Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting : Greater Green Triangle (GGT) Diabetes Prevention Project

Background
Randomised controlled trials demonstrate a 60% reduction in type 2 diabetes incidence through lifestyle modification programmes. The aim of this study is to determine whether such programmes are feasible in primary health care.

Methods
An intervention study including 237 individuals 40–75 years of age with moderate or high risk of developing type 2 diabetes. A structured group programme with six 90 minute sessions delivered during an eight month period by trained nurses in Australian primary health care in 2004–2006. Main outcome measures taken at baseline, three, and 12 months included weight, height, waist circumference, fasting plasma glucose and lipids, plasma glucose two hours after oral glucose challenge, blood pressure, measures of psychological distress and general health outcomes. To test differences between baseline and follow-up, paired t-tests and Wilcoxon rank sum tests were performed.

Results
At twelve months participants' mean weight reduced by 2.52 kg (95% confidence interval 1.85 to 3.19) and waist circumference by 4.17 cm (3.48 to 4.87). Mean fasting glucose reduced by 0.14 mmol/l (0.07 to 0.20), plasma glucose two hours after oral glucose challenge by 0.58 mmol/l (0.36 to 0.79), total cholesterol by 0.29 mmol/l (0.18 to 0.40), low density lipoprotein cholesterol by 0.25 mmol/l (0.16 to 0.34), triglycerides by 0.15 mmol/l (0.05 to 0.24) and diastolic blood pressure by 2.14 mmHg (0.94 to 3.33). Significant improvements were also found in most psychological measures.

Conclusion
This study provides evidence that a type 2 diabetes prevention programme using lifestyle intervention is feasible in primary health care settings, with reductions in risk factors approaching those observed in clinical trials.

Trial Number
Current Controlled Trials ISRCTN38031372

ICT and girls: the need for a large scale intervention programme

In recent years there have been fewer students enrolling into ICT courses and subsequently there has been a significant decline in ICT graduates. The decline in participation by females has been even greater than for males resulting in a further widening of the gender imbalance in this discipline. Much of the research indicates that it is the early years that influence children's decisions regarding career choice. For many girls, although
they are initially interested and engaged with IT in their early years of schooling, this fades as they reach middle and senior secondary school. Reasons for this decline in interest include the perceptions that, among other things, IT is ‘geeky’, male dominated and generally not a people focused career. There have been many initiatives to try and redress the problem however most are localised, poorly funded and depend very much on one key individual usually in schools. This paper briefly describes the outcomes of the Young Girls ICT project designed to encourage girls to continue with computing. The paper considers what the best options might be for encouraging more girls to continue to study computing.

CHD and stroke : Scotland`s pandemics also need co-ordinated and vigorous primary prevention programmes

Further reductions in the incidence and mortality from CHD and stroke in Scotland will be largely dependent upon changes in the three major risk factors – cholesterol, blood pressure and smoking. Vigorous and co-ordinated primary prevention programmes are therefore required. This paper outlines the main elements of such a prevention programme starting in the Scottish Borders. It considers the three major risk factors and discusses local action within high risk groups and within the population at large for each. The importance of considering environmental changes and social supports for change are emphasised, and because of this, the key role of local authorities and other local partners. Suggestions for action at the national level to encourage and support the growth of such programmes across Scotland are given.

Long-term effects of a reduced fat diet intervention on cardiovascular disease risk factors in individuals with glucose intolerance

The long-term effects on cardiovascular disease risk factors of a reduced fat (RF), ad libitum diet were compared with usual diet (control, CD) in glucose intolerance individuals.

Participants were 136 adults aged ≥40 years with ‘glucose intolerance’ (2 h blood glucose 7–11.0 mmol/l) detected at a Diabetes Survey who completed at 1 year intervention study of reduced fat, ad libitum diet versus usual diet. They were re-assessed at 2, 3 and 5 years. Main outcome measures were blood pressure, serum concentrations of total cholesterol, HDL and LDL cholesterol, total cholesterol:HDL ratio, triglycerides and body weight.

The reduced fat diet lowered total cholesterol (P<0.01), LDL cholesterol (P≤0.05), total cholesterol:HDL ratio (P≤0.05), body weight (P<0.01) and systolic blood pressure (P≤0.05) initially and diastolic blood pressure (P<0.01) long-term. No significant changes occurred in HDL cholesterol or triglycerides. In the more compliant 50% of the intervention group, systolic and diastolic blood pressure levels and body weight were lower at 1, 2 and 3 years (P<0.05).

