Diabetes prevention research: a systematic review of external validity in lifestyle interventions

Context

Type 2 diabetes is a major contributor to disease burden globally. A number of systematic reviews support the efficacy of lifestyle interventions in preventing Type 2 diabetes in adults; however, relatively little attention has been paid to the generalizability of study findings. This study systematically reviews the reporting of external validity components and generalizability of diabetes prevention studies.

Evidence acquisition

Lifestyle intervention studies for the prevention of Type 2 diabetes in adults with at least 6 months' follow-up, published between 1990 and 2011, were identified through searches of major electronic databases. External validity reporting was rated using an assessment tool, and all analysis was undertaken in 2011.

Evidence synthesis

A total of 31 primary studies (n=95 papers) met the selection criteria. All studies lacked full reporting on external validity elements. Description of the study sample, intervention, delivery agents, and participant attrition rates were reported by most studies. However, few studies reported on the representativeness of individuals and settings, methods for recruiting settings and delivery agents, costs, and how interventions could be institutionalized into routine service delivery. It is uncertain to what extent the findings of diabetes prevention studies apply to men, socioeconomically disadvantaged individuals, those living in rural and remote communities, and to low- and middle-income countries.

Conclusions

Reporting of external validity components in diabetes prevention studies needs to be enhanced to improve the evidence base for the translation and dissemination of these programs into policy and practice.

Histopathological fish health index: a biomarker of pollution effect

 Changes in cellular structure in Antarctic Rock-cod signified biological impact of untreated human wastewater on the marine ecosystem at Davis Station, East Antarctica. Based on these alterations a Histological Health Index was developed to identify and compare changes in fish health correlated to the degree of wastewater exposure. The health index provides a risk assessment tool applicable for all Antarctic Treaty research stations.

Assessing the impact of drought and forestry on streamflows in south-eastern Australia using a physically based hydrological model

An increase in plantation forestry has been linked to a reduction in streamflows in some catchments. Quantifying the relative contribution of this land-use change on streamflows can be complex when those changes occur during weather extremes such as drought. In this study, the Soil and Water Assessment Tool (SWAT) model was applied to two sub-catchments in south-eastern Australia which have seen the introduction and establishment of plantation land use in the past 15 years, coinciding with severe drought (1997–2009). The models were both manually and auto-calibrated and produced very good fits to observed streamflow data during both calibration (1980–1991) and validation (1992–2009) periods. Sensitivity analyses indicated that the models were most sensitive to soil and groundwater parameterisation. Analysis of drought conditions on streamflows showed significant declines from long-term average streamflows, while assessment of baseflow contributions by the models indicated a mix of over- and underestimation depending on catchment and season. The modelled introduction of plantation forestry did not significantly change streamflows for a scenario which did not include the land-use change, suggesting that the modelled land-use change in the catchments was not sufficiently extensive to have an impact on streamflows despite simulating actual rates of change. The SWAT models developed by this study will be invaluable as a basis for future use in regional climate-change studies and for the assessment of land management and land-use change impact on streamflows.

The use of Integral Theory to evaluate architectural sustainability - a case study

DeKay’s concept of Integral Sustainable Design (ISD) is based on Integral Theory, a framework proposed by the American philosopher, Ken Wilber. It offers four simultaneous perspectives (represented by quadrants) which each take a different view of the problem. The ‘experiences’ quadrant focuses on individual human experiences. The ‘behaviours’ quadrant looks at environmental performance. The ‘cultures’ perspective focuses on the collective interpretation of meaning, symbolism and worldviews and the ‘systems’ quadrant investigates the response and interaction with context. Integral Theory can act as a reminder for architects of the different perspectives that a sustainable building should address. In order to evaluate ISD, the Waterfront Campus Building of Deakin University has been used as a case study. The building, its performance, impact and perception, has been evaluated using both quantitative and qualitative data. Two surveys have been conducted to gather qualitative data to: (i) determine the experience of building users (staff and students) and (ii) the perception of non-users (Geelong residents and tourists). Data from building services and a site analysis has enabled quantitative assessments to be made. These inputs have been analysed, guided by ISD, to evaluate the usefulness of ISD as a sustainability assessment tool.

