Cervical cancer services for Indigenous Women: Advocacy, Community-Based Research and Policy Change in Australia

Collaborative research undertaken in the state of Queensland, Australia, resulted in major changes in cervical cancer screening and treatment for Indigenous women. Guided by an Indigenous statewide reference group and with an Indigenous researcher playing a lead role, qualitative data were collected using interviews, focus groups, and larger community meetings; and case studies were conducted with health workers and community members from diverse rural, remote and urban communities, to explore the different cultural and structural factors affecting understanding and awareness of cervical cancer and Indigenous women's use of and access to health services for screening, diagnosis and treatment. These data were supplemented by an analysis of clinical data and health service checklists. We discuss the methodology and summarize the key social and structural factors that discourage women from presenting for screening or returning for follow-up. These include women's misunderstanding of cervical cancer screening, fear of cancer, distrust of health services, poor recall and follow-up systems, and the economic and social burden to women presenting for treatment. We describe how the research process and subsequent activities provided Indigenous women with a vehicle for their own advocacy, resulting in important policy and program changes.

Cost-effectiveness of dexamphetamine and methylphenidate for the treatment of childhood attention deficit hyperactivity disorder

Objective: To analyze from a health sector perspective the cost-effectiveness of dexamphetamine (DEX) and methylphenidate (MPH) interventions to treat childhood attention deficit hyperactivity disorder (ADHD), compared to current practice.

Method: Children eligible for the interventions are those aged between 4 and 17 years in 2000, who had ADHD and were seeking care for emotional or behavioural problems, but were not receiving stimulant medication. To determine health benefit, a meta-analysis of randomized controlled trials was performed for DEX and MPH, and the effect sizes were translated into utility values. An assessment on second stage filter criteria ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Simulation modelling techniques are used to present a 95% uncertainty interval (UI) around the incremental costeffectiveness ratio (ICER), which is calculated in cost (in A$) per DALY averted.

Results: The ICER for DEX is A$4100/DALY saved (95% UI: negative to A$14 000) and for MPH is A$15 000/DALY saved (95% UI: A$9100-22 000). DEX is more costly than MPH for the government, but much less costly for the patient.

Conclusions: MPH and DEX are cost-effective interventions for childhood ADHD. DEX is more cost-effective than MPH, although if MPH were listed at a lower price on the Pharmaceutical Benefits Scheme it would become more cost-effective. Increased uptake of stimulants for ADHD would require policy change. However, the medication of children and wider availability of stimulants may concern parents and the community.

Children with persistent conduct problems who dropout of treatment

Dropout of treatment is one of the key issues in outcome in a child and adolescent mental health service. We report two studies focusing on the treatment process and the dropout rate of children with persistent conduct problems presenting to a community mental health service, using a prospective design. The first study included 32 children and used a randomised controlled treatment design comparing a CBT approach with conjoint family therapy and an eclectic approach. The overall dropout rate was 36%. Dropout occurred significantly less frequently in the CBT group. The dropout group was associated with mothers who were younger and less educated, a poorer rating by the clinicians at the last meeting, parental dissatisfaction with the treatment service and perception that the treatment was less organised and having less behavioural tasks. In the second study we used a naturalistic follow-up design. Forty-six children were included. The overall dropout rate was 48%. Again, the children who defaulted were rated by clinicians as less likely to have improved and dropout was also  significantly associated with parental perception of a less organised treatment. In both studies dropout usually occurred after assessment and at the early phase of treatment.

The overt behaviour scale (OBS): a tool for measuring challenging behaviours following ABI in community settings