It was concluded that a reduced fat ad libitum diet has short-term benefits for cholesterol, body weight and systolic blood pressure and long-term benefits for diastolic blood pressure without significantly effecting HDL cholesterol and triglycerides despite participants regaining their lost weight.

Evidence-based public health: what does it offer developing countries?

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public health and health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted in developing countries. The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

Background: Exposure to other people’s cigarette smoke (environmental tobacco smoke, or ETS) is an important child health issue.
Objectives: To determine the effectiveness of interventions aiming to reduce exposure of children to ETS.
Search strategy: The Tobacco Addiction Group register of studies was searched.MEDLINE, EMBASE and four other health and psychology databases were searched electronically, bibliographies of retrieved primary studies were checked and specialists in the area consulted.
Selection criteria: Controlled trials with or without random allocation were included in this review if they addressed participants (parents and other family members, child care workers and teachers) involved with the care and education of infants and young children (aged 0-12 years). All mechanisms for reduction of children’s environmental tobacco smoke exposure, and smoking prevention, cessation, and control programmes targeting these participants are included. These include smoke free policies and legislation, health promotion, social behavioural therapies, technology, education and clinical interventions.
Data collection and analysis: Two reviewers independently assessed studies and extracted data. Due to heterogeneity of methodologies and outcomes, no summary measures were possible and results were synthesised using narrative summaries.
Main results: Nineteen studies met the inclusion criteria, one of which was subsequently excluded. Three interventions were targeted at populations or community settings, seven studies were conducted in the well child health care setting and eight in the ill child health care setting. Twelve of these studies are from North America. In 12 of the 18 studies there was reduction of ETS exposure for children in both intervention and comparison groups. In only four of the 18 studies was there a statistically significant intervention effect. Three of these successful studies employed intensive counselling interventions targeted to smoking parents. There is little difference between the well infant, child respiratory illness and other child illness settings as contexts for parental smoking cessation interventions. The fourth successful intervention was in the school setting targeting the ETS exposure of children from smoking fathers.
Authors’ conclusions: Brief counselling interventions, successful in the adult health setting when coming from physicians, cannot be extrapolated to adults in the setting of child health. There is limited support for more intensive counselling interventions. There is no clear evidence for differences between the respiratory, non-respiratory ill child, well child and peripartum settings as contexts for reduction of children’s ETS exposure.

Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children

Objective
 To assess from a societal perspective the incremental cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. The intervention was modelled on the LEAP (live, eat and play) trial, a randomised controlled trial conducted by the Centre for Community Child Health, Melbourne, Australia in 2002–2003. This study was undertaken as part of the assessing cost-effectiveness (ACE) in obesity project which evaluated, using consistent methods, 13 interventions targeting unhealthy weight gain in children and adolescents.
Method
A logic pathway was used to model the effects of the intervention compared to no intervention on body mass index (BMI) and health outcomes (disability-adjusted life years—DALYs). Disease costs and health benefits were tracked until the cohort of eligible children reached the age of 100 years or death. Simulation-modelling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. The intervention was also assessed against a series of filters (‘equity’, ‘strength of evidence’, ‘acceptability’, ‘feasibility’, sustainability’ and ‘side-effects’) to incorporate additional factors that impact on resource allocation decisions.
Results
The intervention, as modelled, reached 9685 children aged 5–9 years with a BMI z-score of ≥3.0, and cost $AUD6.3M (or $AUD4.8M excluding time costs). It resulted in an incremental saving of 2300 BMI units which translated to 511 DALYs. The cost-offsets stemming from the intervention totalled $AUD3.6M, resulting in a net cost per DALY saved of $AUD4670 (dominated; $0.1M) (dominated means intervention costs more for less effect).
Conclusion
Compared to a ‘no intervention’ control group, the intervention was cost-effective under current assumptions, although the uncertainty intervals were wide. A key question related to the long-term sustainability of the small incremental weight loss reported, based on the 9-month follow-up results for LEAP.

Intervention strategies to engage small and medium sized enterprise in environmental good practice

Small and medium sized enterprises (SMEs) are an important part of the world economy but they are thought to be responsible for around 60% of all carbon dioxide emissions by businesses in the UK and 70% of all pollution. SMEs often have major problems with limited resources, limited knowledge and limited technical capabilities to deal with their own environmental impact. SMEs exhibit widely differing characteristics and behaviours where environmental issues are concerned. Yet under these conditions they are all expected to engage in environmentally responsible business for the greater good of society. Interventions that encourage good environmental behaviour are often polarised between regulation and legislation at one extreme and voluntary environmental agreements at the other. It is clear that a holistic mixture of interventions is necessary to achieve maximum engagement by all SMEs. This paper categorises the main behaviours observed in SMEs towards environmental issues and develops a selection or 'tool kit' of intervention strategies that might be deployed within each category of SME for maximum effect.

