A nurse managed kidney disease program in regional and remote Australia

Health services that aim to prevent and manage chronic kidney disease (CKD) in rural and remote Aboriginal communities in Australia, including the Goldfields region of Western Australia (WA), require innovative approaches. Nursing roles can significantly improve access to renal services in rural and remote areas as they are able to address a range of renal health promotion and prevention activities, and provide renal clinical education and support to Aboriginal people. The Goldfields Kidney Disease Nursing Management Program (GKDNMP), funded through the Council of Australian Governments (COAG) National Partnership Agreements, was developed to provide a comprehensive approach to primary health care that incorporates a range of health promotion and disease management activities. In the first year, the program increased home dialysis rates and decreased patient travel due to expanded access to renal care within the region. Context-specific health programs generated in response to local needs can be successful in addressing specific health care challenges in rural and remote health.

Measurement issues in the evaluation of chronic disease self-management programs

Objectives: 

The Melbourne Diabetes Prevention Study (MDPS) : study protocol for a randomized controlled trial

Background
Worldwide, type 2 diabetes (T2DM) prevalence has more than doubled over two decades. In Australia, diabetes is the second highest contributor to the burden of disease. Lifestyle modification programs comprising diet changes, weight loss and moderate physical activity, have been proven to reduce the incidence of T2DM in high risk individuals.

As part of the Council of Australia Governments, the State of Victoria committed to develop and support the diabetes prevention program ‘Life! Taking action on diabetes’ (Life!) which has direct lineage from effective clinical and implementation trials from Finland and Australia. The Melbourne Diabetes Prevention Study (MDPS) has been set up to evaluate the effectiveness and cost-effectiveness of a specific version of the Life! program.

Methods/design
We intend to recruit 796 participants for this open randomized clinical trial; 398 will be allocated to the intervention arm and 398 to the usual care arm. Several methods of recruitment will be used in order to maximize the number of participants. Individuals aged 50 to 75 years will be screened with a risk tool (AUSDRISK) to detect those at high risk of developing T2DM. Those with existing diabetes will be excluded. Intervention participants will undergo anthropometric and laboratory tests, and comprehensive surveys at baseline, following the fourth group session (approximately three months after the commencement of the intervention) and 12 months after commencement of the intervention, while control participants will undergo testing at baseline and 12 months only.

The intervention consists of an initial individual session followed by a series of five structured-group sessions. The first four group sessions will be carried out at two week intervals and the fifth session will occur eight months after the first group session. The intervention is based on the Health Action Process Approach (HAPA) model and sessions will empower and enable the participants to follow the five goals of the Life! program.

Discussion
This study will determine whether the effect of this intervention is larger than the effect of usual care in reducing central obesity and cardiovascular risk factors and thus the risk of developing diabetes and cardiovascular disease. Also it will evaluate how these two options compare economically.

Protocol for a home-based integrated physical therapy program to reduce falls and improve mobility in people with Parkinson’s disease

Background The high incidence of falls associated with Parkinson’s disease (PD) increases the risk of injuries and immobility and compromises quality of life. Although falls education and strengthening programs have shown some benefit in healthy older people, the ability of physical therapy interventions in home settings to reduce falls and improve mobility in people with Parkinson’s has not been convincingly demonstrated.
Methods/design 180 community living people with PD will be randomly allocated to receive either a home-based integrated rehabilitation program (progressive resistance strength training, movement strategy training and falls education) or a home-based life skills program (control intervention). Both programs comprise one hour of treatment and one hour of structured homework per week over six weeks of home therapy. Blinded assessments occurring before therapy commences, the week after completion of therapy and 12 months following intervention will establish both the immediate and long-term benefits of home-based rehabilitation. The number of falls, number of repeat falls, falls rate and time to first fall will be the primary measures used to quantify outcome. The economic costs associated with injurious falls, and the costs of running the integrated rehabilitation program from a health system perspective will be established. The effects of intervention on motor and global disability and on quality of life will also be examined.
Discussion This study will provide new evidence on the outcomes and cost effectiveness of home-based movement rehabilitation programs for people living with PD.

Psychosocial risk factors for coronary heart disease: a consensus statement from the National Heart Foundation of Australia

In 2003, the National Heart Foundation of Australia published a position statement on psychosocial risk factors and coronary heart disease (CHD). This consensus statement provides an updated review of the literature on psychosocial stressors, including chronic stressors (in particular, work stress), acute individual stressors and acute population stressors, to guide health professionals based on current evidence. It complements a separate updated statement on depression and CHD.

