Improving coronary heart disease self-management using mobile technologies (Text4Heart): a randomised controlled trial protocol

BACKGROUND: Cardiac rehabilitation (CR) is a secondary prevention program that offers education and support to assist patients with coronary heart disease (CHD) make lifestyle changes. Despite the benefits of CR, attendance at centre-based sessions remains low. Mobile technology (mHealth) has potential to reach more patients by delivering CR directly to mobile phones, thus providing an alternative to centre-based CR. The aim of this trial is to evaluate if a mHealth comprehensive CR program can improve adherence to healthy lifestyle behaviours (for example, physically active, fruit and vegetable intake, not smoking, low alcohol consumption) over and above usual CR services in New Zealand adults diagnosed with CHD.

METHODS/DESIGN: A two-arm, parallel, randomised controlled trial will be conducted at two Auckland hospitals in New Zealand. One hundred twenty participants will be randomised to receive a 24-week evidence- and theory-based personalised text message program and access to a supporting website in addition to usual CR care or usual CR care alone (control). The primary outcome is the proportion of participants adhering to healthy behaviours at 6 months, measured using a composite health behaviour score. Secondary outcomes include overall cardiovascular disease risk, body composition, illness perceptions, self-efficacy, hospital anxiety/depression and medication adherence.

DISCUSSION: This study is one of the first to examine an mHealth-delivered comprehensive CR program. Strengths of the trial include quality research design and in-depth description of the intervention to aid replication. If effective, the trial has potential to augment standard CR practices and to be used as a model for other disease prevention or self-management programs.

How do the Australian guidelines for lipid-lowering drugs perform in practice? Cardiovascular disease risk in the AusDiab Study, 1999-2000

OBJECTIVE: To determine how well the current Pharmaceutical Benefits Scheme (PBS) eligibility criteria for subsidy of lipid-lowering drugs compare with current national guidelines for determining the population at high risk of developing cardiovascular disease (CVD). DESIGN AND PARTICIPANTS: Analyses of the population-based, cross-sectional Australian Diabetes, Obesity and Lifestyle (AusDiab) study, conducted in 1999-2000. The 1991 Framingham risk prediction equation was used to compute 5-year risk of developing first-time CVD in 8286 participants aged 30-74 years with neither CVD nor diabetes. Based on the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand guidelines, people with either 5-year CVD risk > or = 15% or with 5-year CVD risk of 10%-< 15% and the metabolic syndrome were defined as having estimated high absolute CVD risk. MAIN OUTCOME MEASURES: 5-year CVD risk; estimated population with high CVD risk. RESULTS: Among participants without prevalent CVD or diabetes, 7.9% of men and 1.5% of women had a 5-year CVD risk > or = 15%. Of the estimated residential Australian population in 2000 aged 30-74 years without CVD or diabetes, 717 000 people were considered to be at high absolute CVD risk. Among the high-risk AusDiab participants without CVD or diabetes, only 16.9% of men and 15.4% of women were being treated with lipid-lowering drugs. Of the 9.6% of participants free of CVD and diabetes who were untreated but eligible for subsidy under PBS criteria, only 27.4% had an estimated high absolute CVD risk. CONCLUSION: Strategies for CVD prevention using lipid-lowering medications can be improved by adoption of the absolute-risk approach.

Predicting the effectiveness of prevention: a role for epidemiological modeling

It is well known that the current combination of aging populations and advances in health technology is resulting in burgeoning health costs in developed countries. Prevention is a potentially important way of containing health costs. In an environment of intense cost pressures, coupled with developments in disease prevention and health promotion, it is increasingly important for decision-makers to have a systematic, coordinated approach to the targeting and prioritization of preventive strategies. However, such a systematic approach is made difficult by the fact that preventive strategies need to be compared over the long term, in a variety of populations, and in real life settings not found in most trials. Information from epidemiological models can provide the required evidence base. In this review, we outline the role of epidemiological modeling in this context and detail its application using examples. Editors' Strategic Implications: Policymakers and researchers will benefit from this description of the utility of epidemiological modeling as a means of generating translational evidence that helps to prioritize data-based prevention approaches and bridge the gap between clinical research and public health practice.

Benefits and barriers to the consumption of a vegetarian diet in Australia

Objective: The aim of this study was to examine consumers' perceived benefits and barriers to the consumption of a vegetarian diet.

Design: Survey (written questionnaire) that included questions on perceived benefits and barriers to the consumption of a vegetarian diet.

Setting: South Australia.

Subjects: Six hundred and one randomly selected South Australians.

