'Work it out': Evaluation of a chronic condition self-management program for urban Aboriginal and Torres Strait Islander people with or at risk of cardiovascular disease

This thesis evaluates a chronic condition self-management program for Aboriginal and Torres Strait Islander people in urban south-east Queensland who have or are at risk of cardiovascular disease. Outcomes showed short-term improvements for some anthropometry measures which could be a trend for improvement in other anthropometry indicators over the longer term. The program was of particular benefit for participants who had several social and emotional wellbeing conditions. The use of an Aboriginal and Torres Strait Islander conceptual framework was critical in undertaking culturally competent quantitative research in this project.

Relationship between malnutrition and selected risk factors in two hospitals in Vietnam

Aim: The purpose of this study was to determine the percentage of patients assessed as malnourished using the Subjective Global Assessment in two hospitals in Ho Chi Minh City and Can Tho across multiple wards; and to investigate the association with factors including gender, age, days since admission, medical diagnosis and number of medications used. Methods: This cross-sectional study involved 205 inpatients from a hospital in Ho Chi Minh City and 78 inpatients and 89 outpatients from a hospital in Can Tho. Malnutrition status was assessed using Subjective Global Assessment. Ward, gender, age, medical diagnosis, time since admission and medication number were extracted from medical records. Results: 35.6% of inpatients and 9.0% of outpatients were malnourished. Multivariate analysis revealed factors predicting malnutrition status within inpatients (OR (95%CI)) were: age (OR = 1.03 (1.01-1.06)); cancer diagnosis (OR = 34.25 (3.16-370.89)); respiratory ward (11.49 (1.05-125.92)); or general medicine ward (20.34 (2.10-196.88)). Conclusions: Results indicate that malnutrition is a common problem in hospitals in Vietnam. Further research is needed to confirm this finding across a wider range of hospitals and to investigate the feasibility and efficacy of implementation of nutrition interventions in hospital settings.

Long-term ambient air pollution exposure and self-reported morbidity in the Australian Longitudinal Study on Women's Health: A cross-sectional study

- Objective We sought to assess the effect of long-term exposure to ambient air pollution on the prevalence of self-reported health outcomes in Australian women. - Design Cross-sectional study - Setting and participants The geocoded residential addresses of 26 991 women across 3 age cohorts in the Australian Longitudinal Study on Women's Health between 2006 and 2011 were linked to nitrogen dioxide (NO2) exposure estimates from a land-use regression model. Annual average NO2 concentrations and residential proximity to roads were used as proxies of exposure to ambient air pollution. - Outcome measures Self-reported disease presence for diabetes mellitus, heart disease, hypertension, stroke, asthma, chronic obstructive pulmonary disease and self-reported symptoms of allergies, breathing difficulties, chest pain and palpitations. - Methods Disease prevalence was modelled by population-averaged Poisson regression models estimated by generalised estimating equations. Associations between symptoms and ambient air pollution were modelled by multilevel mixed logistic regression. Spatial clustering was accounted for at the postcode level. - Results No associations were observed between any of the outcome and exposure variables considered at the 1% significance level after adjusting for known risk factors and confounders. - Conclusions Long-term exposure to ambient air pollution was not associated with self-reported disease prevalence in Australian women. The observed results may have been due to exposure and outcome misclassification, lack of power to detect weak associations or an actual absence of associations with self-reported outcomes at the relatively low annual average air pollution exposure levels across Australia.

Multidisciplinary review of teaching and assessing competency attainment by non-medical prescribers

