by the nursing staff who reported to them. Over time, at 3-month testing, NS rated nurse unit managers' leader behaviour scores significantly lower in two leader behaviours and two leader behaviour outcome scores. At 6-month testing, over time, one leader behaviour score was rated significantly lower and the nontransactional leader behaviour was rated significantly higher. Discussion: The study represents the first attempt to test the effectiveness of a leadership development program (LDP) for nurse unit managers using a RCT. The program's design, contents, teaching strategies and learning environment were based on a summary of the literature. The overall improvement in role satisfaction was sustained for at least 6-months post intervention. The study's results may reflect the program's evidence-based approach to developing the LDP, which increased the nurse unit managers' confidence in their role and thereby their job satisfaction. Two other factors possibly contributed to nurse unit managers' increased job satisfaction scores. These are: the program's teaching strategies, which included the involvement of the executive nursing team of the hospital, and the fact that the LDP provided recognition of the importance of the NUM role within the hospital. Consequently, participating in the program may have led to nurse unit managers feeling valued and rewarded for their service; hence more satisfied. Leadership behaviours remaining unchanged between groups at the 6 months data collection time may relate to the LDP needing to be conducted for a longer time period. This is suggested because within the intervention group, over time, at 3 and 6 months there were significant increases in self-reported leader behaviours. The lack of significant changes in leader behaviour scores between groups may equally signify that leader behaviours require different interventions to achieve change. Nursing staff results suggest that the LDP's design needs to consider involving NS in the program's aims and progress from the outset. It is also possible that by including regular feedback from NS to the nurse unit managers during the LDP that NS's job satisfaction and their perception of nurse unit managers' leader behaviours may alter. Conclusion/Implications: This study highlights the value of providing an evidence-based leadership program to nurse unit managers to increase their job satisfaction. The evidence based leadership program increased job satisfaction but its effect on leadership behaviour was only seen over time. Further research is required to test interventions which attempt to change leader behaviours. Also further research on NS' job satisfaction is required to test the indirect effects of LDP on NS whose nurse unit managers participate in LDPs.

Development and evaluation of a program to improve clinician and patient communication during a telehealth consultation : C.R.I.S.P. Telehealth

Introduction: The delivery of health care in the 21st century will look like no other in the past. The fast paced technological advances that are being made will need to transition from the information age into clinical practice. The phenomenon of e-Health is the over-arching form of information technology and telehealth is one arm of that phenomenon. The uptake of telehealth both in Australia and overseas, has changed the face of health service delivery to many rural and remote communities for the better, removing what is known as the tyranny of distance. Many studies have evaluated the satisfaction and cost-benefit analysis of telehealth across the organisational aspects as well as the various adaptations of clinical pathways and this is the predominant focus of most studies published to date. However, whilst comments have been made by many researchers about the need to improve and attend to the communication and relationship building aspects of telehealth no studies have examined this further. The aim of this study was to identify the patient and clinician experiences, concerns, behaviours and perceptions of the telehealth interaction and develop a training tool to assist these clinicians to improve their interaction skills. Methods: A mixed methods design combining quantitative (survey analysis and data coding) and qualitative (interview analysis) approaches was adopted. This study utilised four phases to firstly qualitatively explore the needs of clients (patients) and clinicians within a telehealth consultation then designed, developed, piloted and quantitatively and qualitatively evaluated the telehealth communication training program. Qualitative data was collected and analysed during Phase 1 of this study to describe and define the missing 'communication and rapport building' aspects within telehealth. This data was then utilised to develop a self-paced communication training program that enhanced clinicians existing skills, which comprised of Phase 2 of this study to develop the interactive program. Phase 3 included evaluating the training program with 26 clinicians and results were recorded pre and post training, whilst phase 4 was the pilot for future recommendations of this training program using a patient group within a Queensland Health setting at two rural hospitals. Results: Comparisons of pre and post training data on 1) Effective communication styles, 2) Involvement in communication training package, 3) satisfaction pre and post training, and 4) health outcomes pre and post training indicated that there were differences between pre and post training in relation to effective communication style, increased satisfaction and no difference in health outcomes between pre and post training for this patient group. The post training results revealed over half of the participants (N= 17, 65%) were more responsive to non-verbal cues and were better able to reflect and respond to looks of anxiousness and confusion from a 'patient' within a telehealth consultation. It was also found that during post training evaluations, clinicians had enhanced their therapeutic communication with greater detail to their own body postures, eye contact and presentation. There was greater time spent looking at the 'patient' with an increase of 35 second intervals of direct eye contact and less time spent looking down at paperwork which decreased by 20 seconds. Overall 73% of the clinicians were satisfied with the training program and 61% strongly agreed that they recognised areas of their communication that needed improving during a telehealth consultation. For the patient group there was significant difference post training in rapport with a mean score from 42 (SD = 28, n = 27) to 48 (SD = 5.9, n = 24). For communication comfort of the patient group there was a significant difference between the pre and post training scores t(10) = 27.9, p = .002, which meant that overall the patients felt less inhibited whilst talking to the clinicians and more understood. Conclusion: The aim of this study was to explore the characteristics of good patient-clinician communication and unmet training needs for telehealth consultations. The study developed a training program that was specific for telehealth consultations and not dependent on a 'trainer' to deliver the content. In light of the existing literature this is a first of its kind and a valuable contribution to the research on this topic. It was found that the training program was effective in improving the clinician's communication style and increased the satisfaction of patient's within an e-health environment. This study has identified some historical myths that telehealth cannot be part of empathic patient centred care due to its technology tag.

