"Tell us something new!" : the response of planning and transport professionals to public health guidance on the built environment and physical activity

A large proportion of non-communicable disease can be attributed to modifiable risk factors such as poor nutrition and physical inactivity. We present data on planning and transport practitioners' perceptions and responses to government public health guidance aimed at modifying environmental factors to promote physical activity. This study was informed by questions on the role of evidence-based guidance, the views of professionals towards the guidance, the links between guidance and existing legislation and policy and the practicality of guidelines. A key informant 'snowball' sampling technique was used to recruit participants from the main professional planning organisations across England. Seventy-six people were interviewed in eight focus groups. We found that evidence-based public health guidance is a new voice in urban and town planning, although much of the advice is already reflected by the 'accepted wisdom' of these professions. Evidence-based health guidance could be a powerful driver affecting planning practice, but other legislated planning guidance may take priority for planning and transport professionals.

Men's health literacy : advancing evidence and priorities

Men's health literacy and its bearing on health-related attitudes and behaviour are curiously absent from discussions on health literacy and men's health. This is perhaps understandable given the lack of a theoretical understanding and empirical evidence. In this article, we review and comment on the published literature addressing health literacy and men's health literacy. We define 'health literacy', note a silent discourse on gender in the international debate on health literacy and identify gaps addressing men's health literacy. We also raise issues for research priorities and the practical development and implementation of evidence-based policies and programs aimed at improving men's health.

Food security measurement in cultural pluralism : missing the point or conceptual misunderstanding?

Objective : Food Security has become a global concern, yet its measurement has varied considerably across disciplines and countries. We examined the current discrepancies in the definitions of food security and propose a framework for understanding and measuring food security.

Methods : This conceptual review draws from a range of works published in Medline and the gray literature to advance the understanding of food security concepts. We begin by examining the historical background of food security and then move on to examine its various definitions and interpret food through cultural lenses in terms of food access and utilization. We finish by examining various measurements and indicators of food security and reviewing implications for public health.

Results : We argue that the reliance on coping strategies as surrogate measurements of food insecurity without taking into account the social, cultural, and political contexts in which they occur is misleading, and viewing food insecurity solely from a food access or availability perspective, without taking into account food utilization and asset creation as pillars of food security, paints an incomplete picture. Although this review does not claim to provide solutions to the discrepancies in the conceptual definition of food security, it attempts to highlights areas of concern and provide a way forward.

Conclusion : When coping strategies are used as an indicator of food insecurity, they need to be culturally relevant and focus tested, and together with objective measurements of nutritional outcomes, would allow policy makers to make evidence-based decisions to inform social and nutrition policies.

Death and late-stage dementia in institutions : a cultural analysis

The first purpose of this study was to describe the deaths of fifteen nursing home residents with late-stage dementia. The devastating effect of dementia on a person has been called a ‘living death’ (Woods, 1989). The caring which occurs when someone is going through this process in a nursing home was recorded and analysed. In analysing this act of caring, the second purpose was to look for the origins of the structures and the sources of pressure that shaped the context and therefore helped determine the behaviour of the various groups under observation. These groups were residents and their relatives, the staff of the nursing home and the treating doctors. Before commencing observations and carrying out this study, an understanding needed to be developed of: the condition of dementia as it is perceived by health professionals and presented in the media; the institutions in which the majority of people with dementia end their days; the background and conditions of the staff who nurse in them; the models of care that guide and determine policies; and the conceptions of life and death which underpin relevant laws and moral standpoints. Accordingly, in part 1. chapter 1 the history, causes, pathology and effects of dementing conditions are examined. Relevant medical and lay literature including media influences are examined which pertain to the subject of death and dementia and nursing home care. The history of this institutional care is briefly examined together with the growth of the discipline of gerontological nursing. Chapter 2 discusses some of the effects of this history on present day care and the concept of emotional work being carried out within the present day aged care public policy regulations. The moral arguments surrounding illness and dying in Australian society today are briefly discussed. Chapter 3 describes the conceptual framework for the study, the ethnographic method that has been employed and an outline of critical theory as the basis for analysis. The chapter concludes by recounting the practical steps taken to arrange the field work, secure the consent of participants, record data and gather documents, and outlines the ethical considerations given to the undertaking of the study. Chapter 4 describes the context in which the study took place and the first tentative exploration of the culture from an etic perspective. Part 2 describes the death trajectories observed and raises some questions about alternative strategies that may have been considered within a different paradigm of caring. In chapter 5 the death trajectories of each of the fifteen residents in the study are described, each written with a particular emphasis to illustrate aspects of the culture of care that emerged through thematic analysis. Observations, comments and feelings from staff and family are wound in and around these case studies. Chapter 6 looks more closely at the impact of policy and institutional pressure on the milieu in which these deaths took place. Part 3 draws conclusions from the observations and makes suggestions for emancipatory change as viewed from the author's standpoint of critical ethnographic analysis. In the final chapter an argument is presented for policy change that leads a movement towards palliative care practices for people with late-stage dementia. Approaches to implementation of palliative care will need to take account of any expression by the resident such as an advanced directive, indicating a preferred approach to treatment in the period prior to death; a need for a better understanding of such issues as the significance of body breakdown, the manifestations of pain and electrolyte imbalances; the surrounding ethical complexities and shift in public opinion, and perhaps, most of ail, the culture of the institutions in which this dying will take place. A definition of late-stage dementia which might be used in determining patterns of care is set out. A discussion about changes in practice which relate lo communication with treating doctors, the administering of antibiotics, the relief of pain, the mobilisation of residents and the provision of food and water takes place in light of the evidence found. The discussion of these issues is raised in the form of debate. Each aspect needs more rigorous analysis and information so that evidence-based practice, rather than care which is value-laden and emotional, can be used when treatment decisions are made for people with late-stage dementia.