Perceived chronic job strain and shift work are associated with a small absolute increased risk of developing CHD, but there is limited evidence regarding their effect on the prognosis of CHD. Evidence regarding a relationship between CHD and job (in)security, job satisfaction, working hours, effort-reward imbalance and job loss is inconclusive.

Expert consensus is that workplace programs aimed at weight loss, exercise and other standard cardiovascular risk factors may have positive outcomes for these risk factors, but no evidence is available regarding the effect of such programs on the development of CHD.

Social isolation after myocardial infarction (MI) is associated with an adverse prognosis. Expert consensus is that although measures to reduce social isolation are likely to produce positive psychosocial effects, it is unclear whether this would also improve CHD outcomes. Acute emotional stress may trigger MI or takotsubo ("stress") cardiomyopathy, but the absolute increase in transient risk from an individual stressor is low. Psychosocial stressors have an impact on CHD, but clinical significance and prevention require further study.

Awareness of the potential for increased cardiovascular risk among populations exposed to natural disasters and other conditions of extreme stress may be useful for emergency services response planning. Wider public access to defibrillators should be available where large populations gather, such as sporting venues and airports, and as part of the response to natural and other disasters.

The Healthy Migrant Families Initiative: Development of a culturally competent obesity prevention intervention for African migrants Disease epidemiology - Chronic

Background: Although obesity among immigrants remains an important area of study given the increasing migrant population in Australia and other developed countries, research on factors amenable to intervention is sparse. The aim of the study was to develop a culturally-competent obesity prevention program for sub-Saharan African (SSA) families with children aged 12-17 years using a community-partnered participatory approach. Methods: A community-partnered participatory approach that allowed the intervention to be developed in collaborative partnership with communities was used. Three pilot studies were carried out in 2008 and 2009 which included focus groups, interviews, and workshops with SSA parents, teenagers and health professionals, and emerging themes were used to inform the intervention content. A cultural competence framework containing 10 strategies was developed to inform the development of the program. Using findings from our scoping research, together with community consultations through the African Review Panel, a draft program outline (skeleton) was developed and presented in two separate community forums with SSA community members and health professionals working with SSA communities in Melbourne. Results: The 'Healthy Migrant Families Initiative (HMFI): Challenges and Choices' program was developed and designed to assist African families in their transition to life in a new country. The program consists of nine sessions, each approximately 1 1/2 hours in length, which are divided into two modules based on the topic. The first module 'Healthy lifestyles in a new culture' (5 sessions) focuses on healthy eating, active living and healthy body weight. The second module 'Healthy families in a new culture' (4 sessions) focuses on parenting, communication and problem solving. The sessions are designed for a group setting (6-12 people per group), as many of the program activities are discussion-based, supported by session materials and program resources. Conclusion: Strong partnerships and participation by SSA migrant communities enabled the design of a culturally competent and evidence-based intervention that addresses obesity prevention through a focus on healthy lifestyles and healthy families. Program implementation and evaluation will further inform obesity prevention interventions for ethnic minorities and disadvantaged communities.

Diabetes prevention research: a systematic review of external validity in lifestyle interventions

Context

Type 2 diabetes is a major contributor to disease burden globally. A number of systematic reviews support the efficacy of lifestyle interventions in preventing Type 2 diabetes in adults; however, relatively little attention has been paid to the generalizability of study findings. This study systematically reviews the reporting of external validity components and generalizability of diabetes prevention studies.

Evidence acquisition

Lifestyle intervention studies for the prevention of Type 2 diabetes in adults with at least 6 months' follow-up, published between 1990 and 2011, were identified through searches of major electronic databases. External validity reporting was rated using an assessment tool, and all analysis was undertaken in 2011.

Evidence synthesis

A total of 31 primary studies (n=95 papers) met the selection criteria. All studies lacked full reporting on external validity elements. Description of the study sample, intervention, delivery agents, and participant attrition rates were reported by most studies. However, few studies reported on the representativeness of individuals and settings, methods for recruiting settings and delivery agents, costs, and how interventions could be institutionalized into routine service delivery. It is uncertain to what extent the findings of diabetes prevention studies apply to men, socioeconomically disadvantaged individuals, those living in rural and remote communities, and to low- and middle-income countries.

