Prediction of psychological adjustment to multiple sclerosis

This study examined the utility of self-efficacy as a predictor of social activity and mood control in multiple sclerosis (MS). Seventy-one subjects with MS were recruited from people attending an MS centre or from a mailing list and were examined on two occasions that were two months apart. Clinic patients were more disabled than patients who completed assessments by post, but they were of higher socioeconomic status and were less dysphoric. We attempted to predict self-reported performance of mood control and social activity at two months, from self-efficacy or performance on these tasks at pretest. Demographic variables, disorder status, disability, self-esteem and depression were also allowed to compete for entry into multiple regressions. Substantial stability in mood, performance and disability was observed over the two months. In both mood control and social activity, past performance was the strongest predictor of later performance, but self-efficacy also contributed significantly to the prediction. The disability level entered a prediction of socila activity, but no other variables predicted either type of performance. A secondary analysis predicting self-esteem at two months also included self-efficacy for social activity, illustrating the contribution of perceived capability to later assessments of self-worth. The study provided support for self-efficacy as a predictor of later behavioural outcomes and self-esteem in multiple sclerosis.

Social adaptation of children with mild intellectual disability : effects of partial integration within primary school classes

Examined the social adaptation of 32 children in grades 3–6 with mild intellectual disability: 13 Ss were partially integrated into regular primary school classes and 19 Ss were full-time in separate classes. Sociometric status was assessed using best friend and play rating measures. Consistent with previous research, children with intellectual disability were less socially accepted than were a matched group of 32 children with no learning disabilities. Children in partially integrated classes received more play nominations than those in separate classes, but had no greater acceptance as a best friend. On teachers' reports, disabled children had higher levels of inappropriate social behaviours, but there was no significant difference in appropriate behaviours. Self-assessments by integrated children were more negative than those by children in separate classes, and their peer-relationship satisfaction was lower. Ratings by disabled children of their satisfaction with peer relationships were associated with ratings of appropriate social skills by themselves and their teachers, and with self-ratings of negative behaviour. The study confirmed that partial integration can have negative consequences for children with an intellectual disability.

Inclusive Education Statement - policy analysis

This study analyses the Inclusive Education Statement – 2005, Education Queensland. (Appendix 1). The Statement was a product of the Queensland State Government response to Federal Legislation. The Federal Disability Discrimination Act (DDA), 1992 and the subsequent Standards for Education 2005, sought to eliminate discrimination against people with disabilities. Under Section 22 of the Act, it became unlawful for an educational authority to discriminate against a person on the grounds of the person’s disability.

“I want to see the Queen” : experiences of service use by ageing people with an intellectual disability

People with intellectual disability are a relatively new but growing minority group within Australia's ageing population. Disability policies point to the equal right of people with disabilities to a quality of life similar to that of other citizens. Disability services are increasingly required to provide individualised and responsive services, irrespective of age, for people with lifelong disabilities. The present study explored the everyday lives of older people with intellectual disability in Victoria and Queensland, examining their experiences of using disability services and the ways in which services responded to their ageing. The aim of the study was to inform practice and service development for older people with intellectual disability. The findings suggest that services facilitate important social relationships with other service users and staff. Most older people had a sense of belonging and led busy but directionless lives in two disconnected worlds. Their lives were subject to significant external present-focused control. Yet, despite this, neither services nor family members took responsibility for ensuring their sense of continuity or supporting the development of plans about their future. The experiences described suggest an urgent need for, but significant challenges in the implementation of, holistic indivdualised planning similar to the UK concept of person-centred planning.

Rethinking the notion of culture in the national history curriculum

Major global changes are placing new demands on the Australian education system. Recent statements by the Prime Minister, together with current education policy and national curriculum documents available in the public domain, look to education’s role in promoting economic prosperity and social cohesion. Collectively, they emphasise the need to equip young Australians with the knowledge, understandings and skills required to compete in the global economy and participate as engaged citizens in a culturally diverse world. However, the decision to prioritise discipline-based learning in the forthcoming Australian history curriculum without specifically encompassing culture as a referent, raises the following question. How will students acquire the cultural knowledge, understandings and skills necessary for this process? This paper addresses this question by situating the current push for a national history curriculum, with specific reference to the study of Indigenous history and the study of Asia in Australia.

