Silly us! Of course the grid doesn`t work : reading methodologies and policy texts on principals' work

This symposium presents work in progress from an ARC (discovery grant) funded investigation of principal supply, conducted by Jill Blackman, Judyth Sachs and Pat Thomas. Our research goals are to examine claims of an impending shortage of school principals in particular schools and localities, critically evaluate a range of possible reasons for this shortage, and ultimately, through woprk with principals' organisations, to develop some possibilities for policy action. In this symposium we focus on: (1) existing studies of principal supply (2) trends apparent from demographic and employment data, and (3) a text and interview based study of 'human resources' policy. We invite discussion on the implications of this first stage for the next - a national survey and interviews with teachers in pre-service training and in their first years of teaching.

An evaluation framework for the qualitative investigation of a physical activity prescription program in rural Victoria

Physical activity (PA) has consistently been shown to improve ones' physical, social and mental health. Hence, the rationale for promoting regular physical activity is relatively straightforward. However, what is less clear from the literature is the mix of strategies, (i.e. 'what is working and why?'), to increase in physical activity levels within a population. Of particular interest to primary care is the concept of Physical Activity Prescription Programs (PAPPs) delivered by general practitioners (GPs).

Several examples of a PAPP exist within England, America, New Zealand and Australia. These all aim to encourage GPs to deliver physical activity advice to their patients effectively and in a timely manner. Notwithstanding, the authors of a recent review of published literature on PAPPs, reveal a deficit of evidence regarding the components for successful PA interventions.

This research through an ethnographic enquiry aims to build on the evidence formulated to date. Through a case study research design, the researcher has developed a methodology to define what is/is not working within this recent trend.

In two rural Divisions of GP, participants have been identified as key stakeholders in the implementation of a PAPPs. They are categorised according to three theoretical paradigms, namely, Policy Makers, Linkers and Adaptors. Following this the three paradigms will be studied on the contextual factors, the characteristics and behaviours of members within all three paradigms. The study has also further defined certain elements for investigation, these include the:
intention of the players
effort undertaken by players, and
effect of parties within.

Primarily qualitative data will be collected; through Desk Analysis (Policies, Strategic and Business plans), Site Visits (Participant Observation) and semi-structured interviews. This presentation defines a qualitative framework and methodology for investigating the outcome of programs that historically has been evaluated using quantitative measures. Hence, the author of this study aims to present a qualitative investigation and subsequent results, defining aspects of a PAPP that allow for successful and sustainable implementation.

Aluminium powder forging process using a rotating platen

A torsional upset forging process is analysed on the basis of plasticity theory for powder metal forging. Torsional upset forging is a process to be performed by rotating a lower die with a punch travelling along the longitudinal direction of a work-piece. In this study, an upper bound analysis considering bulging effect, finite element method simulation (DEFORM3D), and experimental research have been performed for the process. A simple kinematically admissible velocity field for a three dimensional deformation is presented for the torsional upset forging of a cylindrical billet. Distributions of stress, strain, and forging load in the process have been obtained, and compared with those in conventional upset forging. In the process, an increase in a friction factor and rotation speed results in a decrease in magnitude of upset force, dead metal zone, and non-homogeneous deformation. This process can reduce forming load, which leads to improvement of die life, and also reduce bulging effect. In addition, the initial sintered-structure and density distribution is improved by the process and surface defect due to high deformation is decreased.

Cardiac rehabilitation in south west Victoria : factors influencing attendance

Background : The benefits of cardiac rehabilitation (CR) programs are well established. Despite these benefits their utilisation remains sub-optimal, with an average of 24% of eligible cardiac patients attending outpatient CR programs across Victoria.
Aims & rationale/Objectives : The objectives of this study were to (a) identify local barriers and enablers to the uptake of hospital-based CR programs, and (b) identify preferred alternatives for the delivery of CR.
Methods : Six hospital-based CR programs within the region agreed to participate in this study. A consecutive series of patients referred to the programs were surveyed by the CR coordinators to identify the local barriers and enablers influencing CR program attendance. In addition, focus groups with CR participants and health professionals were conducted at two hospitals in order to ascertain their views on current programs, suggestions for improvements and alternative methods of CR delivery.
Principal findings : Survey data was obtained from a total of 97 patients referred to the CR programs during the study period, 27 (28%) females and 70 (72%) males. Main reasons given for CR non-attendance were related to distance to travel, cost of petrol, reliance on others for transport and lack of interest or motivation to attend. For CR attenders, main enablers included encouragement by family, medical and other health professionals, and having someone else to drive them. Suggestions for alternative methods of CR delivery included more programs in outlying communities, home and GP based programs, telephone support and a patient manual or workbook.
Discussion : The results of this study provide valuable information for designing strategies to increase utilisation of existing CR programs as well as pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.
Implications : These findings suggest that many of the barriers identified could be addressed by a more creative use of existing resources and the provision of CR services in primary care settings.
Presentation type : Poster