Results: The main perceived barriers to adopting a vegetarian diet were enjoying eating meat and an unwillingness to alter eating habits. This was the case for men, women and all age groups, although there were sex and age differences present in over half of the barrier items. For example, family food preferences were a greater problem for women than for men, while the oldest group was more likely to agree that humans are ‘meant’ to eat meat than the younger groups. The main benefits associated with vegetarian diets were health benefits: increased fruit and vegetable intake, decreased saturated fat intake, weight control. Animal welfare-related benefits and disease prevention were also important. Age and sex differences were apparent, although age differences were more important than sex differences.

Conclusions: The majority of respondents perceived there to be health benefits associated with the consumption of a vegetarian diet, but also, predictably, enjoyed eating meat. Given this, it is likely that interest in plant-based diets that contain some meat is higher than that in no-meat diets. An understanding of the perceived benefits and barriers of consuming a vegetarian diet will allow the implementation of strategies to influence meat and vegetarianism beliefs, dietary behaviour and, hence, public health.

Consumers' health perceptions of three types of milk: a survey in Australia

A survey was conducted among 345 randomly selected shoppers in Melbourne, Australia, to identify their perceptions of the healthiness of whole milk, reduced fat milk and soy milk and to investigate demographic influences on health perceptions and types of milk consumption. The survey revealed major differences in shoppers' perceptions of the three types of milk along the themes of bone health, weight control, disease prevention, and, allergy and disease causation. Generally whole milk was perceived more negatively than soy or reduced fat milk. There were few demographic differences in the shoppers' perceptions of the three products. Reported consumption of reduced fat milk was more frequent among women and elderly people, and whole milk consumption was positively related to parenthood. The findings suggest that previous marketing and education campaigns have been effective but the widespread uncertainty and erroneous beliefs about milk products suggest that many consumers have not assimilated new findings about milk products. This represents a challenge for industry and public health practitioners.

Public views of the benefits and barriers to the consumption of a plant-based diet

Objective: The aim of this study was to examine consumers' perceived benefits and barriers to the consumption of a plant-based diet. Design: Mail survey that included questions on perceived benefits and barriers to the consumption of a plant-based diet. Setting: Victoria, Australia. Subjects: Four hundred and fifteen randomly selected Victorian adults. Results: The main perceived barrier to adoption of a plant-based diet was a lack of information about plant-based diets (42% agreement). Sex, age and education differences were present in over a quarter of the barrier items. For example, non-university-educated respondents and older people were less willing to change their current eating pattern than were university educated and younger respondents. The main benefits associated with plant-based diets were health benefits, particularly decreased saturated fat intake (79% agreement), increased fibre intake (76%), and disease prevention (70%). Age, sex and education differences with regard to benefits were apparent, although sex differences were more important than age or education differences. Conclusions: The majority of respondents perceived there to be health benefits associated with the consumption of a plant-based diet. Compared with the proportion of respondents who agreed that there were particular benefits of eating a plant-based diet, perceived barriers were relatively low. An understanding of the perceived benefits and barriers of consuming a plant-based diet will help formulate strategies that aim to influence beliefs about plant foods, plant food consumption, and, ultimately, public health.

Randomised controlled trial evaluating lifestyle interventions in people with impaired glucose tolerance

Aim

To evaluate the effectiveness of lifestyle interventions in people with impaired glucose tolerance (IGT).
Methods

Participants with IGT (n = 78), diagnosed on two consecutive oral glucose tolerance tests (OGTTs), were randomly assigned to a 2-year lifestyle intervention or to a control group. Main outcome measures were changes from baseline in: nutrient intake; physical activity; anthropometry, glucose tolerance and insulin sensitivity. Measurements were repeated at 6, 12 and 24 months follow-up.
Results

After 24 months follow-up, there was a significant fall in total fat consumption (difference in change between groups (Δ intervention − Δ control) = −17.9, 95% confidence interval (CI) −33.6 to −2.1 g/day) as a result of the intervention. Body mass was significantly lower in the intervention group compared with controls after 6 months (−1.6, 95% CI −2.9 to −0.4 kg) and 24 months (−3.3, 95% CI −5.7 to −0.89 kg). Whole body insulin sensitivity, assessed by the short insulin tolerance test (ITT), improved after 12 months in the intervention group (0.52, 95% CI 0.15–0.89%/min).
Conclusions

These findings complement the findings of the Finnish Diabetes Prevention Study and the American Diabetes Prevention Study, both of which tested intensive interventions, by showing that pragmatic lifestyle interventions result in improvements in obesity and whole body insulin sensitivity in individuals with IGT, without change in other cardiovascular risk factors.