Celebrating difference/censoring difference? : Marie Chouinard’s bODY rEMIX

This paper examines performances that defy established representations of disease, deformity and bodily difference. Historically, the ‘deformed’ body has been cast – onstage and in sideshows – as flawed, an object of pity, or an example of the human capacity to overcome. Such representations define the boundaries of the ‘normal’ body by displaying its Other. They bracket the ‘abnormal’ body off as an example of deviance from the ‘norm’, thus, paradoxically, decreasing the social and symbolic visibility (and agency) of disabled people. Yet, in contemporary theory and culture, these representations are reappropriated – by disabled artists, certainly, but also as what Carrie Sandahl has called a ‘master trope’ for representing a range of bodily differences. In this paper, I investigate this phenomenon. I analyse French Canadian choreographer Marie Chouinard’s bODY rEMIX/gOLDBERG vARIATIONS, in which 10 able-bodied dancers are reborn as bizarre biotechnical mutants via the use of crutches, walkers, ballet shoes and barres as prosthetic pseudo-organs. These bodies defy boundaries, defy expectations, develop new modes of expression, and celebrate bodily difference. The self-inflicted pain dancers experience during training is cast as a ‘disablement’ that is ultimately ‘enabling’. I ask what effect encountering able bodies celebrating ‘dis’ or ‘diff’ ability has on audiences. Do we see the emergence of a once-repressed Other, no longer silenced, censored or negated? Or does using ‘disability’ to express the dancers’ difference and self-determination usurp a ‘trope’ by which disabled people themselves might speak back to the dominant culture, creating further censorship?

Duplicity/complicity : misperforming the social drama of disability

In this paper, I investigate the (mis)performance of ‘passing’ in the context of bodies with disabilities. The desire to conceal, control or contain a body’s idiosyncrasies can be a deceitful act, complicit with dominant cultural assumptions about the benefits of fitting in. Passing, and the performative tricks, techniques and prostheses that support the ‘lie’ of passing, upholding a social contract in which a closeting-as-cure approach accommodates discomfort with difference. In this paper, I consider moments of non-passing, where people are caught out by mistakes or deliberate misperformances of the daily social drama of ability and disability. I reference the work of disabled artists Bill Shannon, Aaron Williamson and Katherine Araniello, who re-perform their daily personal interactions in the public sphere as a sort of guerilla theatre. Their work brings hidden assumptions about how disabled people should act and interact to the brink of visibility. It challenges passers-by to confront their complicity in these discourses by pressing them to re-perform their own spontaneous reactions to bodies that misperform the ‘lie’ of normalcy.