An evidence-based approach to podiatry workforce enhancement and service provision in Western Victoria

Aims & rationale/Objectives : The objectives of this workforce and service enhancement project include: (i) establishing the magnitude of podiatry needs; and (ii) developing a model that can be used to enhance podiatry workforce and podiatry services.
Methods : Surveys to podiatrists and health agencies to determine vacancies, waiting lists, work practices and recruitment methods. Desktop analysis of predictive data for burden of disease and population changes per local government area (LGA). Meetings with podiatrists and their professional association, health care agencies, universities, and Local and State Governments.
Principal findings : Results showed
Long podiatry waiting lists (up to 12 months)
Podiatry vacancies and service gaps
Absence of qualified foot assistants
A high chronic disease burden
A population age mix that is predicted to change dramatically over the next 25 years in favour of those who are 60 years of age or older
Ineffective recruitment methods
The workforce enhancement model that emanated from the meetings with the steering group includes podiatrists as well as auxiliaries such as foot-care assistants who work together in an interprofessional model of care that expands across the region. In addition to training foot-care assistants and the development of a podiatry teaching clinic to enhance student placement, the model builds onto a current continuous professional development program for allied health professionals.
Discussion : Although the allied health workforce (including podiatry) is playing an increasingly important role in the prevention and treatment of chronic diseases, rural areas in particular are disadvantaged by recruitment and retention problems. The podiatry workforce shortage is compounded by ageing populations. Age is associated with increased podiatry usage due to chronic diseases such as diabetes, cardiovascular disease and osteoarthritis.
Implications : A strategic plan developed in consultation with stakeholders aims to improve rural podiatry services in a sustainable manner. The project will be implemented when adequate funding is allocated this year and will be evaluated on its impact on services.
Presentation type : Paper

Balancing work and lifestyle : an exploratory study of chartered accountants in Australia

In today’s work environment, achieving a work-life balance is not only desirable, for employers it is a necessity to maintain a healthy workforce. Accounting careers are impacted by many factors, including technology and an increasing complexity in the demands for financial services, with resulting changes in where, when and how accountants perform their jobs. In addition, due to the general skills shortage faced by the businesses, the need for work-life balance has become a key determining factor for decisions regarding career choices.

The Institute of Chartered Accountants in Australia (The Institute) has embarked on a long term goal of developing a work environment which helps Chartered Accountants (CAs) to gain work-life balance to complement the demand of the workforce. Three studies have been completed. The first study was conducted in 1995 in which the career expectations and barriers for women Chartered Accountants were examined amongst CAs in Victoria. In 2001, a follow-up survey of both male and female CAs was conducted in Victoria and Tasmania. The present study reports on the latest part of the project – a national survey of all 6,600 CAs regarding their work-life balance and expectations. This paper discusses the trend established by the three studies, and identifies some interesting scenarios of the accounting careers for CAs in Australia.

Influences on the supply of accounting graduates in Australia: a focus on international students

This paper examines the influences on the potential supply of accounting graduates in Australia with reference to the personal and social influences on the decision to major in accounting using the Theory of Reasoned Action and focusing on differences between local and international students. Responses from 437 accounting majors' found that personal attitudes linked to 'intrinsic interest' and 'extrinsic interest' was influential in choice of major. 'Reference groups' were an important social influence for international students. The findings have implications for government policy and the accounting profession in terms of attracting students and particularly international students, who are sufficiently interested in accounting as a career choice to address the skill shortage in Australia.