Background Prescribing is a complex task, requiring specific knowledge and skills, and the execution of effective, context-specific clinical reasoning. Systematic reviews indicate medical prescribing errors have a median rate of 7% [IQR 2%-14%] of medication orders [1-3]. For podiatrists pursuing prescribing rights, a clear need exists to ensure practitioners develop a well-defined set of prescribing skills, which will contribute to competent, safe and appropriate practice. Aim To investigate the methods employed to teach and assess the principles of effective prescribing in the undergraduate podiatry program and compare and contrast these findings with four other non-medical professions who undertake prescribing after training at Queensland University of Technology. Method The NPS National Prescribing Competency Standards were employed as the prescribing standard. A curriculum mapping exercise was undertaken to determine whether the prescribing principles articulated in the competency standards were addressed by each profession. Results A range of methods are currently utilised to teach prescribing across disciplines. Application of prescribing competencies to the context of each profession appears to influence the teaching methods used. Most competencies were taught using a multimodal format, including interactive lectures, self-directed learning, tutorial sessions and clinical placement. In particular clinical training was identified as the most consistent form of educating safe prescribers across all five disciplines. Assessment of prescribing competency utilised multiple techniques including written and oral examinations and research tasks, case studies, objective structured clinical examination exercises and the assessment of clinical practice. Effective and reliable assessment of prescribing undertaken by students in diverse settings remains challenging e.g. that occurring in the clinical practice environment. Conclusion Recommendations were made to refine curricula and to promote efficient cross-discipline teaching by staff from the disciplines of podiatry, pharmacy, nurse practitioner, optometry and paramedic science. Students now experience a sophisticated level of multidisciplinary learning in the clinical setting which integrates the expertise and skills of experience prescribers combined with innovative information technology platforms (CCTV and live patient assessments). Further work is required to establish a practical, effective approach to the assessment of prescribing competence especially between the university and clinical settings.

Adipocytes promote prostate cancer stem cell self-renewal through amplification of the cholecystokinin autocrine loop

Obesity has long been linked with prostate cancer progression, although the underlying mechanism is still largely unknown. Here, we report that adipocytes promote the enrichment of prostate cancer stem cells (CSCs) through a vicious cycle of autocrine amplification. In the presence of adipocytes, prostate cancer cells actively secrete the peptide hormone cholecystokinin (CCK), which not only stimulates prostate CSC self-renewal, but also induces cathepsin B (CTSB) production of the adipocytes. In return, CTSB facilitates further CCK secretion by the cancer cells. More importantly, inactivation of CCK receptor not only suppresses CTSB secretion by the adipocytes, but also synergizes the inhibitory effect of CTSB inhibitor on adipocyte-promoted prostate CSC self-renewal. In summary, we have uncovered a novel mechanism underlying the mutual interplay between adipocytes and prostate CSCs, which may help explaining the role of adipocytes in prostate cancer progression and provide opportunities for effective intervention.

Motorcycle riders' self-reported aggression when riding compared with car driving

Aggressive driving has been shown to be related to increased crash risk for car driving. However, less is known about aggressive behaviour and motorcycle riding and whether there are differences in on-road aggression as a function of vehicle type. If such differences exist, these could relate to differences in perceptions of relative vulnerability associated with characteristics of the type of vehicle such as level of protection and performance. Specifically, the relative lack of protection offered by motorcycles may cause riders to feel more vulnerable and therefore to be less aggressive when they are riding compared to when they are driving. This study examined differences in self-reported aggression as a function of two vehicle types: passenger cars and motorcycles. Respondents (n = 247) were all motorcyclists who also drove a car. Results were that scores for the composite driving aggression scale were significantly higher than on the composite riding aggression scale. Regression analyses identified different patterns of predictors for driving aggression from those for riding aggression. Safety attitudes followed by thrill seeking tendencies were the strongest predictors for driving aggression, with more positive safety attitudes being protective while greater thrill seeking was associated with greater self-reported aggressive driving behaviour. For riding aggression, thrill seeking was the strongest predictor (positive relationship), followed by self-rated skill, such that higher self rated skill was protective against riding aggression. Participants who scored at the 85th percentile or above for the aggressive driving and aggressive riding indices had significantly higher scores on thrill seeking, greater intentions to engage in future risk taking, and lower safety attitude scores than other participants. In addition participants with the highest aggressive driving scores also had higher levels of self-reported past traffic offences than other participants. Collectively, these findings suggest that people are less likely to act aggressively when riding a motorcycle than when driving a car, and that those who are the most aggressive drivers are different from those who are the most aggressive riders. However, aggressive riders and drivers appear to present a risk to themselves and others on road. Importantly, the underlying influences for aggressive riding or driving that were identified in this study may be amenable to education and training interventions.

