Family physician preceptors' conceptualizations of health advocacy: implications for medical education

PURPOSE: Despite its official acceptance as an important physician responsibility, health advocacy remains difficult to define, teach, role model, and assess. The aim of the current study was to explore physicians' conceptions of health advocacy based on their experience with health-advocacy-related activities. METHOD: In 2012, the authors conducted 11 semistructured interviews with family physician clinical preceptors and analyzed the interviews in the tradition of phenomenography. RESULTS: The authors identified three distinct but related ways of understanding health advocacy: (1) Clinical: Health advocacy as support of individual patients in addressing health care needs related to the immediate clinical problem within the health care system, (2) Paraclinical: Health advocacy as support of individual patients in addressing needs that the physician preceptors viewed as peripheral yet parallel to both the health care system and the immediate clinical problem, and (3) Supraclinical: Health advocacy as population-based activities aimed at practice- and system-level changes that address the social determinants of health. CONCLUSIONS: The qualitatively different understandings of health advocacy shed light on why current approaches to defining, teaching, role modeling, and assessing health advocacy competencies in medical education appear idiosyncratic. The authors suggest the development of an inclusive and extensive conceptual framework that may allow the medical education community to imagine novel ways of understanding and engaging in health advocacy.

The epidemiology of cataract: a review of the literature

Cataract is a major cause of blindness, accounting for nearly half of all blindness worldwide. Epidemiological research provides the principles and methods to assess the extent of cataract, and supplies the necessary information for policy planning. Obtaining accurate epidemiological data on cataract is essential to ascertain and estimate the cost of primary and secondary eye health care needs. Determining risk factors is also necessary to reduce the economic and social repercussions associated with the disease. The following paper presents a review of the epidemiology of cataract in the middle to elderly age group.

The importance of epidemiology in understanding eye disease

Most leading causes of visual impairment are age related, so the health care implications of an increasing prevalence of eye disease in the elderly are significant. Epidemiological research provides the foundation to address immediate and long-term needs associated with visual impairment and eye disease. It contributes to a community's knowledge of the presence, diagnosis, characteristics, and distribution of eye conditions affecting the elderly. Obtaining accurate epidemiological information on the extent of visual impairment and eye disease in the community is essential to determine and estimate the cost of primary and secondary eye health care needs.

Morbidity patterns among the underweight, overweight and obese between 2 and 18 years: population-based cross-sectional analyses

CONTEXT: No study has documented how symptomatic morbidity varies across the body mass index (BMI) spectrum (underweight, normal weight, overweight and obese) or across the entire child and adolescent age range. OBJECTIVE: To (1) quantify physical and psychosocial morbidities experienced by 2-18-year-olds according to BMI status and (2) explore morbidity patterns by age. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional data from two Australian population studies (the Longitudinal Study of Australian Children and the Health of Young Victorians Study) were collected during 2000-2006. Participants were grouped into five age bands: 2-3 (n=4606), 4-5 (n=4983), 6-7 (n=4464), 8-12 (n=1541) and 13-18 (n=928) years. MAIN MEASURES: Outcomes-Parent- and self-reported global health; physical, psychosocial and mental health; special health-care needs; wheeze; asthma and sleep problems. Exposure-measured BMI (kg m(-2)) categorised using standard international cutpoints. ANALYSES: The variation in comorbidities across BMI categories within and between age bands was examined using linear and logistic regression models. RESULTS: Comorbidities varied with BMI category for all except sleep problems, generally showing the highest levels for the obese category. However, patterns differed markedly between age groups. In particular, poorer global health and special health-care needs were associated with underweight in young children, but obesity in older children. Prevalence of poorer physical health varied little by BMI in 2-5-year-olds, but from 6 to 7 years was increasingly associated with obesity. Normal-weight children tended to experience the best psychosocial and mental health, with little evidence that the U-shaped associations of these variables with BMI status varied by age. Wheeze and asthma increased slightly with BMI at all ages. CONCLUSIONS: Deviation from normal weight is associated with health differences in children and adolescents that vary by morbidity and age. As well as lowering risks for later disease, promoting normal body weight appears central to improving the health and well-being of the young.

