Process evaluation of a community-based adolescent obesity prevention project in Tonga

Background: The rising burden of obesity in Tonga is alarming. The promotion of healthy behaviours and environments requires immediate urgent action and a multi-sectoral approach. A three-year community based study titled the Ma’alahi Youth Project (MYP) conducted in Tonga from 2005-2008 aimed to increase the capacity of the whole community (schools, churches, parents and adolescents) to promote healthy eating and regular physical activity and to reduce the prevalence of overweight and obesity amongst youth and their families. This paper reflects on the process evaluation for MYP, against a set of Best Practice Principles for community-based obesity prevention.
Methods: MYP was managed by the Fiji School of Medicine. A team of five staff in Tonga were committed to planning, implementation and evaluation of a strategic plan, the key planks of which were developed during a two day community workshop. Intervention activities were delivered in villages, churches and schools, on the main island of Tongatapu. Process evaluation data covering the resource utilisation associated with all intervention activities were collected, and analysed by dose, frequency and reach for specific strategies. The action plan included three standard objectives around capacity building, social marketing and evaluation; four nutrition; two physical activity objectives; and one around championing key people as role models.
Results: While the interventions included a wide mix of activities straddling across all of these objectives and in both school and village settings, there was a major focus on the social marketing and physical activity objectives. The intervention reach, frequency and dose varied widely across all activities, and showed no consistent patterns.
Conclusions: The adolescent obesity interventions implemented as part of the MYP program comprised a wide range of activities conducted in multiple settings, touched a broad spectrum of the population (wider than the target group), but the dose and frequency of activities were generally insufficient and not sustained. Also the project confirmed that, while the MYP resulted in increased community awareness of healthy behaviours, Tonga is still in its infancy in terms of conducting public health research and lacks research infrastructure and capacity.

Incorporating sustainability into community-based healthcare practice

There is now irrefutable evidence that climate change and increasing environmental degradation negatively affect population health. Healthcare plays an important role in addressing these emerging environmental challenges, considering its core aim is to protect and promote health. Preliminary research in Victoria, Australia, suggests that healthcare practitioners are endeavouring to factor in environmental concerns into their practice. Health promotion, an integral part of the healthcare system, is considered an area of practice that can support action on sustainability. Based on five qualitative case studies and key stakeholder interviews, this article explores key barriers and facilitators to incorporating sustainability into community-based healthcare practice. The findings demonstrate that despite multiple barriers, including funding and lack of policy direction, health promotion principles and practices can enable action on sustainability.

Strengthening work integrated learning (WIL) experiences for rural education students : exploring community based partnerships

This paper investigates three areas of priority for rural teacher education: work integrated learning (WIL); attraction and retention of teachers to rural areas; and the potential challenges and benefits of community based partnerships to address these areas of need. The data on which this paper is based focuses on a Victorian project around six case studies that explored the research and scholarship of teaching graduates to be work ready for the needs of rural and regional communities. The project also aimed to explore how preservice teacher education can develop and better support pre-service teachers (PSTs) through rural and regional community-based WIL experiences.
The project investigated what sort of support PSTs undertaking WIL experiences in rural and regional communities need in order to develop positive attitudes and understandings in relation to working in a rural/regional community. Consideration was also given to how support from the university, school,
supervising teacher and broader local community enhances or detracts from the PST’s experience of WIL in rural and regional areas. In order to explore these issues in this paper the authors will outline some recommendations with regards to ways in which teacher education programs may enhance the experiences of stakeholders involved in rural and regional WIL experiences, including PSTs, supervising teachers, university teacher educators and community members.
The project’s underlying conceptual framework of place, productivity and partnerships will be explained in terms of its overlapping dimensions of community, creativity and capital in order to reconceptualise preservice teacher education in local, rural and regional and global contexts as adaptive community-based work integrated learning within a knowledge economy.
The final discussion will make recommendations on how universities and other identified stakeholders can better facilitate WIL and enhance stakeholder engagement in rural and regional areas in order to equip PSTs
and classroom teachers to work creatively together in productive partnerships to meet the future demands of local rural and global contexts of change in a knowledge economy.

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

Community based rehabilitation for people with disability in Iraq

This thesis explores the role of government and non-government organisations and international agencies in community based rehabilitation in Iraq. It examines the possibility of initiating and running community-based rehabilitation programmes for people with disability by NGOs regardless of Iraqi government commitment or participation. The research results show that implementation of CBR in Iraq is vital but not widely- spread. Non-government organisations seem more active, committed and capable in the time being to initiate, run and manage CBR programmes compared to the government of Iraq. Despite the high numbers of people with disabilities and lack of capacity to respond to their needs, there is little evidence that the Iraqi government has made efforts in adopting CBR as a cost-effective response.