Fusion of worlds?: Consumers' self-narrative in a hybrid digital/physical world

As the Internet becomes deeply embedded in consumers' life and continuously accessed through mobile devices, the boundary between the digital and the physical becomes less defined. This thesis investigates how this blurring boundary impacts on consumers' construction of their self-narrative and found that consumers' narrative is paradoxically coherent and fragmented and depicts a heroic story of the self. Prior studies show consumers achieve their desired life story through meaningful consumption, however, the notion of fragmented lives are challenged. Further, extensive digital leisure consumption is often viewed in a less positive light. Nevertheless, consumers, who significantly consume digital leisure, do not disregard their physical world or favour one space over the other. Rather, they negotiate key aspects from their digital and physical lives and fluidly move between these two worlds, creating a hybrid narrative that saves their self and others.

The effect of a self-development coaching program on the psychological health and the academic performance among medical and dental students in Saudi Arabia

Observational studies have shown that medical and dental students have poor psychological health worldwide; however, few interventional studies have been used to test approaches to help students. This thesis used a randomised control trial study design to evaluate the effect of a self-development coaching program on psychological health and the academic performance among medical and dental students in Saudi Arabia. The outcomes indicated that these medical and dental students in Saudi Arabia experienced high levels of depression, anxiety and stress, and that the self-development coaching program was a promising intervention to improve students' psychological health.

Development and feasibility testing of an education program to improve knowledge and self-care among Aboriginal and Torres Strait Islander patients with heart failure

Background/Aim There is a 70% higher age-adjusted incidence of heart failure (HF) amongst Aboriginal and Torres Strait Islander people, three times more hospitalisations and twice as many deaths than non-Aboriginal people. There is a need to develop holistic yet individualised approaches in accord with the values of Aboriginal community healthcare to support patient education and self-care. The aim of this study was to re-design an existing HF educational resource (Fluid Watchers-Pacific Rim©) to be culturally safe for Aboriginal and Torres Strait Islander peoples, working in collaboration with the local community, and to conduct feasibility testing. Methods This study was conducted in two phases and utilised a mixed methods approach (qualitative and quantitative). Phase 1 of this study used action research methods to develop a culturally safe electronic resource to be provided to Aboriginal HF patients via a tablet computer. A HF expert panel adapted the existing resource to ensure it was evidence-based and contained appropriate language and images that reflects Aboriginal culture. A stakeholder group (which included Aboriginal workers and HF patients, as well as researchers and clinicians) then reviewed the resources and changes were made accordingly. In Phase 2, the new resource was tested on a sample of Aboriginal HF patients to assess feasibility and acceptability. Patient knowledge, satisfaction and self-care behaviours were measured using a before and after design with validated questionnaires. As this was a pilot test to determine feasibility, no statistical comparisons were made. Results - Phase 1: Throughout the process of resource development, two main themes emerged from the stakeholder consultation. These were the importance of identity, meaning that it was important to ensure that the resource accurately reflected the local community, with the appropriate clothing, skin tone and voice. The resource was adapted to reflect this and of the local community voiced the recordings for the resource. The other theme was comprehension; images were important and all text was converted to the first person and used plain language. - Phase 2: Five Aboriginal participants, mean age 61.6 ± 10.0 years, with NYHA Class III and IV heart failure were enrolled. Participants reported a high level of satisfaction with the resource (83.0%). HF knowledge (percentage of correct responses) increased from 48.0 ± 6.7% to 58.0 ± 9.7%, a 20.8% increase and results of the self-care index indicated that the biggest change was in patient confidence for self-care with a 95% increase in confidence score (46.7 ± 16.0 to 91.1 ± 11.5). Changes in management and maintenance scores varied between9275 patients. Conclusion By working in collaboration with HF experts, Aboriginal researchers and patients, a culturally safe HF resource has been developed for Aboriginal and Torres Strait Islander patients. Engaging Aboriginal researchers, capacity-building, and being responsive to local systems and structures enabled this pilot study to be successfully completed with the Aboriginal community and positive participant feedback demonstrated that the methodology used in this study was appropriate and acceptable; participants were able to engage with willingness and confidence.

The role of professional identity & self-interest in career choices in the emerging ICT workforce

The influence of professional identity and self-interest on the educational and career choices of the emerging Information and Communications Technology (ICT) workforce is considered in this thesis. Interviews were conducted with 52 ICT students from four Australian tertiary education institutions and the findings indicated that professional identity and self-interest should be considered together, rather than separately, to understand career decisions in relation to the ICT industry. Professional identity is associated with the accrual of symbolic resources including status and esteem, mastery, sense of belonging and attachment. By contrast, self-interest is associated with the perceived likelihood of the accrual of material (economic and social) resources.

