The Gambling Urge Scale : reliability and validity in a clinical population

The aim of this study was to establish reliability and validity of the Gambling Urge Scale (GUS) in a clinical population of problem gamblers. This cohort study was conducted in South Australia between March 2008 and March 2009. Participants were problem gamblers aged ≥18 years (n = 158) who were seeking treatment from a range of gambling help services. Measures included gambling urge, problem gambling screening, gambling behaviour and problems caused by gambling, such as personal health and relationships. The psychometric properties investigated were internal reliability, criterion-related validity, concurrent validity and construct validity. Results showed high internal consistency for GUS (α = 0.93) and significant item-rest correlations ranging from 0.72 to 0.86. For criterion-related validity, a GUS cut score of three correctly classified 81.13% of participants as problem gambling with sensitivity 84.75% and specificity 76.6%. Concurrent validity was significant with a number of gambling-related symptoms and problems including psychological disturbance, work and social functioning and gambling-related cognitions (p < 0.001). An insignificant correlation was found between gambling urge and sensation seeking traits (p = 0.663). When controlling for gender and age the instrument was shown to have significant predictive properties for different levels of gambling severity (p < 0.001). A principal component analysis for the one component showed an overall explained variance of 75.54%. These findings indicate that GUS is a valid and reliable instrument for problem gambling screening, to measure treatment outcomes and may predict relapse in problem gambling.

The influence of depression and other co-occurring conditions on treatment outcomes for problem gamblers : a cohort study

Objective: To examine the influence of co-occurring conditions on gambling treatment outcomes.

Design, setting and participants: Prospective cohort study of problem gamblers. Participants were recruited from consecutive referrals to a gambling therapy service in 2008. Inclusion criteria were: (i) assessed as a problem gambler based on a screening interview including DSM-IV criteria for pathological gambling, and (ii) suitable for admission to a treatment program. Cognitive-behavioural therapy was based on graded exposure-to-gambling urge. One-to-one treatment was conducted with 1-hour sessions weekly for up to 12 weeks.

Main outcome measures: Problem gambling screening and co-occurring conditions including depression, anxiety and alcohol use.

Results: Of 127 problem gamblers, 69 were males (54%), mean age was 43.09 years, and 65 (51%) reported a duration of problem gambling greater than 5 years. Median time for participants’ enrolment in the study was 8.9 months. Results from mixed effects logistic regression analysis indicated that individuals with higher depression levels had a greater likelihood (13% increase in odds [95% CI, 1%–25%]) of problem gambling during treatment and at follow-up.

Conclusion: Addressing depression may be associated with improved treatment outcomes in problem gambling; conversely, treatment of problem gambling improves affective instability. We therefore recommend a dual approach that treats both depression and problem gambling.

Two-group randomised, parallel trial of cognitive and exposure therapies for problem gambling: a research protocol

BACKGROUND: Problem gambling is a serious public health concern at an international level where population prevalence rates average 2% or more and occurs more frequently in younger populations. The most empirically established treatments until now are combinations of cognitive and behavioural techniques labelled cognitive behaviour therapy (CBT). However, there is a paucity of high quality evidence for the comparative efficacy of core CBT interventions in treating problem gamblers. This study aims to isolate and compare cognitive and behavioural (exposure-based) techniques to determine their relative efficacy.

METHODS: A sample of 130 treatment-seeking problem gamblers will be allocated to either cognitive or exposure therapy in a two-group randomised, parallel design. Repeated measures will be conducted at baseline, mid and end of treatment (12 sessions intervention period), and at 3, 6 and 12 months (maintenance effects). The primary outcome measure is improvement in problem gambling severity symptoms using the Victorian Gambling Screen (VGS) harm to self-subscale. VGS measures gambling severity on an extensive continuum, thereby enhancing sensitivity to change within and between individuals over time.

DISCUSSION: This article describes the research methods, treatments and outcome measures used to evaluate gambling behaviours, problems caused by gambling and mechanisms of change. This study will be the first randomised, parallel trial to compare cognitive and exposure therapies in this population.