An Asia Pacific six-country study on HIV-related discrimination : introduction

This paper outlines a six-country study of institutionalised forms of HIV/AIDS-related discrimination in the Asia-Pacific region. Although recognised as a barrier to disease prevention and treatment, very limited data are available on the effects of institutionalised HIV-related stigma and discrimination. Understanding the forms of discrimination within the institutions where they occur is the first step to identifying effective ways of promoting compassionate, non-discriminatory treatment of PLWHA. Thus, the goal of this research project was to document institutional discrimination against PLWHA, as guided by the UNAIDS Protocol for the Identification of Discrimination Against People Living with HIV (2000), in six Asian countries: India, Thailand, Philippines, China, Vietnam and Indonesia. As a precursor to the six individual studies, this paper provides a brief overview of the literature on HIV discrimination, and then describes the UNAIDS Protocol and the shared methodological considerations relevant to all of the study sites. Commonalities in sampling, procedures and analysis are also discussed.

Gender and health promotion: A multisectoral policy approach

Women and men are different as regards their biology, the roles and responsibilities that society assigns to them and their position in the family and community. These factors have a great influence on causes, consequences and management of diseases and ill-health and on the efficacy of health promotion policies and programmes. This is confirmed by evidence on male–female differences in cause-specific mortality and morbidity and exposure to risk factors. Health promoting interventions aimed at ensuring safe and supportive environments, healthy living conditions and lifestyles, community involvement and participation, access to essential facilities and to social and health services need to address these differences between women and men, boys and girls in an equitable manner in order to be effective. The aim of this paper is to (i) demonstrate that health promotion policies that take women's and men's differential biological and social vulnerability to health risks and the unequal power relationships between the sexes into account are more likely to be successful and effective compared to policies that are not concerned with such differences, and (ii) discuss what is required to build a multisectoral policy response to gender inequities in health through health promotion and disease prevention. The requirements discussed in the paper include i) the establishment of joint commitment for policy within society through setting objectives related to gender equality and equity in health as well as health promotion, ii) an assessment and analysis of gender inequalities affecting health and determinants of health, iii) the actions needed to tackle the main determinants of those inequalities and iv) documentation and dissemination of effective and gender sensitive policy interventions to promote health. In the discussion of these key policy elements, we use illustrative examples of good practices from different countries around the world.

Modelling income group differences in the health and economic impacts of targeted food taxes and subsidies

Objective : To examine the effects, by income group, of targeted food taxes and subsidies on nutrition, health and expenditure in the UK.

Methods : A model based on consumption data and demand elasticity was constructed to predict the effects of four food taxation-subsidy regimens. Resulting changes in demand, expenditure, nutrition, cardiovascular disease (CVD) and cancer mortality were estimated.

Data : Expenditure data were taken from the Expenditure and Food Survey; estimates of price elasticities of demand for food were taken from a report based on the National Food Survey 1988–2000. Estimates of effect on CVD and cancer mortality of changing fat, salt, fruit and vegetable intake were taken from previous meta-analyses.

Results : (i) Taxing principal sources of dietary saturated fat is unlikely to reduce cardiovascular disease (CVD) or cancer mortality. (ii) Taxing ‘less healthy’ foods (defined by the WXYfm nutrient profiling model) could increase CVD and cancer deaths by 35–1300 yearly. (iii) Taxing ‘less healthy’ foods and subsidising fruits and vegetables by 17.5% could avert up to 2900 CVD and cancer deaths yearly. (iv) Taxing ‘less healthy’ foods and using all tax revenue to subsidize fruits and vegetables could avert up to 6400 CVD and cancer deaths yearly. Few obesity-related CVD deaths are averted by any of the regimens. All four regimens would be economically regressive and positive health effects will not necessarily be greater in lower-income groups where the need for dietary improvement is higher.

Conclusions : A targeted food tax combined with the appropriate subsidy on fruits and vegetables could reduce deaths from CVD and cancer.

Lifestyle management : preventing Type 2 diabetes and cardiovascular complications

For individuals with Type 2 diabetes, cardiovascular disease is the principle cause of morbidity and mortality. Lifestyle management is recognized as being an essential part of diabetes and cardiovascular disease prevention. Meta-analyses demonstrate that lifestyle interventions, including diet and physical activity, led to a 63% reduction in diabetes incidence in those at high risk. ‘Real-world’ lifestyle modification programs have demonstrated encouraging improvement in risk factors for diabetes; however, the effect on diabetes incidence has not been reported. It has been demonstrated that lifestyle interventions reduce cardiovascular risk factors; however, data on long-term cardiovascular outcomes is lacking. The aim of this review is to discuss the current evidence of lifestyle interventions in the prevention of diabetes and cardiovascular disease.