A group psychological intervention to enhance the coping and acculturation of international students

There is a shortage of psychological interventions to aid the acculturation of international students. To address this issue, the present study developed and trialled a brief group psychological intervention, the STAR program: Strengths, Transitions, Adjustments, and Resilience. This program was developed using suggestions from international students and university professional and academic staff that had significant dealings and designated roles to guide support international students. It comprises of four weekly two-hour sessions, and is experiential and cognitive-behavioural in nature. The STAR program aims to enhance coping, which is predicted to subsequently improve psychological adaptation (an acculturation outcome). Sixteen international students participated in the pilot trial of the STAR program. The participants completed measures on coping self-efficacy, social self-efficacy, psychological adaptation, and psychological distress pre-intervention, post-intervention, and one-month follow-up. Results showed that participants’ psychological adaptation and coping self-efficacy significantly increased from pre to post, with the treatment gain maintained at the one-month follow-up for psychological adaptation. Increases in social self-efficacy were evident, but these did not reach significance, possibly due to a lack of power. The STAR program did not have an impact on psychological distress; however, participants were only minimally distressed at the commencement of the program. The qualitative feedback gathered from the participants, provided suggestions for further refinement, as well as information about the clinical utility of the STAR program.

Evaluating NEXUS: A suicide prevention program for young people from refugee backgrounds (2007 – 2009)

Although suicide deaths in Australia continue to decline since the peak of 2,720 suicide deaths in 1997, youth suicide and self-harm are a major health issue. In 2006, in the 20 to 24 year age group, suicide accounted for approximately 21% of all male deaths and 14% of all female deaths. There is a lack of solid data on the rates of suicide and self-harm among young people from refugee backgrounds. However, this population faces a significant number of post-resettlement stressors that may add to their vulnerability and increase their risk of suicide and self-harm. The NEXUS program is an innovative strategy developed by the Queensland Program of Assistance to Survivors of Torture and Trauma (QPASTT) that aims to reduce risk factors for suicide and self-harm and to promote protective factors among youth from refugee backgrounds living in Brisbane and Toowoomba. QPASTT is a non-government organisation that provides culturally appropriate support services to refugee and humanitarian entrants to Australia. QPASTT’s primary function is to provide counselling, advocacy support and community development activities for survivors of torture and trauma at an individual, family and community level. Since 2002 the NEXUS program has been developed and implemented by QPASTT. Since then, this multi-component program has been funded by the Commonwealth Department of Health and Ageing through the National Suicide Prevention Strategy (NSPS). NSPS funding of local community suicide prevention activities will contribute to the outcomes specified in the strategic framework: Living is for Everyone (LIFE): A framework for prevention of suicide and self-harm in Australia. The focus of this report is the evaluation of the NEXUS program conducted by QPASTT between August 2007 and May 2009.