Conclusions

Reporting of external validity components in diabetes prevention studies needs to be enhanced to improve the evidence base for the translation and dissemination of these programs into policy and practice.

Migratory implications for coronary heart disease risk prevention in Asian Indians: Evidence from the leading health indicators.

OBJECTIVEctives of this descriptive comparative study were to (1) review data obtained from the World Health Organisation Statistical Information System (WHOSIS) database relating to the prevalence of risk factors for coronary heart disease (CHD) among Indians and Australians and (2) compare these data with published epidemiological studies of CHD riskfactors in adult migrant Asian Indians to provide a comprehensive and comparable assessment of risk factors relating to CHD and the mortality attributable to these risk factors. Design: ThDESIGNdy was undertaken using a database search and integrative review methodology. Data were obtained for comparison of CHD risk factors between Indians and Australians using the WHOSIS database. For the integrative review the MEDLINE, CINAHL, EMBASE, and Cochrane databases were searched using the keywords 'Migrants', 'Asian Indian', 'India', 'Migration', 'Immigration', 'Risk factors', and coronary heart disease. Two reviewers independently assessed the eligibility of the studies for inclusion in the review, the methodological quality and extracted details of eligible studies. Results from the integrative review on CHD risk factors in Asian Indians are presented in a narrative format, along with results from the WHOSIS database. Results: TRESULTSadjusted mortality for CHD was four times higher in migrant Asian Indians when compared to both the native population of the host country and migrants from other countries. Similarly when compared to migrants from other countries migrant Asian Indians had the highest prevalence of overweight individuals. Prevalence rates for hypercholesterolemia were up to 18.5 % among mgrant Asian Indians and migrant Asian Indian women had a higher prevalence of hypertriglyceridaemia compared to Caucasian females. Migrant Asian Indians also had a higher incidence of hypertension and upto 71 % of migrnt Asian Indian men did not meet current guidelines for participation in physical activity. Ethnic-specific prevalence of diabetes ranged from 6-7% among the normal weight to 19-33% among the obese migrant Asian Indians compared with non-Hispanic whites. ConclusionCONCLUSIONAsian Indians have an increased risk of CHD. Culturally sensitive strategies that recognise the effects of migration and extend beyond the health sector should be developed to target lifestyle changes in this high risk population.

Eight month post program completion: change in risk factors for chronic disease amongst participants in a four-month pedometer workplace health program

Objective: To evaluate whether participation in a 4-month, pedometer-based, physical activity, workplace health program is associated with long-term sustained improvements in risk factors for type 2 diabetesand cardiovascular disease, 8 months after the completion of the program.Design and Methods: A sample size of 720 was required. 762 Australian adults employed in primarily sedentary occupations and voluntarily enrolled in a workplace program were recruited. Demographic, behavioral, anthropometric and biomedical measurements were completed at baseline, 4 and 12 months.Results: About 76% of participants returned at 12 months. Sustained improvements at 12 months were observed for self-reported vegetable intake, self-reported sitting time and independently measured bloodpressure. Modest improvements from baseline in self-reported physical activity and independently measured waist circumference at 12 months indicated that the significant improvements observed immediately after the health program could not be sustained. Approximately half of those not meetingguidelines for physical activity, waist circumference and blood pressure at baseline, were meeting guidelines at 12 months.Conclusions: Participation in this 4-month, pedometer-based, physical activity, workplace health program was associated with sustained improvements in chronic disease risk factors at 12 months. These results indicate that such programs can have a long-term benefit and thus a potential role to play in population prevention of chronic disease.

Preventive social health programs : are they Australia's answer to rising health care costs in rural communities?

Although we have good evidence to support the notion that early intervention, prevention and community education programs can mitigate the impact of preventable disease, expanded primary health care is also being promoted by Australian governments as a panacea for reducing growth in demand generally. While preventive programs do reduce acute demand, they may not do so the extent that resources, currently allocated to the acute sector, can be substituted to provide the additional primary care services necessary to reduce acute demand permanently. These developments have particular relevance for rural and isolated communities where access to acute services is already very limited. What appears to be occurring, in rural South Australia at least, is that traditional acute services are being reduced and replaced with lower level care and social intervention programs. This is well and good, but eventually the acute care being provided in rural health units now will still need to be provided by other units elsewhere and probably at much higher cost to the system and to consumers. Where rural communities have previously managed much of their own acute service demand, they may now be forced to send patients to more distant centres for care but at much greater social and economic cost to individuals and the system.