OBJECTIVES: The Overt Behaviour Scale (OBS) was designed as a comprehensive measure of common challenging behaviours observed after acquired brain injury (ABI) in community settings. The OBS comprises 34 items in nine categories that measure aggression, inappropriate sexual behaviour, perseveration, wandering, inappropriate social behaviour and lack of initiation. The aim of the current study was to determine the reliability, validity and responsiveness of the OBS. METHOD: Two adult community-based samples of people with ABI were recruited. Sample 1 (n= 30) were concurrently evaluated on the OBS by two raters and again 1 week later to test stability. Other validating scales were also administered. Sample 2 (n= 28) were clients of the ABI Behaviour Consultancy who were treated for challenging behaviours and were administered the OBS before treatment commenced and then again 4 months later. RESULTS: Inter-rater reliability and stability coefficients for the OBS total score was strong (0.97 and 0.77, respectively). Initial evidence of convergent and divergent validity was shown by the differential pattern of correlations with other measures. Moderate-to-strong coefficients (range 0.37-0.66) were observed between the OBS and other measures that had behavioural content (i.e. Mayo-Portland Adaptability Inventory, Current Behaviour Scale, Neurobehavioural Rating Scale-Revised). Divergent validity was shown by the lack of correlation between the OBS and the sub-scales of these tools that do not measure challenging behaviour. Finally, responsiveness was demonstrated with a significant decrease in OBS scores in the expected direction over the 4-month period. This improvement was confirmed by corroborating evidence from key informants. CONCLUSION: The OBS shows promise as a reliable, valid and responsive measure that can be used for the systematic assessment of challenging behaviours in community settings.

Re-visioning cultural competence in community health services in Victoria

There are few studies exploring the need to develop and manage culturally competent health services for refugees and migrants from diverse backgrounds. Using data from 50 interviews with service providers from 26 agencies, and focus group discussion with nine different ethnic groups, this paper examines how the Victorian state government funding and service agreements negatively impact on the quest to achieve cultural competence. The study found that service providers have adopted 'one approach fits all' models of service delivery. The pressure and competition for resources to address culturally and linguistically diverse communities' needs allows little opportunity for partnership and collaboration between providers, leading to insufficient sharing of information and duplication of services, poor referrals, incomplete assessment of needs, poor compliance with medical treatment, underutilisation of available services and poor continuity of care. This paper outlines a model for cultural consultation and developing needs-led rather than service-led programs.

Challenging behaviour profiles of people with acquired brain injury living in community settings

Primary objective: To determine the type and severity of challenging behaviours among a cohort of brain-injured persons referred to a community-based behaviour management service; and to determine whether different behaviour profiles were associated with aetiology of brain injury.
Methods and procedures: A sample of clients (n= 190) referred to the ABI Behaviour Consultancy for assessment and treatment of challenging behaviours was evaluated using the Overt Behaviour Scale (OBS) and other measures of disability and support needs.
Main outcomes and results: The most common challenging behaviour categories were, in order of frequency: verbal aggression, inappropriate social behaviours and lack of initiation. Clients typically exhibited four categories of challenging behaviour and multiple kinds of the behaviours represented by each category. There was some evidence of differences in occurrence of specific behaviours associated with aetiology of brain injury, particularly for hypoxia and alcohol-related brain injury.
Conclusions: A systematic assessment of challenging behaviours in community settings has revealed the profiles of broad behavioural disturbance that can occur following ABI. Assessing the breadth of disturbance is important in understanding a client's presentation and thus planning appropriate behaviour management interventions.

Depression in people with intellectual disability : an evaluation of a staff-administered treatment program

The prevalence of co-morbid depression in people with intellectual disability (ID) provides a strong rationale for the early identification and treatment of individuals at risk. The aim of this study was to evaluate a staff-administered group CBT program for the treatment of depression in people with mild ID. A sample of 13 staff employed at two community-based disability agencies were trained to deliver the program to 47 individuals with mild ID and symptoms of depression. A wait list control group comprised of 27 individuals subsequently completed the program. Compared to the control group, individuals who had participated in the treatment program showed lower depression scores, and fewer automatic negative thoughts. Furthermore, these changes were maintained at a 3-month follow-up. The results indicate that staff can be trained to deliver a CBT program within community settings that is effective in the reduction of depression symptomatology in people with mild ID.

A literature review of the application of the geriatric depression scale, depression anxiety stress scales and post-traumatic stress disorder checklist to community nursing cohorts

Aims and objectives. To explore through literature review the appropriateness of three common tools for use by community nurses to screen war veteran and war widow(er) clients for depression, anxiety and post-traumatic stress disorder.