Effects of a pediatric weight management program with and without active video games

Importance Active video games may offer an effective strategy to increase physical activity in overweight and obese children. However, the specific effects of active gaming when delivered within the context of a pediatric weight management program are unknown. Objective To evaluate the effects of active video gaming on physical activity and weight loss in children participating in an evidence-based weight management program delivered in the community. Design, Setting, and Participants Group-randomized clinical trial conducted during a 16-week period in YMCAs and schools located in Massachusetts, Rhode Island, and Texas. Seventy-five overweight or obese children (41 girls [55%], 34 whites [45%], 20 Hispanics [27%], and 17 blacks [23%]) enrolled in a community-based pediatric weight management program. Mean (SD) age of the participants was 10.0 (1.7) years; body mass index (BMI) z score, 2.15 (0.40); and percentage overweight from the median BMI for age and sex, 64.3% (19.9%). Interventions All participants received a comprehensive family-based pediatric weight management program (JOIN for ME). Participants in the program and active gaming group received hardware consisting of a game console and motion capture device and 1 active game at their second treatment session and a second game in week 9 of the program. Participants in the program-only group were given the hardware and 2 games at the completion of the 16-week program. Main Outcomes and Measures Objectively measured daily moderate-to-vigorous and vigorous physical activity, percentage overweight, and BMI z score. Results Participants in the program and active gaming group exhibited significant increases in moderate-to-vigorous (mean [SD], 7.4 [2.7] min/d) and vigorous (2.8 [0.9] min/d) physical activity at week 16 (P < .05). In the program-only group, a decline or no change was observed in the moderate-to-vigorous (mean [SD] net difference, 8.0 [3.8] min/d; P = .04) and vigorous (3.1 [1.3] min/d; P = .02) physical activity. Participants in both groups exhibited significant reductions in percentage overweight and BMI z scores at week 16. However, the program and active gaming group exhibited significantly greater reductions in percentage overweight (mean [SD], −10.9% [1.6%] vs −5.5% [1.5%]; P = .02) and BMI z score (−0.25 [0.03] vs −0.11 [0.03]; P < .001). Conclusions and Relevance Incorporating active video gaming into an evidence-based pediatric weight management program has positive effects on physical activity and relative weight.

Conceptions of learning held by Aboriginal students in a tertiary program in Indigenous primary health care

This paper is a description of a pilot investigation into conceptions of learning held by a sample of 10 Aboriginal students in a Bachelors degree courses. Results from this study suggest that this group of students view and approach learning in much the same way as other university students. They mostly hold quantitative conceptions of learning and use repetitive strategies which are potentially at odds with the objectives and procedures of the problems based program in which they are studying.

The impact of transformative learning in a critical service-learning program on teacher development: Building a foundation for inclusive teaching

With international and national policies requiring teachers to adopt inclusive practices worldwide, this paper examines the impact of transformational learning in a critical service-learning program on final-year pre-service teachers’ approaches to inclusive teaching. Data from emailed questionnaires and focus group interviews are analysed through a social, critical framework. The results indicate that the critical service-learning program provided the students with an opportunity to consider diversity and inclusion in selecting teaching strategies, and to enact values suitable to inclusive practices and appreciation of diversity in schools. In this paper we argue that transformative learning experiences about inclusivity and diversity are needed if pre-service teachers are to be challenged to adopt inclusive values and practice in schools. A critical service-learning program for pre-service teachers provides a solid foundation on which to develop or build on the ability to think and teach inclusively.