An investigation into how work-related road safety can be enhanced

Despite the facts that vehicle incidents continue to be the most common mechanism for Australian compensated fatalities and that employers have statutory obligations to provide safe workplaces, very few organisations are proactively and comprehensively managing their work-related road risks. Unfortunately, limited guidance is provided in the existing literature to assist practitioners in managing work-related road risks. The current research addresses this gap in the literature. To explore how work-related road safety can be enhanced, three studies were conducted. Study one explored the effectiveness of a range of risk management initiatives and whether comprehensive risk management practices were associated with safety outcomes. Study two explored barriers to, and facilitators for, accepting risk management initiatives. Study three explored the influence of organisational factors on road safety outcomes to identify optimal work environments for managing road risks. To maximise the research sample and increase generalisability, the studies were designed to allow data collection to be conducted simultaneously drawing upon the same sample obtained from four Australian organisations. Data was collected via four methods. A structured document review of published articles was conducted to identify what outcomes have been observed in previously investigated work-related road safety initiatives. The documents reviewed collectively assessed the effectiveness of 19 work-related road safety initiatives. Audits of organisational practices and process operating within the four researched organisations were conducted to identify whether organisations with comprehensive work-related road risk management practices and processes have better safety outcomes than organisations with limited risk management practices and processes. Interviews were conducted with a sample of 24 participants, comprising 16 employees and eight managers. The interviews were conducted to identify what barriers and facilitators within organisations are involved in implementing work-related road safety initiatives and whether differences in fleet safety climate, stage of change and safety ownership relate to work-related road safety outcomes. Finally, questionnaires were administered to a sample of 679 participants. The questionnaires were conducted to identify which initiatives are perceived by employees to be effective in managing work-related road risks and whether differences in fleet safety climate, stage of change and safety ownership relate to work-related road safety outcomes. Seven research questions were addressed in the current research project. The key findings with respect to each of the research questions are presented below. Research question one: What outcomes have been observed in previously investigated work-related road safety initiatives? The structured document review indicated that initiatives found to be positively associated with occupational road safety both during and after the intervention period included: a pay rise; driver training; group discussions; enlisting employees as community road safety change agents; safety reminders; and group and individual rewards. Research question two: Which initiatives are perceived by employees to be effective in managing work-related road risks? Questionnaire findings revealed that employees believed occupational road risks could best be managed through making vehicle safety features standard, providing practical driver skills training and through investigating serious vehicle incidents. In comparison, employees believed initiatives including signing a promise card commitment to drive safely, advertising the organisation’s phone number on vehicles and consideration of driving competency in staff selection process would have limited effectiveness in managing occupational road safety. Research question three: Do organisations with comprehensive work-related road risk management practices and processes have better safety outcomes than organisations with limited risk management practices and processes? The audit identified a difference among the organisations in their management of work-related road risks. Comprehensive risk management practices were associated with employees engaging in overall safer driving behaviours, committing less driving errors, and experiencing less fatigue and distraction issues when driving. Given that only four organisations participated in this research, these findings should only be considered as preliminary. Further research should be conducted to explore the relationship between comprehensiveness of risk management practices and road safety outcomes with a larger sample of organisations. Research question four: What barriers and facilitators within organisations are involved in implementing work-related road safety initiatives? The interviews identified that employees perceived six organisational characteristics as potential barriers to implementing work-related road safety initiatives. These included: prioritisation of production over safety; complacency towards work-related road risks; insufficient resources; diversity; limited employee input in safety decisions; and a perception that road safety initiatives were an unnecessary burden. In comparison, employees perceived three organisational characteristics as potential facilitators to implementing work-related road safety initiatives. These included: management commitment; the presence of existing systems that could support the implementation of initiatives; and supportive relationships. Research question five: Do differences in fleet safety climate relate to work-related road safety outcomes? The interviews and questionnaires identified that organisational climates with high management commitment, support for managing work demands, appropriate safety rules and safety communication were associated with employees who engaged in safer driving behaviours. Regression analyses indicated that as participants’ perceptions of safety climate increased, the corresponding likelihood of them engaging in safer driving behaviours increased. Fleet safety climate was perceived to influence road safety outcomes through several avenues. Some of these included: the allocation of sufficient resources to manage occupational road risks; fostering a supportive environment of mutual responsibility; resolving safety issues openly and fairly; clearly communicating to employees that safety is the top priority; and developing appropriate work-related road safety policies and procedures. Research question six: Do differences in stage of change relate to work-related road safety outcomes? The interviews and questionnaires identified that participants’ perceptions of initiative effectiveness were found to vary with respect to their individual stage of readiness, with stage-matched initiatives being perceived most effective. In regards to safety outcomes, regression analyses identified that as participants’ progress through the stages of change, the corresponding likelihood of them being involved in vehicle crashes decreases. Research question seven: Do differences in safety ownership relate to work-related road safety outcomes? The interviews and questionnaires revealed that management of road risks is often given less attention than other areas of health and safety management in organisations. In regards to safety outcomes, regression analyses identified that perceived authority and perceived shared ownership both emerged as significant independent predictors of self-reported driving behaviours pertaining to fatigue and distractions. The regression models indicated that as participants’ perceptions of the authority of the person managing road risks increases, and perceptions of shared ownership of safety tasks increases, the corresponding likelihood of them engaging in driving while fatigued or multitasking while driving decreases. Based on the findings from the current research, the author makes several recommendations to assist practitioners in developing proactive and comprehensive approaches to managing occupational road risks. The author also suggests several avenues for future research in the area of work-related road safety.