HealthMap: a cluster randomised trial of interactive health plans and self-management support to prevent coronary heart disease in people with HIV

BACKGROUND: The leading causes of morbidity and mortality for people in high-income countries living with HIV are now non-AIDS malignancies, cardiovascular disease and other non-communicable diseases associated with ageing. This protocol describes the trial of HealthMap, a model of care for people with HIV (PWHIV) that includes use of an interactive shared health record and self-management support. The aims of the HealthMap trial are to evaluate engagement of PWHIV and healthcare providers with the model, and its effectiveness for reducing coronary heart disease risk, enhancing self-management, and improving mental health and quality of life of PWHIV.

METHODS/DESIGN: The study is a two-arm cluster randomised trial involving HIV clinical sites in several states in Australia. Doctors will be randomised to the HealthMap model (immediate arm) or to proceed with usual care (deferred arm). People with HIV whose doctors are randomised to the immediate arm receive 1) new opportunities to discuss their health status and goals with their HIV doctor using a HealthMap shared health record; 2) access to their own health record from home; 3) access to health coaching delivered by telephone and online; and 4) access to a peer moderated online group chat programme. Data will be collected from participating PWHIV (n = 710) at baseline, 6 months, and 12 months and from participating doctors (n = 60) at baseline and 12 months. The control arm will be offered the HealthMap intervention at the end of the trial. The primary study outcomes, measured at 12 months, are 1) 10-year risk of non-fatal acute myocardial infarction or coronary heart disease death as estimated by a Framingham Heart Study risk equation; and 2) Positive and Active Engagement in Life Scale from the Health Education Impact Questionnaire (heiQ).

DISCUSSION: The study will determine the viability and utility of a novel technology-supported model of care for maintaining the health and wellbeing of people with HIV. If shown to be effective, the HealthMap model may provide a generalisable, scalable and sustainable system for supporting the care needs of people with HIV, addressing issues of equity of access.

Nurse-led group consultation intervention reduces depressive symptoms in men with localised prostate cancer: a cluster randomised controlled trial

BACKGROUND: Radiotherapy for localised prostate cancer has many known and distressing side effects. The efficacy of group interventions for reducing psychological morbidity is lacking. This study investigated the relative benefits of a group nurse-led intervention on psychological morbidity, unmet needs, treatment-related concerns and prostate cancer-specific quality of life in men receiving curative intent radiotherapy for prostate cancer.

METHODS: This phase III, two-arm cluster randomised controlled trial included 331 men (consent rate: 72 %; attrition: 5 %) randomised to the intervention (n = 166) or usual care (n = 165). The intervention comprised four group and one individual consultation all delivered by specialist uro-oncology nurses. Primary outcomes were anxious and depressive symptoms as assessed by the Hospital Anxiety and Depression Scale. Unmet needs were assessed with the Supportive Care Needs Survey-SF34 Revised, treatment-related concerns with the Cancer Treatment Scale and quality of life with the Expanded Prostate Cancer Index -26. Assessments occurred before, at the end of and 6 months post-radiotherapy. Primary outcome analysis was by intention-to-treat and performed by fitting a linear mixed model to each outcome separately using all observed data.

RESULTS: Mixed models analysis indicated that group consultations had a significant beneficial effect on one of two primary endpoints, depressive symptoms (p = 0.009), and one of twelve secondary endpoints, procedural concerns related to cancer treatment (p = 0.049). Group consultations did not have a significant beneficial effect on generalised anxiety, unmet needs and prostate cancer-specific quality of life.

CONCLUSIONS: Compared with individual consultations offered as part of usual care, the intervention provides a means of delivering patient education and is associated with modest reductions in depressive symptoms and procedural concerns. Future work should seek to confirm the clinical feasibility and cost-effectiveness of group interventions.