ETHICS AND DISSEMINATION: The study was approved by the Southern Adelaide Health Service/Flinders University Human Research Ethics Committee. Study findings will be disseminated through peer-reviewed publications and conference presentations.

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.

Next steps in the logic of consumer-led self-management : translating chronic condition self-management programmes (CCSM) into lifestyle management programmes for young people

The techniques applied in chronic condition self-management programmes (CCSM) to support patients with chronic conditions are basic counselling and communication strategies that would benefit people at all stages of life and wellness. The question being explored here is why, as a society, we wait until people develop essentially preventable chronic conditions before helping them to develop the life skills they need to manage their lives and their human interactions better rather than working to avoid or prevent many chronic conditions that develop as a result of people lacking such skills? If we were to teach coping and managing skills to everyone in a supportive and structured way, using the peer-led teaching and learning strategies and basic counselling and education processes that have been shown to be successful for other older groups with chronic illness, the overall population impact would be more significant. Therefore why wait until people have chronic conditions before empowering them with basic life management techniques? Do people need to be sick before they can be motivated to live more effective lives? Is sickness the main stimulus for triggering health-related behaviour change or can other factors in people’s lives serve to inform and motivate lifestyle change?

Science, research and social change in Indigenous health – evolving ways of knowing

History tells us of the overwhelming destructive influence of exotic culture, politics and knowledge forms upon the worldview and wellbeing of Indigenous Australians. The power of dominant culture to oppress, control and dominate traditional Indigenous ways of knowing and being has been identified as a being a crucial influence on the health status, future hopes and aspirations of Indigenous Australians. Fundamental to this assertion is that the alienating effect of the belief in and application of the scientific method in relation to learning and knowing is a phenomenon that is incompatible with the law and cultural ways of traditional Indigenous people. The establishment of the Centre of Clinical Research Excellence (CCRE) is predicated upon and responds to a deep need in our community today to synthesise the ideological and epistemological premises of an increasing range of cultures and world views. It recognises that clinical research, for example, is important to the health of Aboriginal and Torres Strait Islander peoples, but also that the way such research is designed and carried out is also crucial to its potential to effect change in and improve the state of Indigenous health in Australia. This paper examines knowledge principles and processes associated with research in Indigenous communities, explores emerging research trends in science and proposes an epistemological framework for synthesis of traditional approaches with those of the scientific paradigm.

Self-management support and training for patients with chronic and complex conditions improves health-related behaviour and health outcomes

The Sharing Health Care SA chronic disease self-management (CDSM) project in rural South Australia was designed to assist patients with chronic and complex conditions (diabetes, cardiovascular disease and arthritis) to learn how to participate more effectively in the management of their condition and to improve their self-management skills. Participants with chronic and complex conditions were recruited into the Sharing Health Care SA program and offered a range of education and support options (including a 6-week peer-led chronic disease self-management program) as part of the Enhanced Primary Care care planning process. Patient self-reported data were collected at baseline and subsequent 6-month intervals using the Partners in Health (PIH) scale to assess self-management skill and ability for 175 patients across four data collection points. Health providers also scored patient knowledge and self-management skills using the same scale over the same intervals. Patients also completed a modified Stanford 2000 Health Survey for the same time intervals to assess service utilisation and health-related lifestyle factors. Results show that both mean patient self-reported PIH scores and mean health provider PIH scores for patients improved significantly over time, indicating that patients demonstrated improved understanding of their condition and improved their ability to manage and deal with their symptoms. These results suggest that involvement in peer-led self-management education programs has a positive effect on patient self-management skill, confidence and health-related behaviour.