Ecological perspectives and wellness

Since the industrial revolution, the development of a lifestyle lived predominantly indoors has resulted in less contact with nature. Research over the last twenty years has gradually been identifying the human health benefits attributed to re-connecting with the natural environment. The significance of feeling connected to natural environments, families and friends are described as a foundational requirement for human health and wellbeing (Maller et al., 2008). Also, the early findings of Schultz‟s (2002) work indicated that by feeling connected to the natural world a person is more likely to be committed to positively interact with and protect the natural world. Research on young people has indicated that young people are even more disconnected from the natural world. Leading some writers to call this disconnection a crisis termed “Nature Deficit Disorder.” Participants (n = 131) from 1st year university Physical Education and Human Movement Studies were asked to complete two questionnaires the Connectedness to Nature scale (CNS) (Mayer & Frantz, 2004) and the New Ecological Paradigm Scale (NEP) (Dunlap, Van Liere, Mertig, & Jones, 2000). The NEP and CNS are two scales most commonly used to explore beliefs and feelings of connectedness to the natural world (Schultz, 2002). The NEP was developed over thirty years ago by Dunlap and Van Liere (1978) and originally termed the New Environmental Paradigm. The NEP is now the foremost International tool for measuring beliefs about the natural world (Dunlap, 2008). The CNS measures an individual‟s trait levels of emotional connection to the natural world. It is a relatively new tool for understanding ecological behaviour based on ecopsychology theory and employed to predict behaviour (Mayer and Frantz, 2004). Both questionnaires are based on a 1-5 scale (Strongly disagree to Strongly agree). By combing both scales the researchers aim to develop a snap shot of beliefs and emotional feelings towards the natural world and therefore an idea of intended behaviour. The two questionnaires were combined as one online survey with additional material asking for demographics and self assessments of type of leader included before the surveys. An email inviting outdoor leaders to participate was sent out to networks and interest groups. A basic descriptive statistical analysis was used to interpret data.

The nature and extent of policing alcohol related crime and reducing violence in and around late night entertainment areas