Background. War veterans and, to a lesser extent, war widow(er)s, are prone to mental health challenges, especially depression, anxiety and post-traumatic stress disorder. Community nurses do not accurately identify such people with depression and related disorders although they are well positioned to do so. The use of valid and reliable self-report tools is one method of improving nurses' identification of people with actual or potential mental health difficulties for referral to a general practitioner or mental health practitioner for diagnostic assessment and treatment. The Geriatric Depression Scale, Depression Anxiety Stress Scales and Post-traumatic Stress Disorder Checklist are frequently recommended for mental health screening but the appropriateness of using the tools for screening war veteran and war widow(er) community nursing clients who are often aged and have functional impairment, is unknown.

Design. Systematic review.

Conclusions. Current literature informs that the Geriatric Depression Scale accurately predicts a diagnosis of depression in community nursing cohorts. The three Depression Anxiety Stress Scales subscales of depression, anxiety and stress are valid; however, no studies were identified that compared the performance of the Depression Anxiety Stress Scales in predicting diagnoses of depression or anxiety. The Post-traumatic Stress Disorder Checklist predicts post-traumatic stress disorder in community cohorts although no studies meeting the selection criteria included male participants.

Relevance to clinical practice. This review provides recommendations for the use of the Geriatric Depression Scale, Depression Anxiety Stress Scales and The Post-traumatic Stress Disorder Checklist based on examination of the published evidence for the application of these screening tools in samples approximated to community nursing cohorts. Findings and recommendations would guide community nurses, managers and health planners in the selection of mental health screening tools to promote holistic community nursing care.

The effectiveness of physical activity interventions for the treatment of overweight and obesity and type 2 diabetes

This review summarises current evidence relating to the effectiveness of physical activity (PA) interventions for treating overweight and obesity and type 2 diabetes. Interventions to increase PA for the treatment of overweight and obesity in both children and adults have primarily consisted of health education and behaviour modification strategies in clinical settings or with selected families or individuals. Although evidence is limited, strategies to reduce sedentary behaviours appear to have potential for reducing obesity among children and adolescents. Among adults, strategies that combine diet and PA are more effective than PA strategies alone. Combined lifestyle strategies are most successful for maintained weight loss, although most programs are unsuccessful in producing long-term changes. There is little evidence about compliance to prescribed behaviour changes or the factors that promote or hinder compliance to lifestyle changes. Limited evidence suggests that continued professional contact and self-help groups can help sustain weight loss. Most of the interventions for the treatment of type 2 diabetes have been conducted in clinical settings and have typically required the use of extensive resources. Evidence suggests that interventions can lead to small but clinically meaningful improvements in glycaemic control, even in the absence of weight loss. A recent study demonstrated that a multifactorial intervention (diet, PA and pharmaceutical) can reduce the risk of diabetes complications in individuals with type 2 diabetes. Nevertheless, there is little evidence about the effectiveness of community-based interventions in producing long-term changes in glycaemic control and reduced mortality in people with type 2 diabetes.

Addressing evidence treatment gaps for cardiovascular disease through primary care collaboration

Aims & Rationale/Objectives
The aim is to establish the frequency of counselling by general practitioners (GPs) and community pharmacists (CPs) for patients with uncontrolled CVD risk factors. This will identify conditions for which CPs might collaborate with GPs in addressing evidence-treatment gaps.

Methods
A population survey undertaken in the Wimmera region of Victoria in 2006. 1425 adults aged 25-84 yrs were randomly selected using age/sex stratified electoral role samples. A representative 723 participants were recruited.

Principal Findings
Data on GP and CP visits were available for 694 participants. Overall, participants visited GPs 4.6 times and CPs 6.0 times/annum. However, one third of participants never consulted a pharmacist in 12 months compared to just 11.5% for GPs. Among obese patients (BMI ?? 30), the average number of visits/annum was 4.5 to GPs and 6.8 to CPs. The equivalent numbers were 5.6 and 8.6 respectively for those with systolic BP ?? 140 mmHg; 3.7 and 5.5 for total cholesterol > 5.0 mmol/L; and, 6.7 and 14.6 for patients with random blood glucose concentrations ?? 7.0 mmol/L.

Implications
People with suboptimal status for most common CVD risk factor are counselled frequently by CPs. A coordinated approach with GPs to the delivery of cardiovascular health promotion could provide valuable reinforcement of key messages and offers greater opportunity to identify at-risk individuals. Acknowledgements: KM is a pharmacist-academic at Greater Green Triangle UDRH, a position funded by the Department of Health and Ageing through the Rural and Remote Pharmacy Workforce Development Program

Prevalence, awareness, treatment, and control of hypertension in China data from the China National Nutrition and Health Survey 2002

Background— The present article aims to provide accurate estimates of the prevalence, awareness, treatment, and control of hypertension in adults in China.