An observational study of health professionals’ use of evidence to inform the development of clinical management tools

Aim. This observational study sought to investigate the process of evidence use by health professionals during development of evidence-based clinical management tools.

Background. Studies conducted to explore the process of research use are scarce and knowledge of this process is essential for our understanding of the influences on research use in practice.

Design. A qualitative, non-participant, observational design.

Methods. Behaviour and actions of two separate multidisciplinary teams were observed and audio-recorded during a combined total of seven meetings for the development of clinical management tools. Semi-structured, one-to-one interviews were conducted approximately half-way through the development process and following completion of the clinical management tools.

Results. Three major themes emerged from this research. First, the process of clinical management tool development and evidence use. Nurses assumed responsibility for coordination of development which focused on describing current practice. Second, the forms of evidence employed during the development process included the use of experiential knowledge, opinions and knowledge of the context, in addition to research evidence. However, reference to research evidence was limited and its incorporation into the instrument was infrequently observed. Third, the use of research evidence emerged with respect to how such evidence was employed.

Conclusion. This study focused on real-life discussion and decision-making that occurred between health professionals when developing evidence-based clinical management tools. Health professionals may have a tendency to rely on their professional experience and current practice in preference to seeking and applying relevant research evidence.

Relevance to clinical practice. Nurses have an important role to play in the development of multidisciplinary evidence-based clinical management tools, but to actively participate in this process they need to be familiar with the relevant research evidence and have the skills and confidence to integrate the evidence into practice.

Evaluation of a community pharmacy-based intervention for improving patient adherence to antihypertensives: a randomised controlled trial

Background
The majority of patients using antihypertensive medications fail to achieve their recommended target blood pressure. Poor daily adherence with medication regimens and a lack of persistence with medication use are two of the major reasons for failure to reach target blood pressure. There is no single intervention to improve adherence with antihypertensives that is consistently effective. Community pharmacists are in an ideal position to promote adherence to chronic medications. This study aims to test a specific intervention package that could be integrated into the community pharmacy workflow to enable pharmacists to improve patient adherence and/or persistence with antihypertensive medications - Hypertension Adherence Program in Pharmacy (HAPPY).

Methods/Design
The HAPPY trial is a multi-centre prospective randomised controlled trial. Fifty-six pharmacies have been recruited from three Australian states. To identify potential patients, a software application (MedeMine CVD) extracted data from a community pharmacy dispensing software system (FRED Dispense®). The pharmacies have been randomised to either 'Pharmacist Care Group' (PCG) or 'Usual Care Group' (UCG). To check for 'Hawthorne effect' in the UCG, a third group of patients 'Hidden Control Group' (HCG) will be identified in the UCG pharmacies, which will be made known to the pharmacists at the end of six months. Each study group requires 182 patients. Data will be collected at baseline, three and six months in the PCG and at baseline and six months in the UCG. Changes in patient adherence and persistence at the end of six months will be measured using the self-reported Morisky score, the Tool for Adherence Behaviour Screening and medication refill data.