The misuse of alcohol is well documented in Australia and has been associated with disorders and harms that often require police attention. The extent of alcohol-related incidents requiring police attention has been recorded as substantial in some Australian cities (Arro, Crook, & Fenton, 1992; Davey & French, 1995; Ireland & Thommeny, 1993). A significant proportion of harmful drinking occurs in and around licensed premises (Jochelson, 1997; Stockwell, Masters, Phillips, Daly, Gahegan, Midford, & Philp, 1998; Borges, Cherpitel, & Rosovsky, 1998) and most of these incidents are not reported to police (Bryant & Williams, 2000; Lister, Hobbs, Hall, & Winlow, 2000). Alcohol-related incidents have also been found to be concentrated in certain places at certain times (Jochelson, 1997) and therefore manipulating the context in which these incidents occur may provide a means to prevent and reduce the harm associated with alcohol misuse. One of the major objectives of the present program of research was to investigate the occurrence and resource impact of alcohol-related incidents on operational (general duties) policing across a large geographical area. A second objective of the thesis was to examine the characteristics and temporal/spatial dynamics of police attended alcohol incidents in the context of Place Based theories of crime. It was envisaged that this approach would reveal the patterns of the most prevalent offences and demonstrate the relevance of Place Based theories of crime to understanding these patterns. In addition, the role of alcohol, time and place were also explored in order to examine the association between non criminal traffic offences and other types of criminal offences. A final objective of the thesis was to examine the impact of a situational crime prevention strategy that had been initiated to reduce the violence and disorder associated with late-night liquor trading premises. The program of research in this doctorate thesis has been undertaken through the presentation of published papers. The research was conducted in three stages which produced six manuscripts, five of which were submitted to peer reviewed journals and one that was published in a peer reviewed conference proceedings. Stage One included two studies (Studies 1 & 2) both of which involved a cross sectional approach to examine the prevalence and characteristics of alcohol-related incidents requiring police attendance across three large geographical areas that included metropolitan cities, provincial regions and rural areas. Stage Two of the program of research also comprised two cross sectional quantitative studies (Studies 3 & 4) that investigated the temporal and spatial dynamics of the major offence categories attended by operational police in a specific Police District (Gold Coast). Stage Three of the program of research involved two studies (Studies 5 & 6) that assessed the effectiveness of a situational crime prevention strategy. The studies employed a pre-post design to assess the impact on crime, disorder and violence by preventing patrons from entering late-night liquor trading premises between 3 a.m. and 5 a.m. (lockout policy). Although Study Five was solely quantitative in nature, Study Six included both quantitative and qualitative aspects. The approach adopted in Study Six, therefore facilitated not only a quantative comparison of the impact of the lockout policy on different policing areas, but also enabled the processes related to the implementation of the lockout policy to be examined. The thesis reports a program of research involving a common data collection method which then involved a series of studies being conducted to explore different aspects of the data. The data was collected from three sources. Firstly a pilot phase was undertaken to provide participants with training. Secondly a main study period was undertaken immediately following the pilot phase. The first and second sources of data were collected between 29th March 2004 and 2nd May 2004. Thirdly, additional data was collected between the 1st April 2005 and 31st May 2005. Participants in the current program of research were first response operational police officers who completed a modified activity log over a 9 week period (4 week pilot phase & 5 week survey study phase), identifying the type, prevalence and characteristics of alcohol-related incidents that were attended. During the study period police officers attended 31,090 alcohol-related incidents. Studies One and Two revealed that a substantial proportion of current police work involves attendance at alcohol-related incidents (i.e., 25% largely involving young males aged between 17 and 24 years). The most common incidents police attended were vehicle and/or traffic matters, disturbances and offences against property. The major category of offences most likely to involve alcohol included vehicle/traffic matters, disturbances and offences against the person (e.g., common & serious assaults). These events were most likely to occur in the late evenings and early hours of the morning on the weekends, and importantly, usually took longer for police to complete than non alcohol-related incidents. The findings in Studies Three and Four suggest that serious traffic offences, disturbances and offences against the person share similar characteristics and occur in concentrated places at similar times. In addition, it was found that time, place and incident type all have an influence on whether an incident attended by a police officer is alcohol-related. Alcohol-related incidents are more likely to occur in particular locations in the late evenings and early mornings on the weekends. In particular, there was a strong association between the occurrence of alcohol-related disturbances and alcohol-related serious traffic offences in regards to place and time. In general, stealing and property offences were not alcohol-related and occurred in daylight hours during weekdays. The results of Studies Five and Six were mixed. A number of alcohol-related offences requiring police attention were significantly reduced for some policing areas and for some types of offences following the implementation of the lockout policy. However, in some locations the lockout policy appeared to have a negative or minimal impact. Interviews with licensees revealed that although all were initially opposed to the lockout policy as they believed it would have a negative impact on business, most perceived some benefits from its introduction. Some of the benefits included, improved patron safety and the development of better business strategies to increase patron numbers. In conclusion, the overall findings of the six studies highlight the pervasive nature of alcohol across a range of criminal incidents, demonstrating the tremendous impact alcohol-related incidents have on police. The findings also demonstrate the importance of time and place in predicting the occurrence of alcohol-related offences. Although this program of research did not set out to test Place Based theories of crime, these theories were used to inform the interpretation of findings. The findings in the current research program provide evidence for the relevance of Place Based theories of crime to understanding the factors contributing to violence and disorder, and designing relevant crime prevention strategies. For instance, the results in Studies Five and Six provide supportive evidence that this novel lockout initiative can be beneficial for public safety by reducing some types of offences in particular areas in and around late-night liquor trading premises. Finally, intelligent-led policing initiatives based on problem oriented policing, such as the lockout policy examined in this thesis, have potential as a major crime prevention technique to reduce specific types of alcohol-related offences.

A phenomenological study of contemplative experiences : implications for interior design