Sisyphus and self-management : the chronic condition self-management paradox

Chronic condition self-management is promoted internationally as not only a possible solution to the health problems of our increasingly chronically ill and ageing population, but as part of a new wave of consumer-led and volunteer-managed health care initiatives. Consumers are now indicating that they want to be more involved in the management of their lives and their health care options, while, especially in rural and smaller communities in Australia, a shortage of clinicians means that health care is rapidly changing. This emphasis on self-management raises crucial questions about where consumer action and control in health care should end and where clinical and medical intervention might begin. Hence, as in the case of Sisyphus and his rock, the self-management process is a difficult and demanding one that poses major challenges and loads for health system reformers and represents a struggle in which new difficulties are constantly emerging. This paper examines some implications of new self-management approaches to chronic illness from an ideological perspective and highlights key elements that underpin the effort to promote health-related lifestyle change. While peer-led self-management programs may assist certain individuals to live engaged and meaningful lives, the essential social and economic determinants of health and wellbeing mean that these programs are not the answer to our urgent need for major reform in the health care arena. Rather, self-management, from an ideological perspective, represents a minor adjustment to the fabric of our health system.

Social determinants of health - why we continue to ignore them in the search for improved population health outcomes!

There is now unequivocal evidence that the health status of individuals and of whole communities is socially and economically determined, as are many other aspects of our lives. This suggests, as advocates of public health and population health approaches argue, that our efforts in managing our health and wellbeing should focus much more on early intervention and prevention programs than has been the case to date. However, although this ideology of social and economic determinism is generally accepted, practice does not reflect such values. Indeed, as increasing demand at the critical end of health service provision sees us spending more and more of our limited health care resources on acute and chronic illness, less resources are devoted to constructing and maintaining health-creating communities and environments. Paradoxically, while most of our leaders, academics and policy makers have themselves been nurtured in a sound understanding of cause and effect in the world, they are ignoring these fundamental premises in their approaches to the provision and management of health care. This paper explores some of the reasons why this might be the case and draws on key evidence to suggest that the time has come for us to think more ideologically in approaching health care in the future.

The science of the COAG coordinated care trials

Objectives: To explicate the organisational change agenda of the COAG coordinated care trials within the Australian health system and to illuminate the role of science in this process. Methods and Results: This article briefly outlines the COAG coordinated care trial aims and the effect of the trial as a change initiative in rural South Australia. It is proposed that although the formal trial outcomes are still not clear, the trial had significant impact upon health service delivery in some sites. The trial involved standard research methods with control and intervention groups and with key hypotheses being tested to compare the costs and service utilization profile of intervention and control groups. Formal results indicate that costs were not significantly different between intervention and control groups across all sites, but that the trial, nonetheless, had a powerful impact on the attitude and behaviours of service providers in the rural trial on Eyre Peninsula in particular. Some of the key structural changes now in place are outlined. Conclusions: The COAG trial has had many and varied impacts upon those organisations and individual providers involved with it. It is argued here that since successive initiatives had been implemented before final evaluation results were published, other agendas were served by the trial apart from those of standard scientific research and hypothesis testing. That is, the main impact of the coordinated care trial in Eyre Region at least has been change by stealth, and not through scientific research and demonstration. Implications: The COAG trials have set in train a series of structural and procedural changes in the methods of delivery and management of primary health care systems; changes that are embodied in the Enhanced Primary Care packages (EPC) and other initiatives recently introduced by the Commonwealth Government. These changes have occurred and are occurring across the system without formal evidence as to their efficacy, suggesting that other financial motives are driving these new approaches apart from the goal of improving health outcomes for consumers. Also, if science is to be used in this way to drive policy and procedural change ahead of actual outcome evidence, it is important that we examine the more subtle agendas of such research projects in future if the integrity of the scientific method is to be maintained. The occurrence of such phenomena questions the very foundation of scientific endeavour and weakens the application of scientific principles in the arena of social and political science.

Implementing the Flinders Model of self-management support with Aboriginal people who have diabetes : findings from a pilot study