Methods and Results— Data were obtained from sphygmomanometer measurements and an administered questionnaire from 141 892 Chinese adults 18 years of age who participated in the 2002 China National Nutrition and Health Survey. In 2002, 153 million Chinese adults were hypertensive. The prevalence was higher among men than women (20% versus 17%; P<0.001) and was higher in successive age groups. Overall, the prevalence of hypertension was higher in urban compared with rural areas in men (23% versus 18%; P<0.01) and women (18% versus 16%; P<0.001). Of the 24% affected individuals who were aware of their condition, 78% were treated and 19% were adequately controlled. Despite evidence to suggest improved levels of treatment in individuals with hypertension over the past decade, compared with estimates from 1991, the ratio of controlled to treated hypertension has remained largely unchanged at 1:4.

Conclusions— One in 6 Chinese adults is hypertensive, but only one quarter are aware of their condition. Despite increased rates of blood pressure–lowering treatment, few have their hypertension effectively controlled. National hypertension programs must focus on improving awareness in the wider community, as well as treatment and control, to prevent many tens of thousands of cardiovascular-related deaths.

Preventing falls among older people : current practice and attitudes among community pharmacists

Objective: Falls among older people are a major cause of injury and death in Australia Urgent action is required if we are to stem the .epidemic' increase in falls as our population ages. This paper describes current practice and attitudes of community pharmacists in Northern Rivers, New South Wales, in relation to preventing falls. .. Method: Comm~typhannacists in the Northern Rivers area ofNew South Wales were surveyed to detennine their current activities to reduce the risk of falls in older clients and to gauge awareness of the successful 1992-96 falls prevention program- 'Stay on Your Feet'. Results: Response rate was 79% (53/67). Seventy-two per cent reported that they urge 'most' or 'almost all' older clients to bring in out-of-date medications for disposal, 66% give them falls prevention advice at least 'sometimes', 57% refer at least 'some' older clients to allied health practitioners for assessment or treatment of falls risk. and 92% are interested in receiving more written information regarding falls prevention. Conclusion: The fmdings suggest that while community pharmacists are both ready and keen to play a role in future falls prevention initiatives. their current involvement varies considerably. Specific ways in which they might further help to reduce falls are: regularly checking the potential of client. medications to connibute to falls. giving more verbal or written advice, promoting 'falls safe' products, referring older clients to allied health practitioners for assessment or treatment of falls risk, and training staff [Q provide falls prevention advice

Pharmacist assessment of adherence, risk and treatment in cardiovascular disease (PAART CVD)

Cardiovascular disease (CVD) accounts for 18% of disease burden in Australia, and 35% of deaths. Evidence- based management of CVD risk requires systematic consideration of individual risk factors and overall CVD risk, and a balanced approach to lifestyle modification, the optimal use of medicines, and medicines adherence.

This project examines a pHot model for primary prevention of CVD in community pharmacy aimed at improving quality of care. Pharmacists from ten pharmacies received training in CVD risk factor management and facilitating patient lifestyle modification.

They recruited 70 participants aged 50-74 years, taking medicines for blood pressure (BP) or cholesterol, and without diabetes or CVD, At baseline, research assistants conducted a clinical assessment of anthropometric and biomedical risk factors, and conducted interviews to examine health behaviours, medicines use and related issues. Data was analysed by a consultant pharmacist and summary reports produced, with recommendations and targets for risk reduction. These were addressed by patients and their community pharmacists over five monthly sessions. At follow up, the relative risk reduction for CVD onset over the next five years was 24%, contributed to by reductions in mean systolic BP (-7mmHg), diastolic PP (-5 mmHg), total:HDL cholesterol ratio (—0.2), waist circumference (—2cm in males, —0.7cm in females) and other risk factors.

Several key health behaviours improved, including diet quality and physical activity levels. Prevalence of non-adherence to cardiovascular medicines dropped by 1 6% to 22%.

The potential health benefits from this intervention need to be confirmed via larger, controlled clinical trials. Overall, this appears to be a feasible and potentially effective public health measure.