Discussion
To our knowledge, this is the first research testing a comprehensive package of evidence-based interventions that could be integrated into the community pharmacy workflow to enable pharmacists to improve patient adherence and/or persistence with antihypertensive medications. The unique features of the HAPPY trial include the use of MedeMine CVD to identify patients who could potentially benefit from the service, control for the 'Hawthorne effect' in the UCG and the offer of the intervention package at the end of six months to patients in the UCG, a strategy that is expected to improve retention.

Trial Registration
Australian New Zealand Clinical Trial Registry ACTRN12609000705280

An empirical investigation of hybrid corporate governance systems in large firms : evidence from India

The heightened pace of corporate governance reforms has focussed attention on countryspecific governance models. In relation to India, scholars have observed that a hybrid of the outsider Anglo-Saxon system and the insider Continental system is likely. This paper reports
the results of a study that investigated the corporate governance system of five large firms in 2008. It presents evidence based on publicly available documents and twelve key executive interviews. The paper initially presents a literature review and establishes six propositions
based on the distinguishing features of the two major systems, and then presents the methodology, findings and discussion. The governance characteristics of the Indian firms are classified in terms of the two systems with a view to assessing the extent and nature of hybridization. The findings endorse the hybrid corporate governance system in India.
However, the scope of this study was limited to large listed companies and business groups. Future research should use a larger and more diverse sample including private and unaffiliated firms for outcomes that can be generalized.

Splash!: a prospective birth cohort study of the impact of environmental, social and family-level influences on child oral health and obesity related risk factors and outcomes

Background: Dental caries (decay) is the most prevalent disease of childhood. It is often left untreated and can impact negatively on general health, and physical, developmental, social and learning outcomes. Similar to other health issues, the greatest burden of dental caries is seen in those of low socio-economic position. In addition, a number of diet-related risk factors for dental caries are shared risk factors for the development of childhood obesity. These include high and frequent consumption of refined carbohydrates (predominately sugars), and soft drinks and other sweetened beverages, and low intake of (fluoridated) water. The prevalence of childhood obesity is also at a concerning level in most countries and there is an opportunity to determine interventions for addressing both of these largely preventable conditions through sustainable and equitable solutions. This study aims to prospectively examine the impact of drink choices on child obesity risk and oral health status.
Methods/Design: This is a two-stage study using a mixed methods research approach. The first stage involves qualitative interviews of a sub-sample of recruited parents to develop an understanding of the processes involved in drink choice, and inform the development of the Discrete Choice Experiment analysis and the measurement instruments to be used in the second stage. The second stage involves the establishment of a prospective birth cohort of 500 children from disadvantaged communities in rural and regional Victoria, Australia (with and without water fluoridation). This longitudinal design allows measurement of changes in the child’s diet over time, exposure to fluoride sources including water, dental caries progression, and the risk of childhood obesity.
Discussion: This research will provide a unique contribution to integrated health, education and social policy and program directions, by providing clearer policy relevant evidence on strategies to counter social and environmental factors which predispose infants and children to poor health, wellbeing and social outcomes; and evidence-based strategies to promote health and prevent disease through the adoption of healthier lifestyles and diet. Further, given the absence of evidence on the processes and effectiveness of contemporary policy implementation, such as community water fluoridation in rural and regional communities it’s approach and findings will be extremely
informative.

Defining educational research : a perspective of/on presidential addresses and the Australian Association for Research in Education