Process evaluation of a community-based intervention program: Healthy Youth Healthy Communities, an adolescent obesity prevention project in Fiji

Nearly one-half of the adult population in Fiji between the ages of 15–64 years is either overweight or obese; and rates amongst school children have, on average, doubled during the last decade. There is an urgent need to scale up the promotion of healthy behaviors and environments using a multi-sectoral approach. The Healthy Youth Healthy Community (HYHC) project in Fiji used a settings approach in secondary schools and faith-based organizations to increase the capacity of the whole community, including churches, mosques and temples, to promote healthy eating and regular physical activity, and to prevent unhealthy weight gain in adolescents aged 13–18 years. The team consisted of a study manager, project coordinator and four research assistants (RAs) committed to planning, designing and facilitating the implementation of intervention programs in collaboration with other stakeholders, such as the wider school communities, government and non-governmental organizations and business partners. Process data were collected on all intervention activities and analyzed by dose, frequency and reach for each specific strategy. The Fiji Action Plan included nine objectives for the school settings; four were based on nutrition and two on physical activity in schools, plus three general objectives, namely capacity building, social marketing and evaluation. Long-term change in nutritional behavior was difficult to achieve; a key contributor to this was the unhealthy food served in the school canteens. Whilst capacity-building proved to be one of the best mechanisms for intervening, it is important to consider the cultural and social factors influencing health behaviors and affecting specific groups.

The lifetime experience of traumatic events is associated with hair cortisol concentrations in community-based children

Adversity early in life can disrupt the functioning of the hypothalamic–pituitary–adrenal axis (HPAA) and increase risk for negative health outcomes. Recent research suggests that cortisol in scalp hair represents a promising of HPAA function. However, little is known about the relationship between early exposure to traumatic events and hair cortisol concentrations (HCC) in childhood, a critical period of HPAA development. The current study measured HCC in scalp hair samples collected from 70 community-based children (14 males, mean age = 9.50) participating in the Imaging Brain Development in the Childhood to Adolescence Transition Study (iCATS). Data were also collected on lifetime exposure to traumatic events and current depressive symptoms. Lifetime exposure to trauma was associated with elevated HCC; however, HCC was not associated with current depressive symptoms. Consistent with some prior work, males were found to have higher HCC than females, although results should be treated with caution due to the small number of males who took part. Our findings suggest that hair cortisol may represent a biomarker of exposure to trauma in this age group; however, further study is necessary with a particular focus on the characterization of trauma and other forms of adversity.

Mixed method evaluation of a community-based physical activity program using the RE-AIM framework: practical application in a real-world setting

BACKGROUND: Communities are a pivotal setting in which to promote increases in child and adolescent physical activity behaviours. Interventions implemented in these settings require effective evaluation to facilitate translation of findings to wider settings. The aims of this paper are to i) present findings from a RE-AIM evaluation of a community-based physical activity program, and ii) review the methodological challenges faced when applying RE-AIM in practice.

METHODS: A single mixed-methods case study was conducted based on a concurrent triangulation design. Five sources of data were collected via interviews, questionnaires, archival records, documentation and field notes. Evidence was triangulated within RE-AIM to assess individual and organisational-level program outcomes.

RESULTS: Inconsistent availability of data and a lack of robust reporting challenged assessment of all five dimensions. Reach, Implementation and setting-level Adoption were less successful, Effectiveness and Maintenance at an individual and organisational level were moderately successful. Only community-level Adoption was highly successful, reflecting the key program goal to provide community-wide participation in sport and physical activity.

CONCLUSIONS: This research highlighted important methodological constraints associated with the use of RE-AIM in practice settings. Future evaluators wishing to use RE-AIM may benefit from a mixed-method triangulation approach to offset challenges with data availability and reliability.

Healthy together Victoria and childhood obesity-a methodology for measuring changes in childhood obesity in response to a community-based, whole of system cluster randomized control trial

BACKGROUND: Healthy Together Victoria (HTV) - a complex 'whole of system' intervention, including an embedded cluster randomized control trial, to reduce chronic disease by addressing risk factors (physical inactivity, poor diet quality, smoking and harmful alcohol use) among children and adults in selected communities in Victoria, Australia (Healthy Together Communities).

OBJECTIVES: To describe the methodology for: 1) assessing changes in the prevalence of measured childhood obesity and associated risks between primary and secondary school students in HTV communities, compared with comparison communities; and 2) assessing community-level system changes that influence childhood obesity in HTC and comparison communities.

METHODS: Twenty-four geographically bounded areas were randomized to either prevention or comparison (2012). A repeat cross-sectional study utilising opt-out consent will collect objectively measured height, weight, waist and self-reported behavioral data among primary [Grade 4 (aged 9-10y) and Grade 6 (aged 11-12y)] and secondary [Grade 8 (aged 13-14y) and Grade 10 (aged 15-16y)] school students (2014 to 2018). Relationships between measured childhood obesity and system causes, as defined in the Foresight obesity systems map, will be assessed using a range of routine and customised data.

CONCLUSION: This research methodology describes the beginnings of a state-wide childhood obesity monitoring system that can evolve to regularly inform progress on reducing obesity, and situate these changes in the context of broader community-level system change.