Cardiovascular health behaviours and health needs among people with psychiatric disabilities

Recent research in Australia has found that people with a mental illness experience higher mortality rates from preventable illnesses, such as cardiovascular disease, respiratory disease and diabetes compared to the general population. Lifestyle and other behavioural factors contribute significantly to these illnesses. Lifestyle behaviours that affect these illnesses include lack of physical activity, consumption of a poor diet and cigarette smoking. Research on the influence of these factors has been mainly directed towards the mainstream population in Australia. Consequently, there remains limited understanding of health behaviours among individuals with psychiatric disabilities, their health needs, or factors influencing their participation in protective health behaviours. This thesis presents findings from two studies. Study 1 evaluated the utility of the main components of Roger’s (1983) Protection Motivation Theory (PMT) to explain health behaviours among people with a mental illness. A clinical population of individuals with schizophrenia (N=83), Major Depressive Disorder (MDD) (N=70) and individuals without a mental illness (N=147) participated in the study. Respondents provided information on intentions and self-reported behaviour of engaging in physical activity, following a low-fat diet, and stopping smoking. Study 2 investigated the health care service needs of people with psychiatric disabilities (N=20). Results indicated that the prevalence of overweight, cigarette smoking and a sedentary lifestyle were significantly greater among people with a mental illness compared to that reported for individuals without a mental illness. Major predictors of the lack of intentions to adopt health behaviours among individuals with schizophrenia and MDD were high levels of fear of cardiovascular disease, lack of knowledge of correct dietary principles, lower self-efficacy, a limited social support network and a high level of psychiatric symptoms. In addition, findings demonstrated that psychiatric patients are disproportionately higher users of medical services, but they are under-users of preventive medical care services. These differences are primarily due to a lack of focus on preventive health, feelings of disempowerment and lower satisfaction of patient-doctor relationships. Implications of these results are discussed in terms of designing education and preventive programs for individuals with schizophrenia and MDD.

Barriers to kidney transplants in Indonesia : a literature review

Background: People living with chronic kidney disease will require renal dialysis or a kidney transplant to maintain life. Although Indonesia has a developing healthcare industry, Indonesia's kidney transplant rates are lower than comparable nations.

Purpose: To explore the healthcare literature to identify barriers to kidney transplants in particular in relation to Indonesia.

Methods: Healthcare databases were searched (CINAHL, Medline, EBSCOhostEJS, Blackwell Synergy, Web of Science, PubMed, Google Scholar and Proquest 5000) using the search terms: transplant, kidney disease, renal, dialysis, haemodialysis, Indonesia and nursing. The search was limited to English and Indonesian language data sources from 1997 to 2007. Reference lists of salient academic articles were hand searched.

Results: The results of our search identified six articles that met our criteria. Costs are the major barrier to kidney transplant in Indonesia, followed by cultural beliefs, perception of the law, lack of information and lack of infrastructure. In addition, kidney disease prevention strategies are required.

Conclusions: There are many complex socio-economic, geographical, legal, cultural and religious factors that contribute to low kidney transplant rates in Indonesia. Although an increase in transplantation rates will require strategies from various agencies, healthcare professionals, including nurses, can play a role in overcoming some barriers. Community education programmes, improving their own education levels and by increasing empowerment in nursing we may contribute to improved kidney transplant rates in Indonesia.

Paving pathways : shaping the public health workforce through tertiary education

Public health educational pathways in Australia have traditionally been the province of Universities, with the Master of Public Health (MPH) recognised as the flagship professional entry program. Public health education also occurs within the fellowship training of the Faculty of Public Health Medicine, but within Australia this remains confined to medical graduates. In recent years, however, we have seen a proliferation of undergraduate degrees as well as an increasing public health presence in the Vocational Education and Training (VET) sector. Following the 2007 Australian Federal election, the new Labour government brought with it a refreshing commitment to a more inclusive and strategic style of government. An important example of this was the 2020 visioning process that identified key issues of public health concern, including an acknowledgment that it was unacceptable to allocate less than 2% of the health budget towards disease prevention. This led to the recommendation for the establishment of a national preventive health agency (Australia: the healthiest country by 2020 National Preventative Health Strategy, Prepared by the Preventative Health Taskforce 2009). The focus on disease prevention places a spotlight on the workforce that will be required to deliver the new investment in health prevention, and also on the role of public health education in developing and upskilling the workforce. It is therefore timely to reflect on trends, challenges and opportunities from a tertiary sector perspective. Is it more desirable to focus education efforts on selected lead issues such as the “obesity epidemic”, climate change, Indigenous health and so on, or on the underlying theory and skills that build a flexible workforce capable of responding to a range of health challenges? Or should we aspire to both? This paper presents some of the key discussion points from 2008 - 2009 of the Public Health Educational Pathways workshops and working group of the Australian Network of Public Health Institutions. We highlight some of the competing tensions in public health tertiary education, their impact on public health training programs, and the educational pathways that are needed to grow, shape and prepare the public health workforce for future