This paper is concerned with the definition of the field of educational research and the changing and developing role of the Australian Association for Research in Education (AARE) in representing and constituting this field. The evidence for the argument is derived from AARE Presidential Addresses across its 40-year history. The paper documents the enhanced complexity and diversity of the field over these 40 years, including the emergence of a global educational policy field, theoretical and methodological developments in the social sciences and new research accountabilities such as the Excellence in Research for Australia (ERA) measure. Specifically, the paper suggests that the evidence-based movement in public management and education policy, and the introduction of the ERA, potentially limit and redefine the field of educational research, reducing the usefulness and relevance of educational research to policy makers and practitioners. This arises from a failure to recognise that Education is both a field of research and a field of policy and practice. Located against both developments, the paper argues for a principled eclecticism framed by a reassessment of quality, which can be applied to the huge variety of methodologies, theories, epistemologies and topics legitimately utilised and addressed within the field of educational research. At the same time, the paper argues the need to globalise the educational research imagination and deparochialise educational research. This call is located within a broader argument suggesting the need for a new social imaginary (in a post-neoliberal context of the global financial crisis) to frame educational policy and practice and the contribution that educational theory and research might make to its constitution. In relation to this, the paper considers the difficulties that political representations of such a new imaginary might entail for the President and the Association, given the variety of its membership and huge diversity of its research interests.

The global obesity pandemic : shaped by global drivers and local environments

The simultaneous increases in obesity in almost all countries seem to be driven mainly by changes in the global food system, which is producing more processed, affordable, and effectively marketed food than ever before. This passive overconsumption of energy leading to obesity is a predictable outcome of market economies predicated on consumption-based growth. The global food system drivers interact with local environmental factors to create a wide variation in obesity prevalence between populations. Within populations, the interactions between environmental and individual factors, including genetic makeup, explain variability in body size between individuals. However, even with this individual variation, the epidemic has predictable patterns in subpopulations. In low-income countries, obesity mostly affects middle-aged adults (especially women) from wealthy, urban environments; whereas in high-income countries it affects both sexes and all ages, but is disproportionately greater in disadvantaged groups. Unlike other major causes of preventable death and disability, such as tobacco use, injuries, and infectious diseases, there are no exemplar populations in which the obesity epidemic has been reversed by public health measures. This absence increases the urgency for evidence-creating policy action, with a priority on reduction of the supply-side drivers.

Survey of Directors of Australian university teaching and learning centres

The data provides a representative quantitative snapshot of the characteristics, capacities and constraints of Australian teaching and learning centres as seen through the eyes of their Directors. It provides evidence-based information for sector benchmarking and policy design, and identifies factors that contribute to the effective startegic leadership of Australian teaching and learning centres.

Osteo-cise : Strong bones for life': protocol for a community-based randomised controlled trial of a multi-modal exercise and osteoporosis education program for older adults at risk of falls and fractures

Background : Osteoporosis affects over 220 million people worldwide, and currently there is no 'cure' for the disease. Thus, there is a need to develop evidence-based, safe and acceptable prevention strategies at the population level that target multiple risk factors for fragility fractures to reduce the health and economic burden of the condition.

Methods : The 'Osteo-cise: Strong Bones for Life' study will investigate the effectiveness and feasibility of a multi-component targeted exercise, osteoporosis education/awareness and behavioural change program for improving bone health and muscle function, and reducing falls risk in community-dwelling older adults at an increased risk of fracture. Men and women aged 60 years or above will participate in an 18-month randomised controlled trial comprising a 12-month structured and supervised community-based program and a 6-month 'research to practise' translational phase. Participants will be randomly assigned to either the 'Osteo-cise' intervention or a self-management control group. The intervention will comprise a multi-modal exercise program incorporating high velocity progressive resistance training, moderate impact weight-bearing exercise and high challenging balance exercises performed three times weekly at local community-based fitness centres. A behavioural change program will be used to enhance exercise adoption and adherence to the program. Community-based osteoporosis education seminars will be conducted to improve participant knowledge and understanding of the risk factors and preventative measures for osteoporosis, falls and fractures. The primary outcomes measures, to be collected at baseline, 6, 12, and 18 months, will include DXA-derived hip and spine bone mineral density measurements and functional muscle power (timed stair-climb test). Secondary outcomes measures include: MRI-assessed distal femur and proximal tibia trabecular bone micro-architecture, lower limb and back maximal muscle strength, balance and function (four square step test, functional reach test, timed up-and-go test and 30-second sit-to-stand), falls incidence and health-related quality of life. Cost-effectiveness will also be assessed.