Intervention designed to reduce the use of summary execution in acute psychiatric inpatient settings

Context: Although it may seem preposterous to consider the need to reduce the use of summary executions in acute psychiatric inpatient settings because practitioners simply would not consider using such inhumane treatment, it is sobering that many mental health professionals do not hesitate to use seclusion.

Objectives: We draw attention to the assumption that underlies the thinking of many mental health professionals that seclusion is acceptable simply because it is available.

Key messages: The letter of the law (seclusion is legal) is frequently given precedence over the spirit of the law (seclusion should used as a method of last resort, if at all). The availability of seclusion as an intervention makes its use inevitable. Although sufficient checks and balances exist in society to prevent psychiatric staff from adding summary executions to their ‘‘treatment’’ paradigms, legislators need to set the bar much higher. Outside intervention, in the form of legislation, is needed because the mental health professions seem incapable of discontinuing the use seclusion despite evidence of the trauma it causes to both patients and staff and despite the lack of evidence that it achieves any desirable outcomes.

Conclusion: The use of seclusion is unacceptable and should be as impossible and unthinkable as summarily executing our patients. By the use of what would seem, at first glance, an absurd analogy between seclusion and summary execution we highlight the need for a shift in policy and legislation regarding the use of traumatising interventions.

Change of perspective: a measurable and desired outcome of chronic disease self-management intervention programs that violates the premise of preintervention/postintervention assessment

Objective: To determine if participants in chronic disease self-management courses have a change of perspective of their health status (a response shift), and if this is measurable with a paper-based questionnaire.

Methods: Nine items were developed to measure potential benefits of self-management courses. These were based on the constructs of a previous questionnaire, the Health Education Impact Questionnaire (HEI-Q). Cognitive interviews elicited spontaneous statements about the reasons for paper-based answers. Sensitivity, specificity, and overall accuracy of items were calculated using the interview as a relative gold standard. Response shift can be negative (i.e., after the course, participants realize that, before the course, they were worse than they thought they were), positive (i.e., participants now realize they were better than they thought they were), or absent (no change).

Results: Interviews (n = 39) reflected that true response shift occurred in approximately half the replies to questionnaire items. Of these, 31% were negative response shift, 20% were positive response shift. Response shift was absent in 32% of replies. Presence or absence of response shift could not be determined in 17% of replies across items. Significant concordance between questionnaires and cognitive interviews (average overall accuracy 0.79) indicated that the HEI-Q Perspective questionnaire detects response shift in participants of self-management courses. The questionnaire revealed that 87% of participants had response shift in at least 1 item.

Conclusion: This study suggests that preintervention/postintervention assessments of interventions such as self-management courses are confounded by a change in perspective of a large proportion of respondents. It also indicates response shift is a valuable outcome of self-management courses that can be measured with a paper-based questionnaire.

The effects of an area-based intervention on the uptake of maternal and child health assessments in Australia : a community trial

Background
Recognition of the importance of the early years in determining health and educational attainment and promotion of the World Health Organization Health for All (HFA) principles has led to an international trend towards community-based initiatives to improve developmental outcomes among socio-economically disadvantaged children. In this study we examine whether, Best Start, an Australian area-based initiative to improve child health was effective in improving access to Maternal and Child Health (MCH) services.

Methods
The study compares access to information, parental confidence and annual 3.5 year Ages and Stages visiting rates before (2001/02) and after (2004/05) the introduction of Best Start. Access to information and parental confidence were measured in surveys of parents with 3 year old children. There were 1666 surveys in the first wave and 1838 surveys in the second wave. The analysis of visiting rates for the 3.5 year Ages and Stages visit included all eligible Victorian children. Best Start sites included 1,739 eligible children in 2001/02 and 1437 eligible children in 2004/05. The comparable figures in the rest of the state were and 45, 497 and 45, 953 respectively.

Results
There was a significant increase in attendance at the 3.5 year Ages and Stages visit in 2004/05 compared to 2001/02 in all areas. However the increase in attendance was significantly greater at Best Start sites than the rest of the state. Access to information and parental confidence improved over the course of the intervention in Best Start sites with MCH projects compared to other Best Start sites.