This research reports on a project concerned with the relationship between the person and the environment in the context of achieving a contemplative or existential state – a state which can be experienced either consciously or subconsciously. The need for such a study originated with the desire to contribute to the design of multicultural spaces which could be used for a range of activities within the public and the personal arena, activities including contemplation, meditation and prayer. The concept of ‘sacred’ is explored in the literature review and in primary interviews with the participants of this study. Given that the word ‘sacred’ is highly value-laden and potentially alienating for some people, it was decided to use the more accessible term ‘contemplative’. The outcomes of the study inform the practice of interior design and architecture which tends currently to neglect the potential for all spaces to be existentially meaningful. Informed by phenomenological methodology, data were collected from a diverse group of people, using photo-elicitation and interviews. The technique of photo-elicitation proved to be highly effective in helping people reveal their everyday lived experience of contemplative spaces. Reflective analysis (Van Manen 2000) was used to explore the data collected. The initial stage of analysis produced three categories of data: varying conceptions of contemplation, aspects of the person involved in the contemplation, and aspects of environment involved in contemplation. From this, it was found that achieving a state of contemplation involves both the person and the environment in a dialectic process of unfolding. The unfolding has various physical, psycho-social, and existential dimensions or qualities which operate sequentially and simultaneously. Two concepts emerged as being central to unfolding: ‘Cleansing’ and ‘Nothingness’. Unfolding is found to comprise the Core; Distinction; Manifestation; Cleansing; Creation; and Sharing. This has a parallel with Mircea Eliade’s (1959) definition of sacred as something that manifests itself as different from the profane. The power of design, re-contextualization through utility and purpose, and the existential engagements between the person and environment are used as a basis for establishing the potential contribution of the study to interior design. In this way, the study makes a contribution to our understanding of how space and its elements inspire, support and sustain person environment interaction – particularly at the existential level – as well as to our understanding of the multi-dimensional and holistic nature of this interaction. In addition, it points to the need for a phenomenological re-conceptualisation of the design/client relationship. In summary, the contributions of this research are: the exploration of contemplative experience as sacred experience; an understanding of the design of space as creating engagement between person and environment; a rationale for the introduction of a phenomenological approach to the relationship between designer and clients; and raising awareness of the spiritual in a holistic approach to design.

Age-related maculopathy : linking aetiology and pathophysiological changes to the ischaemia hypothesis

Age-related maculopathy (ARM) has remained a challenging topic with respect to its aetiology, pathomechanisms, early detection and treatment since the late 19th century when it was first described as its own entity. ARM was previously considered an inflammatory disease, a degenerative disease, a tumor and as the result of choroidal hemodynamic disturbances and ischaemia. The latter processes have been repeatedly suggested to have a key role in its development and progression. In vivo experiments under hypoxic conditions could be models for the ischaemic deficits in ARM. Recent research has also linked ARM with gene polymorphisms. It is however unclear what triggers a person's gene susceptibility. In this manuscript, a linking hypothesis between aetiological factors including ischaemia and genetics and the development of early clinicopathological changes in ARM is proposed. New clinical psychophysical and electrophysiological tests are introduced that can detect ARM at an early stage. Models of early ARM based upon hemodynamic, photoreceptor and post-receptoral deficits are described and the mechanisms by which ischaemia may be involved as a final common pathway are considered. In neovascular age-related macular degeneration (neovascular AMD), ischaemia is thought to promote release of vascular endothelial growth factor (VEGF) which induces chorioretinal neovascularisation. VEGF is critical in the maintenance of the healthy choriocapillaris. In the final section of the manuscript the documentation of the effect of new anti-VEGF treatments on retinal function in neovascular AMD is critically viewed.

Remote interaction and user research : anaesthetic preadmission activity

In the absence of telehealth technology, rural patients must travel to a regional or metropolitan hospital for a preadmission consultation one week before their surgery. Currently, examination of the patient’s chest using a stethoscope (auscultation) is not possible over a telehealth network as existing digital stethoscopes have been designed for in-person auscultation. We report on the initial phase of research which ultimately aims to design a digital stethoscope for use in the telehealth context. This initial research phase describes the complexity of the activity of preadmission clinics and the implications for the design of the stethoscope. The research is conducted through field studies of existing face-to-face and remote consultations.