A pilot program for Aboriginal people with diabetes on Eyre Peninsula, South Australia, aimed to test the acceptability and impact of using the Flinders model of self-management care planing to improve patient self-management. A community development approach was used to conduct a twelve-month demonstration project. Aboriginal health workers (AHWs) conducted patient-centred, self-management assessment and care planning. Impacts were measured by patient-completed diabetes self-management assessment tool, goal achievement, quality of life and clinical measures at baseline and 12 months. Impact and acceptability were also assessed by semi-structured interviews and focus groups of AHWs. Sixty Aboriginal people with type 2 diabetes stated their main problems as family and social dysfunction, access to services, nutrition and exercise. Problems improved by 12% and goals by 26%, while quality of life scores showed no significant change. Self-management scores improved in five of six domains. Mean HbA1c reduced from 8.74-8.09 and mean blood pressure was unchanged. AHWs found the process acceptable and appropriate for them and their patients. It was concluded that a diabetes self-management program provided by AHWs is acceptable, improves self-management and is seen to be useful by Aboriginal communities. Barriers include lack of preventative health services, social problems and time pressure on staff. Enablers include community concern regarding the prevalence and mortality associated with diabetes.

Health systems change in 2010

Whilst health science, epidemiology and public health developments have forged enormous progress in understanding, prevention and cure in the health care area we still appear to lack the motivation to tackle the fundamental antecedents of many of our emerging population-based community health problems; the prevention of chronic illness being a prime example.

In spite of much progress in the area of health science, the social, economic and evolutionary forces that cast our physical being in the world still remain poorly understood or accepted in the health care arena. However, if our health care systems are to be manageable and sustainable in the future, these wider antecedents of our health status and wellbeing must be factored more fundamentally in to our management models with more effort being put into preventing lifestyle related chronic illnesses than is currently the case.

As in the past where public health infrastructure innovations such as running water and efficient waste disposal systems served to add greatly to the wellbeing of individuals and communities, we now need to make similar efforts to control preventable illnesses such as metabolic syndrome, type 2 diabetes and lifestyle related cardio-vascular disease at their source rather than waiting until the manifestation of these conditions require major medical and chemical intervention and management before we act. Our young people are at risk of early onset chronic conditions as a result of their emerging sedentary lifestyles, un-healthy dietary habits and health related behaviours, yet we continue to concentrate our health management effort on managing those with existing chronic conditions while leaving younger generations with lifestyle practices and behaviours that pre-dispose individuals to developing chronic illness earlier and earlier in their lives.

It is time we took notice of these emerging trends and began expending more effort to prevent what are essentially lifestyle related illnesses that can be eliminated before they become endemic. By concentrating more upon the social and environmental factors affecting our illness profiles as well as upon dealing more effectively with those who are already suffering from chronic illness we will reduce the need for major end-stage interventions and alleviate the impact and cost of early onset chronic disease. To achieve this new population health vision in Australia at least, we will not only need to utilize the new government funding structures more effectively; those structures that support coordination and more effective management of care, but also take a much broader, environmental and social view of cause and effect in relation to the health of populations.

Ageing well, ageing productively : the essential contribution of Australia's ageing population to the social and economic prosperity of the nation

In Australia we have become preoccupied with the potential adverse impact of our ageing population on our health and social systems. The projected cost of having increasing proportions of our population in the over 70s, retired, chronically ill category of the demographic profile is emerging as a major challenge for governments and private insurers: so much so in fact that the government is now urging older people to stay at work longer. In America, new approaches to the management and self-management of chronic diseases have been invoked to encourage and support older people to improve their quality of life and reduce their recourse to and dependence upon health care technologies, clinical interventions and health care management systems. Unless this is achieved, it is argued, the cost of looking after this emerging ‘bubble’ of elderly people will become increasingly unsustainable as fewer and fewer (proportionately) younger people work to pay the taxes that support ageing, retired, sick and dependent populations. This paper argues that we are at real risk of having our economic wealth and productivity impeded and truncated by the financial burden of looking after high demand and high cost dependants at the aged end of the social demographic. This paper offers an alternative view of our ageing population, as well as highlighting some of the assets we have in our elderly populations, and providing suggestions as to an alternative view of the phenomenon of ageing that incorporates elements such as flexible working arrangements and the application of new, enabling technologies. This approach to our ageing population dilemma is predicated on a concept of lifelong learning and social participation along with better preventive and early intervention systems of health care

Self-management and the health care consumer

This book is especially apt for those interested in implementing the practices and strategies that support programmes of health maintenance, preventive health and strategies for bringing about a change in personal and population health ...