Addressing training needs for community care assessment in remote Indigenous communities

Access to Home and Community Care services in Australia is based on the assessed needs of individual clients, with individual Home and Community Care organisations generally being responsible for initial assessment of eligibility and need. Home and Community Care funded services are expected to operate within the agency's program guidelines and to adhere to minimum service standards. However, service delivery contexts in remote areas of Australia present particular challenges for staff in the practice of assessment and care planning. This paper discusses the findings of a project which investigated approaches to assessment of client needs in remote Home and Community Care services. Some of the challenges of providing care in remote/Indigenous contexts are discussed. The research project highlighted that there was an inadequate knowledge base to assist staff with assessment and care planning in these cross-cultural contexts; a greater focus on developing the assessment skills of staff was needed. Subsequently, an education program incorporating the International Classification of Functioning, Disability and Health was developed for Home and Community Care assessment staff in remote communities. Rather than focusing on process skills and procedures, the program was designed to equip staff with a solid and consistent conceptual framework to assist with assessment and care planning.

Revising the critical care family needs inventory for the emergency department

Background: The Critical Care Family Needs Inventory (CCFNI) has been used widely over the last two decades for analysing the needs of family members in the intensive care unit. However, it has significant limitations as a needs assessment tool for use with families in the Emergency Department (ED). This paper discusses the methodological challenges encountered during the process of reviewing and adapting this tool for use in the ED. Aims: The purpose of this study was to revise and adapt the CCFNI for use with a population of family members of critically ill patients in an Australian Emergency Department. Instrument: The process of tool revision, adaptation and reconstruction included: critique of the CCFNI; concept definition; item review; content and structure revision; scale revision; and testing with a sample of the target population. Methods: Data collection methods were aimed at accessing a vulnerable population, while enhancing response rate and data quality. A sample of 84 relatives of critically ill patients from one Melbourne Metropolitan Emergency Department was used, 73% of whom returned questionnaires. Results: Pilot data were examined with the specific purpose of identifying elements of the tool that required refinement or modification. Methods used for establishing reliability and validity of the revised tool provided satisfactory results. Limitations: Limitations of this study include inadequate sample size for exploratory factor analysis, and an incomplete response set for some items, which influenced item analysis. Conclusion: The process used for addressing the identified methodological issues in reviewing and adapting the CCFNI for use in the ED provides a framework for adapting an established tool for a specific purpose.

Assessment of indigenous older peoples ’ needs for home and community care in remote central Australia

The Home and Community Care (HACC) program in Australia provides services which supports older people to live at home. Individual HACC organisations are generally responsible for initial assessment of eligibility and need of clients presenting for services. This paper reports on a project which aimed to develop an understanding of the various approaches to assessment of client needs in Central Australia. The majority of clients in this geographical area are indigenous. The project was initiated in recognition of the primary importance of assessment in determining service access and service delivery and of the particular challenges faced by service providers in remote areas. This paper discusses key project findings including the client group and services provided, initial needs assessment and care planning processes. Evident inconsistencies in practice reflect a variety of complex contextual factors. Staff in remote areas have an inadequate knowledge base to draw upon to assist them with assessment and care planning decisions, and further research and professional development is required.

Addressing online information needs in palliative care : an action research-inspired approach

Whereas user participation has been embraced worldwide as a means to provide better patient outcomes, the implementation of formative, action research approaches in online health information has remained under-explored. The purpose of this study is to present an action research-based methodology that allows the scoping of health information and design needs in complex, multi-user online environments. The project's four main stages were informed by an iterative, formative approach involving continuous expert and user evaluation. The study suggests that an action research-inspired formative approach can be successfully employed to generate user-participation. Moreover, sustained user-participation effectively addresses most quality issues regarding content, language, and accessibility raised in the recent literature. The paper concludes that an action research approach geared to develop online health resources deserves more attention.

Supporting information needs of senior citizens in community aged care

To address the challenge of an ageing population in an information society, it is important to introduce information systems to assist the aged people in maintaining and improving their quality of life. An understanding of what information aged people need, how they seek and use information, and how they adopt Information and Communication Technology (ICT) is required. This paper reports the findings of an empirical study undertaken in Australia to understand the information needs of senior citizens who reside in the community. The study aims to understand how ICT can support the independent living of senior people in the community from both the social and health perspectives. We offer a new understanding of the information needs of aged people in the community and extend the information systems research in aged care. This research also contributes to the development of innovative ICT enabled aged care service solutions in community aged care.