Confidence to cook vegetables and the buying habits of Australian households

Cooking skills are emphasized in nutrition promotion but their distribution among population subgroups and relationship to dietary behavior is researched by few population-based studies. This study examined the relationships between confidence to cook, sociodemographic characteristics, and household vegetable purchasing. This cross-sectional study of 426 randomly selected households in Brisbane, Australia, used a validated questionnaire to assess household vegetable purchasing habits and the confidence to cook of the person who most often prepares food for these households. The mutually adjusted odds ratios (ORs) of lacking confidence to cook were assessed across a range of demographic subgroups using multiple logistic regression models. Similarly, mutually adjusted mean vegetable purchasing scores were calculated using multiple linear regression for different population groups and for respondents with varying confidence levels. Lacking confidence to cook using a variety of techniques was more common among respondents with less education (OR 3.30; 95% confidence interval [CI] 1.01 to 10.75) and was less common among respondents who lived with minors (OR 0.22; 95% CI 0.09 to 0.53) and other adults (OR 0.43; 95% CI 0.24 to 0.78). Lack of confidence to prepare vegetables was associated with being male (OR 2.25; 95% CI 1.24 to 4.08), low education (OR 6.60; 95% CI 2.08 to 20.91), lower household income (OR 2.98; 95% CI 1.02 to 8.72) and living with other adults (OR 0.53; 95% CI 0.29 to 0.98). Households bought a greater variety of vegetables on a regular basis when the main chef was confident to prepare them (difference: 18.60; 95% CI 14.66 to 22.54), older (difference: 8.69; 95% CI 4.92 to 12.47), lived with at least one other adult (difference: 5.47; 95% CI 2.82 to 8.12) or at least one minor (difference: 2.86; 95% CI 0.17 to 5.55). Cooking skills may contribute to socioeconomic dietary differences, and may be a useful strategy for promoting fruit and vegetable consumption, particularly among socioeconomically disadvantaged groups.

New insights into appetite, inflammation and the use of fish oil in hemodialysis patients