Use of a decision aid for prenatal testing of fetal abnormalities to improve women's informed decision making: a cluster randomised controlled trial [ISRCTN22532458]

Objective To evaluate the effectiveness of a decision aid for prenatal testing of fetal abnormalities compared with a pamphlet in supporting women's decision making.
Design A cluster randomised controlled trial.
Setting Primary health care.
Population Women in early pregnancy consulting a GP.
Methods GPs were randomised to provide women with either a decision aid or a pamphlet. The decision aid was a 24-page booklet designed using the Ottowa Decision Framework. The pamphlet was an existing resource available in the trial setting.
Main outcome measures Validated scales were used to measure the primary outcomes, informed choice and decisional conflict, and the secondary outcomes, anxiety, depression, attitudes to the pregnancy/fetus and acceptability of the resource. Outcomes were measured at 14 weeks of gestation from questionnaires that women completed and returned by post.
Findings Women in the intervention group were more likely to make an informed decision 76% (126/165) than those in the control group 65% (107/165) (adjusted OR 2.08; 95% CI 1.14–3.81). A greater proportion of women in the intervention group 88% (147/167) had a 'good' level of knowledge than those in the control group 72% (123/171) (adjusted OR 3.43; 95% CI 1.79–6.58). Mean (SD) decisional conflict scores were low in both groups, decision aid 1.71 (0.49), pamphlet 1.65 (0.55) (adjusted mean difference 0.10; 95% CI −0.02 to 0.22). There was no strong evidence of differences between the trial arms in the measures of psychological or acceptability outcomes.
Conclusion A tailored prenatal testing decision aid plays an important role in improving women's knowledge of first and second trimester screening tests and assisting them to make decisions about screening and diagnostic tests that are consistent with their values.

Exploring general practitioners' experience of informing women about prenetal screening tests for foetal abnomalities : a qualitative focus group study

Background: Recent developments have made screening tests for foetal abnormalities available earlier in pregnancy and women have a range of testing options accessible to them. It is now recommended that all women, regardless of their age, are provided with information on prenatal screening tests. General Practitioners (GPs) are often the first health professionals a woman consults in pregnancy. As such, GPs are well positioned to inform women of the increasing range of prenatal screening tests available. The aim of this study was to explore GPs experience of informing women of prenatal genetic screening tests for foetal abnormality.
Methods: A qualitative study consisting of four focus groups was conducted in metropolitan and rural Victoria, Australia. A discussion guide was used and the audio-taped transcripts were independently coded
by two researchers using thematic analysis. Multiple coders and analysts and informant feedback were employed to reduce the potential for researcher bias and increase the validity of the findings.
Results: Six themes were identified and classified as 'intrinsic' if they occurred within the context of the consultation or 'extrinsic' if they consisted of elements that impacted on the GP beyond the scope of the
consultation. The three intrinsic themes were the way GPs explained the limitations of screening, the extent to which GPs provided information selectively and the time pressures at play. The three extrinsic
factors were GPs' attitudes and values towards screening, the conflict they experienced in offering screening information and the sense of powerlessness within the screening test process and the health
care system generally. Extrinsic themes reveal GPs' attitudes and values to screening and to disability, as well as raising questions about the fundamental premise of testing.
Conclusion: The increasing availability and utilisation of screening tests, in particular first trimester tests,has expanded GPs' role in facilitating women's informed decision-making. Recognition of the importance
of providing this complex information warrants longer consultations to respond to the time pressures that GPs experience. Understanding the intrinsic and extrinsic factors that impact on GPs may serve to shape
educational resources to be more appropriate, relevant and supportive.