Conclusion
These results suggest that community-based initiatives in disadvantaged areas may improve parents' access to child health information, improve their confidence and increase MCH service use. These outcomes suggest such programmes could potentially contribute to strategies to reduce child health inequalities.

Outcomes and costs of primary care surveillance and intervention for overweight or obese children : the LEAP 2 randomised controlled trial

Objective To determine whether ascertainment of childhood obesity by surveillance followed by structured secondary prevention in primary care improved outcomes in overweight or mildly obese children.

Design Randomised controlled trial nested within a baseline cross sectional survey of body mass index (BMI). Randomisation and outcomes measurement, but not participants, were blinded to group assignment.

Setting 45 family practices (66 general practitioners) in Melbourne, Australia.

Participants 3958 children visiting their general practitioner in May 2005-July 2006 were surveyed for BMI. Of these, 258 children aged 5 years 0 months up to their 10th birthday who were overweight or obese by International Obesity Taskforce criteria were randomised to intervention (n=139) or control (n=119) groups. Children who were very obese (UK BMI z score 3.0) were excluded.

Intervention Four standard consultations over 12 weeks targeting change in nutrition, physical activity, and sedentary behaviour, supported by purpose designed family materials.

Main outcomes measures Primary measure was BMI at 6 and 12 months after randomisation. Secondary measures were mean activity count/min by 7-day accelerometry, nutrition score from 4-day abbreviated food frequency diary, and child health related quality of life. Differences were adjusted for socioeconomic status, age, sex, and baseline BMI.

Results Of 781 eligible children, 258 (33%) entered the trial; attrition was 3.1% at 6 months and 6.2% at 12 months. Adjusted mean differences (intervention – control) at 6 and 12 months were, for BMI, –0.12 (95% CI –0.40 to 0.15, P=0.4) and –0.11 (–0.45 to 0.22, P=0.5); for physical activity in counts/min, 24 (–4 to 52, P=0.09) and 11 (–26 to 49, P=0.6); and, for nutrition score, 0.2 (–0.03 to 0.4, P=0.1) and 0.1 (–0.1 to 0.4, P=0.2). There was no evidence of harm to the child. Costs to the healthcare system were significantly higher in the intervention arm.

Conclusions Primary care screening followed by brief counselling did not improve BMI, physical activity, or nutrition in overweight or mildly obese 5-10 year olds, and it would be very costly if universally implemented. These findings are at odds with national policies in countries including the US, UK, and Australia.

Programs for men who perpetrate domestic violence : an examination of the issues underlying the effectiveness of intervention programs

This review paper seeks to explore some of the reasons why rehabilitation programs for male perpetrators of domestic violence appear to be less effective in reducing recidivism than programs for other offender groups. It is argued that while the model of systems response to domestic violence has predominated at the inter-agency level, further consideration might be given to way in which men’s intervention groups are both designed and delivered. It is concluded that the program logic of men’s domestic violence programs is rarely articulated leading to low levels of program integrity, and that one way to further improve program effectiveness is to incorporate some of the approaches evident in more general violence prevention programs and from what is know about good practice in general about offender rehabilitation.

The development of CBT programmes for anger : the role of interventions to promote perspective-taking skills

Although the emotion of anger has, in recent years, been the subject of increasing theoretical analysis, there are relatively few accounts of how interventions designed to reduce problematic anger might be related to cognitively oriented theories of emotion. In this review of the literature we describe how a cognitive-behavioural approach to the treatment of those with anger-related problems might be understood in relation to conceptualizations of anger from a cognitive perspective. Three additional interventions (visual feedback, chair-work, forgiveness therapy) are identified that aim to improve the perspective-taking skills of angry clients. It is concluded that such interventions might be considered for use within the context of cognitive-behavioural treatment.

Drop-out from parenting training programmes : a retrospective study

Objective: Parent training programmes are a well-established treatment approach for children and adolescents with disruptive behaviour disorders. However, dropout from treatment is a common problem that confounds research on the efficacy of this approach, and wastes important mental health resources. This study sought to further our understanding of the reasons why parents drop out of parent training programmes.

Method: Nine parents of children with disruptive behaviour disorders who had dropped out of a parent training programme were interviewed to investigate why they discontinued the programme.

Results: Parents who dropped out of treatment believed that their children were more difficult than other children with the same disorder and may have been better suited to a child-focused intervention. The parents themselves had very stressful lives, with the majority being single mothers with little support. Dropout parents also had difficulty with the group context and putting strategies into place. Practical concerns included parking, timing of session and the length and number of sessions.

Conclusions: The findings are discussed in terms of what modifications can be made to these programmes to increase retention.