Protein-energy wasting (PEW) is commonly seen in patients with chronic kidney disease (CKD). The condition is characterised by chronic, systemic low-grade inflammation which affects nutritional status by a variety of mechanisms including reducing appetite and food intake and increasing muscle catabolism. PEW is linked with co-morbidities such as cardiovascular disease, and is associated with lower quality of life, increased hospitalisations and a 6-fold increase in risk of death1. Significant gender differences have been found in the severity and effects of several markers of PEW. There have been limited studies testing the ability of anti-inflammatory agents or nutritional interventions to reduce the effects of PEW in dialysis patients. This thesis makes a significant contribution to the understanding of PEW in dialysis patients. It advances understanding of measurement techniques for two of the key components, appetite and inflammation, and explores the effect of fish oil, an anti-inflammatory agent, on markers of PEW in dialysis patients. The first part of the thesis consists of two methodological studies conducted using baseline data. The first study aims to validate retrospective ratings of hunger, desire to eat and fullness on visual analog scales (VAS) (paper and pen and electronic) as a new method of measuring appetite in dialysis patients. The second methodological study aims to assess the ability of a variety of methods available in routine practice to detect the presence of inflammation. The second part of the thesis aims to explore the effect of 12 weeks supplementation with 2g per day of Eicosapentaenoic Acid (EPA), a longchain fatty acid found in fish oil, on markers of PEW. A combination of biomarkers and psychomarkers of appetite and inflammation are the main outcomes being explored, with nutritional status, dietary intake and quality of life included as secondary outcomes. A lead in phase of 3 months prior to baseline was used so that each person acts as their own historical control. The study also examines whether there are gender differences in response to the treatment. Being an exploratory study, an important part of the work is to test the feasibility of the intervention, thus the level of adherence and factors associated with adherence are also presented. The studies were conducted at the hemodialysis unit of the Wesley Hospital. Participants met the following criteria: adult, stage 5 CKD on hemodialysis for at least 3 months, not expected to receive a transplant or switch to another dialysis modality during the study, absence of intellectual impairment or mental illness impairing ability to follow instructions or complete the intervention. A range of intermediate, clinical and patient-centred outcome measures were collected at baseline and 12 weeks. Inflammation was measured using five biomarkers: c-reactive protein (CRP), interleukin-6 (IL6), intercellular adhesion molecule (sICAM-1), vascular cell adhesion molecule (sVCAM-1) and white cell count (WCC). Subjective appetite was measured using the first question from the Appetite and Dietary Assessment (ADAT) tool and VAS for measurements of hunger, desire to eat and fullness. A novel feature of the study was the assessment of the appetite peptides leptin, ghrelin and peptide YY as biomarkers of appetite. Nutritional status/inflammation was assessed using the Malnutrition-Inflammation Score (MIS) and the Patient-Generated Subjective Global Assessment (PG-SGA). Dietary intake was measured using 3-day records. Quality of life was measured using the Kidney Disease Quality of Life Short Form version 1.3 (KDQOL-SF™ v1.3 © RAND University), which combines the Short-Form 36 (SF36) with a kidney-disease specific module2. A smaller range of these variables was available for analysis during the control phase (CRP, ADAT, dietary intake and nutritional status). Statistical analysis was carried out using SPSS version 14 (SPSS Inc, Chicago IL, USA). Analysis of the first part of the thesis involved descriptive and bivariate statistics, as well as Bland-Altman plots to assess agreement between methods, and sensitivity analysis/ROC curves to test the ability of methods to predict the presence of inflammation. The unadjusted (paired ttests) and adjusted (linear mixed model) change over time is presented for the main outcome variables of inflammation and appetite. Results are shown for the whole group followed by analyses according to gender and adherence to treatment. Due to the exploratory nature of the study, trends and clinical significance were considered as important as statistical significance. Twenty-eight patients (mean age 61±17y, 50% male, dialysis vintage 19.5 (4- 101) months) underwent baseline assessment. Seven out of 28 patients (25%) reported sub-optimal appetite (self-reported as fair, poor or very poor) despite all being well nourished (100% SGA A). Using the VAS, ratings of hunger, but not desire to eat or fullness, were significantly (p<0.05) associated with a range of relevant clinical variables including age (r=-0.376), comorbidities (r=-0.380) nutritional status (PG-SGA score, r=-0.451), inflammatory markers (CRP r=-0.383; sICAM-1 r=-0.387) and seven domains of quality of life. Patients expressed a preference for the paper and pen method of administering VAS. None of the tools (appetite, MIS, PG-SGA, albumin or iron) showed an acceptable ability to detect patients who are inflamed. It is recommended that CRP should be tested more frequently as a matter of course rather than seeking alternative methods of measuring inflammation. 27 patients completed the 12 week intervention. 20 patients were considered adherent based on changes in % plasma EPA, which rose from 1.3 (0.94)% to 5.2 (1.1)%, p<0.001, in this group. The major barriers to adherence were forgetting to take the tablets as well as their size. At 12 weeks, inflammatory markers remained steady apart from the white cell count which decreased (7.6(2.5) vs 7.0(2.2) x109/L, p=0.058) and sVCAM-1 which increased (1685(654) vs 2249(925) ng/mL, p=0.001). Subjective appetite using VAS increased (51mm to 57mm, +12%) and there was a trend towards reduction in peptide YY (660(31) vs 600(30) pg/mL, p=0.078). There were some gender differences apparent, with the following adjusted change between baseline and week 12: CRP (males -3% vs females +17%, p=0.19), IL6 (males +17% vs females +48%, p=0.77), sICAM-1 (males -5% vs females +11%, p=0.07), sVCAM-1 (males +54% vs females +19%, p=0.08) and hunger ratings (males 20% vs females -5%, p=0.18). On balance, males experienced a maintainence or reduction in three inflammatory markers and an improvement in hunger ratings, and therefore appeared to have responded better to the intervention. Compared to those who didn’t adhere, adherent patients maintained weight (mean(SE) change: +0.5(1.6) vs - 0.8(1.2) kg, p=0.052) and fat-free mass (-0.1 (1.6) vs -1.8 (1.8) kg, p=0.045). There was no difference in change between the intervention and control phase for CRP, appetite, nutritional status or dietary intake. The thesis makes a significant contribution to the evidence base for understanding of PEW in dialysis patients. It has advanced knowledge of methods of assessing inflammation and appetite. Retrospective ratings of hunger on a VAS appear to be a valid method of assessing appetite although samples which include patients with very poor appetite are required to confirm this. Supplementation with fish oil appeared to improve subjective appetite and dampen the inflammatory response. The effectiveness of the intervention is influenced by gender and adherence. Males appear to be more responsive to the primary outcome variables than females, and the quality of response is improved with better adherence. These results provide evidence to support future interventions aimed at reducing the effects of PEW in dialysis patients.