Discussion : The findings from the Osteo-cise: Strong Bones for Life study will provide new information on the efficacy of a targeted multi-modal community-based exercise program incorporating high velocity resistance training, together with an osteoporosis education and behavioural change program for improving multiple risk factors for falls and fracture in older adults at risk of fragility fracture. Trial Registration: Australian New Zealand Clinical Trials Registry reference ACTRN12609000100291

Getting research into policy : lots of ideas but how do we make it happen? Insights from the policy experience

Evidence and health policy discussions to date have largely focused on the relationship between those generating research evidence and policy decision-makers and how improving this relationship will increase research use in policy development. All too often policy makers are perceived as the problem, not understanding or seeing the importance of research evidence. Policy makers do have a responsibility to source and use available evidence, as do researchers to the sharp and meaningful production and syntheses of policy relevant research evidence. This takes more than improved communication mechanisms between individual researcher and policy makers. Evidence-informed policy making is a science in its own right requiring the development and application of methods that conceptualise, synthesise and exchange research evidence. Policy organisations need to develop as receptor sites for research and its application to day-to-day decision-making, this is a significant program of work if it is to be done well and affect the evidence culture of organisations.

Best practice for prevention and treatment of cardiovascular disease through an equity lens : a review

Background Despite declining rates of cardiovascular disease (CVD) mortality in developed countries, lower socioeconomic groups continue to experience a greater burden of the disease. There are now many evidence-based treatments and prevention strategies for the management of CVD and it is essential that their impact on the more disadvantaged group is understood if socioeconomic inequalities in CVD are to be reduced.

Aims To determine whether key interventions for CVD prevention and treatment are effective among lower socioeconomic groups, to describe barriers to their effectiveness and the potential or actual impact of these interventions on the socioeconomic gradient in CVD.

Methods Interventions were selected from four stages of the CVD continuum. These included smoking reduction strategies, absolute risk assessment, cardiac rehabilitation, secondary prevention medications, and heart failure self-management programmes. Electronic searches were conducted using terms for each intervention combined with terms for socioeconomic status (SES).

Results Only limited evidence was found for the effectiveness of the selected interventions among lower SES groups and there was little exploration of socioeconomic-related barriers to their uptake. Some broad themes and key messages were identified. In the majority of findings examined, it was clear that the underlying material, social and environmental factors associated with disadvantage are a significant barrier to the effectiveness of interventions.

Conclusion Opportunities to reduce socioeconomic inequalities occur at all stages of the CVD continuum. Despite this, current treatment and prevention strategies may be contributing to the widening socioeconomic-CVD gradient. Further research into the impact of best-practice interventions for CVD upon lower SES groups is required.

Knowledge exchange in the Pacific : The TROPIC (translational research into obesity prevention policies for communities) project

Background
Policies targeting obesogenic environments and behaviours are critical to counter rising obesity rates and lifestyle-related non-communicable diseases (NCDs). Policies are likely to be most effective and enduring when they are based on the best available evidence. Evidence-informed policy making is especially challenging in countries with limited resources. The Pacific TROPIC (Translational Research for Obesity Prevention in Communities) project aims to implement and evaluate a tailored knowledge-brokering approach to evidence-informed policy making to address obesity in Fiji, a Pacific nation challenged by increasingly high rates of obesity and concomitant NCDs.
Methods
The TROPIC project draws on the concept of ‘knowledge exchange’ between policy developers (individuals; organisations) and researchers to deliver a knowledge broking programme that maps policy environments, conducts workshops on evidence-informed policy making, supports the development of evidence-informed policy briefs, and embeds evidence-informed policy making into organisational culture. Recruitment of government and nongovernment organisational representatives will be based on potential to: develop policies relevant to obesity, reach broad audiences, and commit to resourcing staff and building a culture that supports evidence-informed policy development. Workshops will increase awareness of both obesity and policy cycles, as well as develop participants’ skills in accessing, assessing and applying relevant evidence to policy briefs. The knowledge-broking team will then support participants to: 1) develop evidence-informed policy briefs that are both commensurate with national and organisational plans and also informed by evidence from the Pacific Obesity Prevention in Communities project and elsewhere; and 2) collaborate with participating organisations to embed evidence-informed policy making structures and processes. This knowledge broking initiative will be evaluated via data from semi-structured interviews, a validated self-assessment tool, process diaries and outputs.
Discussion
Public health interventions have rarely targeted evidence-informed policy making structures and processes to reduce obesity and NCDs. This study will empirically advance understanding of knowledge broking processes to extend evidence-informed policy making skills and develop a suite of national obesity-related policies that can potentially improve population health outcomes.