Look-alike, sound-alike medication errors: A novel case concerning a Slow-Na, Slow-K prescribing error

A 59-year-old man was mistakenly prescribed Slow-Na instead of Slow-K due to incorrect selection from a drop-down list in the prescribing software. This error was identified by a pharmacist during a home medicine review (HMR) before the patient began taking the supplement. The reported error emphasizes the need for vigilance due to the emergence of novel look-alike, sound-alike (LASA) drug pairings. This case highlights the important role of pharmacists in medication safety.

Safe to crush? A pilot study into solid dosage form modification in aged care

Aims To observe medication solid dosage form modification in aged care facilities (ACFs), and assess staff levels of self-perceived knowledge of medication modification and the types of resources available to them. Method Observation of medication rounds in a convenience sample of Australian Capital Territory ACFs and assessment of staff knowledge of dosage form modification and available resources. Results From 160 observations across six medication rounds, 29 residents had a total of 75 medications modified by the nursing staff prior to administration, with 32% of these instances identified as inappropriate. The methods used for crushing and administration resulted in drug mixing, spillage and incomplete dosing. The staff reported adequate resources; however, a lack of knowledge on how to locate and use these resources was evident. Conclusions Improved staff training on how to use available resources is needed to reduce the observed high incidence of inappropriate medication crushing.

Algorithm of medication review in frail older people: Focus on minimizing the use of high-risk medications

Aim Frail older people typically suffer several chronic diseases, receive multiple medications and are more likely to be institutionalized in residential aged care facilities. In such patients, optimizing prescribing and avoiding use of high-risk medications might prevent adverse events. The present study aimed to develop a pragmatic, easily applied algorithm for medication review to help clinicians identify and discontinue potentially inappropriate high-risk medications. Methods The literature was searched for robust evidence of the association of adverse effects related to potentially inappropriate medications in older patients to identify high-risk medications. Prior research into the cessation of potentially inappropriate medications in older patients in different settings was synthesized into a four-step algorithm for incorporation into clinical assessment protocols for patients, particularly those in residential aged care facilities. Results The algorithm comprises several steps leading to individualized prescribing recommendations: (i) identify a high-risk medication; (ii) ascertain the current indications for the medication and assess their validity; (iii) assess if the drug is providing ongoing symptomatic benefit; and (iv) consider withdrawing, altering or continuing medications. Decision support resources were developed to complement the algorithm in ensuring a systematic and patient-centered approach to medication discontinuation. These include a comprehensive list of high-risk medications and the reasons for inappropriateness, lists of alternative treatments, and suggested medication withdrawal protocols. Conclusions The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes.

Prevalence of swallowing difficulties and medication modification in community pharmacy customers

Community pharmacies are in the prime position to provide information to patients who have difficulties swallowing medication.

Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities

Objective: In Australian residential aged care facilities (RACFs), the use of certain classes of high-risk medication such as antipsychotics, potent analgesics, and sedatives is high. Here, we examined the prescribed medications and subsequent changes recommended by geriatricians during comprehensive geriatric consultations provided to residents of RACFs via videoconference. Design: This is a prospective observational study. Setting: Four RACFs in Queensland, Australia, are included. Participants: A total of 153 residents referred by general practitioners for comprehensive assessment by geriatricians delivered by video-consultation. Results: Residents’ mean (standard deviation, SD) age was 83.0 (8.1) years and 64.1% were female. They had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean (SD) of 9.6 (4.2) regular medications. Ninety-one percent of patients were taking five or more medications daily. Of total medications prescribed (n=1,469), geriatricians recommended withdrawal of 9.8% (n=145) and dose alteration of 3.5% (n=51). New medications were initiated in 47.7% (n=73) patients. Of the 10.3% (n=151) medications considered as high risk, 17.2% were stopped and dose altered in 2.6%. Conclusion: There was a moderate prevalence of potentially inappropriate high-risk medications. However, geriatricians made relatively few changes, suggesting either that, on balance, prescription of these medications was appropriate or, because of other factors, there was a reluctance to adjust medications. A structured medication review using an algorithm for withdrawing medications of high disutility might help optimize medications in frail patients. Further research, including a broader survey, is required to understand these dynamics.