Beyond community-based diabetes management and the COAG coordinated care trial

OBJECTIVE: This article describes the patient management processes developed during the Council of Australian Governments (COAG) coordinated care trial and use of health outcome measures to monitor changes in utilisation patterns and patient well-being over time for a subgroup of 398 patients with type 2 diabetes. DESIGN: The Eyre component of the South Australian (SA) HealthPlus coordinated care trial was a matched geographically controlled study in which the outcomes for the intervention group of 1350 patients were compared with those of a similar control group of 500 patients in another rural health region in SA. SETTING: The trial was carried out on Eyre Peninsula in SA across populations in rural communities and in the main centres of Whyalla, Port Lincoln and Ceduna. Care planning was organised through general practitioner practices and services negotiated with allied health services and hospitals to meet patient needs. SUBJECTS: The SA HealthPlus trial included 1350 patients with chronic and complex illness. A subset of this group comprising 398 patients with type 2 diabetes is described in this report. Patients recruited into the three-year trial were care planned using a patient centred care planning model through which patient goals were generated along with medical management goals developed by clinicians and primary health care professionals. Relevant health services were scheduled in line with best practice and care plans were reviewed each year. Patient service utilisation, progress towards achieving health related goals and patient health outcomes were recorded and assessed to determine improvements in health and well-being along with the cost and profile of the services provided. RESULTS: Significant numbers of patients experienced improved health outcomes as a consequence of their involvement in the trial, and utilisation data showed reductions in hospital and medical expenditure for some patients. These results suggest that methods applied in the SA HealthPlus coordinated care trial have led to improvements in health outcomes for patients with diabetes and other chronic illnesses. In addition, the processes associated with the COAG trial motivated significant organisational change in the Regional Health Service as well as providing an opportunity to study the health and well-being outcomes resulting from a major community health intervention. CONCLUSIONS: The importance of the SA HealthPlus trial has been the demonstrated link between a formal research trial and significant developments in the larger health system with the trial not only leading to improvements in clinical outcomes for patients, but also acting as a catalyst for organisational reform. We now need to look beyond the illness focus of health outcome research to develop population based health approaches to improving overall community well-being.

Factors influencing awareness of community-based shorebird conservation projects in Australia

We examine the awareness of potential volunteers (n = 360) living near nine community-based shorebird conservation projects. About half of the people sampled (54%) were unaware of the nearest project. Awareness of interviewees varied substantially among projects (28-78%). Apart from gaining awareness of projects through membership of natural history groups (43%), many respondents heard of projects through friends and relatives (20%), rather than through media such as newspapers (14%) and television (2.3%). We demonstrate that community-based projects can be quantitatively and critically assessed for awareness. The use of rapid, cost-effective assessments of awareness levels has application in many conservation projects.

Community-based study on knowledge, attitude and practice on the mode of transmission, prevention and treatment of the Buruli ulcer in Ga West District, Ghana

Buruli ulcer disease (BUD), a devastating tropical disease caused by Mycobacterium ulcerans, occurs in more than 80% of the administrative districts of Ghana. To elucidate community perceptions and
understanding of the aetiology of BUD, attitudes towards Buruli patients and treatment-seeking behaviours, we conducted a survey with 504 heads of households and seven focus group discussions in Ga West District, Ghana. Although 67% of participants regarded BUD as a health problem, 53% did not know its cause. Sixteen per cent attributed the cause to drinking non-potable water, 8.1% mentioned poor personal hygiene or dirty surroundings, and 5.5% identified swimming or wading in ponds as a risk factor. About 5.2% thought that witchcraft and curses cause BUD, and 71.8% indicated that BU sufferers first seek treatment from herbalists and only refer to the hospital as a last resort. The main
reasons were prospects of prolonged hospital stay, cost of transport, loss of earnings and opportunity associated with parents attending their children’s hospitalization over extended period, delays in being
attended by medical staff, and not knowing the cause of the disease or required treatment. The level of acceptance of BUD sufferers was high in adults but less so in children. The challenge facing health workers is to break the vicious cycle of poor medical outcomes leading to poor attitudes to hospital treatment in the community. Because herbalists are often the first people consulted by those who contract the disease, they need to be trained in early recognition of the pre-ulcerative stage of Buruli lesions.

Community-based sustainability: conservation in the Ballarat region

The discourse of sustainability is promoted internationally, with the United Nations declaring 2005-2014 as a Decade for Education for Sustainable Development. There is discussion concerning the nature, status and significance of Education for Sustainability and its relationship with the somewhat established discourse of environmental education. This debate requires continuing theorising and one approach is to reflect critically on specific examples of sustainability within specific communities. This article seeks to promote further discussion about sustainability, and to contribute to ongoing theorisation about Education for Sustainability, by considering a particular instance – that of environmental sustainability in the Ballarat region of Victoria. The case study suggests that implementation of this local environmental sustainability strategy was dominated by technocratic and individualistic ideologies.