Clincial pharmacogenetics and potential application in personalized medicine

The current `fixed-dosage strategy' approach to medicine, means there is much inter-individual variation in drug response. Pharmacogenetics is the study of how inter-individual variations in the DNA sequence of specific genes affect drug responses. This article will highlight current  pharmacogenetic knowledge on important drug metabolizing enzymes, drug transporters and drug targets to understand interindividual variability in drug clearance and responses in clinical practice and potential use in  personalized medicine. Polymorphisms in the cytochrome P450 (CYP) family may have had the most impact on the fate of pharmaceutical drugs. CYP2D6, CYP2C19 and CYP2C9 gene polymorphisms and gene duplications account for the most frequent variations in phase I metabolism of drugs since nearly 80% of drugs in use today are metabolised by these enzymes. Approximately 5% of Europeans and 1% of Asians lack CYP2D6 activity, and these  individuals are known as poor metabolizers. CYP2C9 is another clinically significant drug metabolising enzyme that demonstrates genetic variants. Studies into CYP2C9 polymorphism have highlighted the importance of the CYP2C9*2 and CYP2C9*3 alleles. Extensive polymorphism also occurs in a majority of Phase II drug metabolizing enzymes. One of the most important polymorphisms is thiopurine S-methyl transferases (TPMT) that catalyzes the S-methylation of thiopurine drugs. With respect to drug transport  polymorphism, the most extensively studied drug transporter is  P-glycoprotein (P-gp/MDR1), but the current data on the clinical impact is limited. Polymorphisms in drug transporters may change drug's distribution, excretion and response. Recent advances in molecular research have revealed many of the genes that encode drug targets demonstrate genetic polymorphism. These variations, in many cases, have altered the targets sensitivity to the specific drug molecule and thus have a profound effect on drug efficacy and toxicity. For example, the β2-adrenoreceptor, which is encoded by the ADRB2 gene, illustrates a clinically significant genetic variation in drug targets. The variable number tandem repeat polymorphisms in serotonin transporter (SERT/SLC6A4) gene are associated with response to antidepressants. The distribution of the common variant alleles of genes that encode drug metabolizing enzymes, drug transporters and drug targets has been found to vary among different populations. The promise of pharmacogenetics lies in its potential to identify the right drug at the right dose for the right individual. Drugs with a narrow therapeutic index are thought to benefit more from pharmacogenetic studies. For example, warfarin serves as a good practical example of how pharmacogenetics can be utilized prior to commencement of therapy in order to achieve maximum efficacy and minimum toxicity. As such, pharmacogenetics has the potential to achieve optimal quality use of medicines, and to improve the efficacy and safety of both prospective and licensed drugs.

A controlled trial of internet-based cognitive-behavioural therapy for panic disorder with face-to-face support from a general practitioner or email support from a psychologist

Background: Panic disorder (PD) is one of the most common anxiety disorders seen in general practice, but provision of evidence-based cognitive-behavioural treatment (CBT) is rare. Many Australian GPs are now trained to deliver focused psychological strategies, but in practice this is time consuming and costly.

Objective: To evaluate the efficacy of an internet-based CBT intervention (Panic Online) for the treatment of PD supported by general practitioner (GP)-delivered therapeutic assistance.

Design: Panic Online supported by GP-delivered face-to-face therapy was compared to Panic Online supported by psychologist-delivered email therapy.

Methods: Sixty-five people with a primary diagnosis of PD (78% of whom also had agoraphobia) completed 12 weeks of therapy using Panic Online and therapeutic assistance with his/her GP (n = 34) or a clinical psychologist (n = 31). The mean duration of PD for participants allocated to these groups was 59 months and 58 months, respectively. Participants completed a clinical diagnostic interview delivered by a psychologist via telephone and questionnaires to assess panic-related symptoms, before and after treatment.

Results: The total attrition rate was 20%, with no group differences in attrition frequency. Both treatments led to significant improvements in panic attack frequency, depression, anxiety, stress, anxiety sensitivity and quality of life. There were no statistically significant differences in the two treatments on any of these measures, or in the frequency of participants with clinically significant PD at post assessment.

Conclusions: When provided with accessible online treatment protocols, GPs trained to deliver focused psychological strategies can achieve patient outcomes comparable to efficacious treatments delivered by clinical psychologists. The findings of this research provide a model for how GPs may be assisted to provide evidence-based mental healthcare successfully.

Therapist-assisted, internet-based treatment for panic disorder: can general practitioners achieve comparable patient outcomes to psychologists

Background: Mental illness is an escalating concern worldwide. The management of disorders such as anxiety and depression largely falls to family doctors or general practitioners (GPs). However, GPs are often too time constrained and may lack the necessary training to adequately manage the needs of such patients. Evidence-based Internet interventions represent a potentially valuable resource to reduce the burden of care and the cost of managing mental health disorders within primary care settings and, at the same time, improve patient outcomes.
Objective: The present study sought to extend the efficacy of a therapist-assisted Internet treatment program for panic disorder, Panic Online, by determining whether comparable outcomes could be achieved and maintained when Panic Online was supported by either GPs or psychologists.
Methods: Via a natural groups design, 96 people with a primary diagnosis of panic disorder (with or without agoraphobia) completed the Panic Online program over 12 weeks with the therapeutic assistance of their GP (n = 53), who had received specialist training in cognitive behavioral therapy, or a clinical psychologist (n = 43). Participants completed a clinical diagnostic telephone interview, conducted by a psychologist, and a set of online questionnaires to assess panic-related symptoms at three time periods (pretreatment, posttreatment, and 6 month follow-up).
Results: Both treatments led to clinically significant improvements on measures of panic and panic-related symptomatology from pretreatment to posttreatment. Both groups were shown to significantly improve over time. Improvements for both groups were maintained at follow-up; however, the groups did differ significantly on two quality of life domains: physical (F₁,₈₂ = 9.13, P = .00) and environmental (F₁,₈₂ = 4.41, P = .04). The attrition rate was significantly higher among those being treated by their GP (χ²₁ = 4.40, P = .02, N = 96).
Conclusions: This study provides evidence that Internet-based interventions are an effective adjunct to existing mental health care systems. Consequently, this may facilitate and enhance the delivery of evidence-based mental health treatments to increasingly large segments of the population via primary care systems and through suitably trained health professionals.

What do general practitioners think depression is? A taxonomy of distress and depression for general practice

Objective:
To create a taxonomy of distress and depression for use in primary care, that mirrors the thinking and practice of experienced general practitioners.

Design:
Qualitative study, using an ethnomethodological approach, with observation of videotaped routine GP–patient consultations and in-depth interviews with GPs.

Setting and participants:
The study was conducted in metropolitan Melbourne in 2005. Fourteen GPs conducted 36 patient consultations where depression was a focus; nine GPs participated in in-depth interviews to elicit details of how they recognised and diagnosed depression in their patients.

Results:
GPs consider distress and depression in three steps. In the first step, a change in a group of symptoms and signs is observed (eg, facial expression, loss of drive). The second step categorises the syndrome according to whether or not there is an identifiable environmental cause (reactive or “endogenous”), with the final step categorising the reactive syndromes according to their most prominent symptoms: either anxiety and worry, or helplessness and hopelessness. The resulting taxonomy includes: endogenous depression (a chronic and perhaps characterological depression characterised by a lack of interest and motivation); anxious depressive reaction (stress or worry); and hopeless depressive reaction (demoralisation).

Conclusion:
This simple and parsimonious taxonomy has validity based on its derivation from within the primary care setting.

Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs

Objective: The objectives of this study were to: (i) identify local barriers and enablers to the uptake of hospital-based cardiac rehabilitation (CR) programs, and (ii) identify preferred alternatives for the delivery of CR.

Design: A questionnaire administered by local CR coordinators and focus groups facilitated by the research team.

Setting: Six regional hospitals in south-west Victoria offering hospital-based CR programs.

Participants: Patients and their carers referred to and eligible for local CR programs; health professionals working within local CR programs.

Main outcomes measures: CR attendees and decliners demographics, patient and health professional perceived factors which contribute to enabling hospital-based CR attendance, patient and health professional perceived barriers to CR attendance, and receptiveness and preferences for alternative modes of CR delivery.

Results: This study identified distance to travel to hospital-based CR programs the only statistically significant factor in determining uptake of CR. Easy access to transport (63%) and to a lesser extent family support (49%) and work flexibility (43%) were the primary enablers to attendance. Of the 97 study participants, 38% were receptive to alternative CR methods such as programs in outlying communities, evening facility-based programs, home and GP based programs, telephone support and a patient manual/workbook.

Conclusions: The results of this study provide valuable information for designing strategies to increase utilisation and improve patient acceptability of existing hospital-based CR programs. It provides a basis for pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.

Androgenic activity of effluent from forty-five municipal waste water treatment plants in Victoria, Australia

It is well known that waste water treatment plant (WWTP) effluents are estrogenic. There has been much less consideration of the androgenic activity of WWTP effluents. To partly address the shortage of information on androgens in Australian WWTP effluents, in August 2006, and again in 2007, we collected discharges from up to 45 Victorian WWTPs (~25% of all WWTPs in Victoria), grouped by treatment process, i.e. activated sludge, extended aeration, and lagoon based treatment, and measured the total estrogenic, androgenic, retinoic acid, and aromatic hydrocarbon hydrogenase activity of the effluents using a hybrid yeast bioassay. This paper will concentrate on the androgenic activity and male hormone concentrations.