Dietary patterns and successful ageing: a systematic review

PURPOSE: Nutrition is a key determinant of chronic disease in later life. A systematic review was conducted of studies examining dietary patterns and quality of life, physical function, cognitive function and mental health among older adults. METHODS: Literature searches in MEDLINE complete, Academic Search Complete, CINAHL Complete, Ageline, Global health, PsycINFO, SCOPUS and EMBASE and hand searching from 1980 up to December 2014 yielded 1236 results. Inclusion criteria included dietary pattern assessment via dietary indices or statistical approaches, a sample of community-dwelling adults aged 45 years and over at baseline and a cross-sectional or longitudinal study design. Exclusion criteria included a single 24-h recall of diet, evaluation of single foods or nutrients, clinical or institutionalised samples and intervention studies. Risk of bias was assessed using the six-item Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies. RESULTS: There were 34 articles (11 cross-sectional and 23 longitudinal) included with 23 studies examining dietary indices and 13 studies using empirical analysis. Most studies examined mental health (n = 10) or cognitive function (n = 18), with fewer studies examining quality of life (n = 6) and physical function (n = 8). Although dietary pattern and outcome assessment methods varied, most studies reported positive associations between a healthier diet and better health outcomes. CONCLUSION: Overall, the number of studies using dietary patterns to investigate diet and successful ageing is small, and further investigation in longitudinal studies is needed, particularly for quality-of-life outcomes. This review provides support for the importance of a healthy diet for the ageing population globally.

Measuring problem gambling in Indigenous communities : an Australian response to the research dilemmas

This paper examines evidence relating to harmful consequences of gambling in the Australian Indigenous population and highlights the failure of research to date to define problem gambling from Indigenous perspectives or to tailor research processes to accommodate the cultural beliefs and experiences of Indigenous groups. It advocates for the development of a unique set of measures to assess the function of problem gambling aspects, negative impacts, trends, risks and protective factors. This would be informed by more recent qualitative studies into gambling that are specific to Indigenous communities. Additionally, this paper argues the need to adapt and validate a commonly applied assessment tool, such as the Canadian Problem Gambling Index, to monitor prevalence of problem gambling over time. Targeted research into Indigenous people's experiences of gambling will facilitate the development of culturally based responses and interventions into problem gambling.

Chronic disease self-management in Aboriginal communities : towards a sustainable program of care in rural communities

The Chronic Disease Self-Management (CDSM) strategy for Aboriginal patients on Eyre Peninsula, South Australia, was designed to develop and trial new program tools and processes for goal setting, behaviour change and self-management for Aboriginal people with diabetes. The project was established as a one-year demonstration project to test and trial a range of CDSM processes and procedures within Aboriginal communities and not as a formal research project. Over a one-year period, 60 Aboriginal people with type-2 diabetes in two remote regional centres participated in the pilot program. This represents around 25% of the known Aboriginal diabetic population in these sites. The project included training for four Aboriginal Health Workers in goal setting and self-management strategies in preparation for them to run the program. Patients completed a Diabetes Assessment Tool, a Quality of Life Questionnaire (SF12), the Work and Social Adjustment Scale (WASAS) at 0, 6 and 12 months. The evaluation tools were assessed and revised by consumers and health professionals during the trial to determine the most functional and acceptable processes for Aboriginal patients. Some limited biomedical data were also recorded although this was not the principal purpose of the project. Initial results from the COAG coordinated care trial in Eyre suggest that goal setting and monitoring processes, when modified to be culturally inclusive of Aboriginal people, can be effective strategies for improving self-management skills and health-related behaviours of patients with chronic illness. The CDSM pilot study in Aboriginal communities has led to further refinement of the tools and processes used in chronic illness self-management programs for Aboriginal people and to greater acceptance of these processes in the communities involved. Participation in a diabetes self-management program run by Aboriginal Health Workers assists patients to identify and understand their health problems and develop condition management goals and patient-centred solutions that can lead to improved health and wellbeing for participants. While the development of self-management tools and strategies led to some early indications of improvements in patient participation and resultant health outcomes, the pilot program and the refinement of new assessment tools used to assist this process has been the significant outcome of the project. The CDSM process described here is a valuable strategy for educating and supporting people with chronic conditions and in gaining their participation in programs designed to improve the way they manage their illness. Such work, and the subsequent health outcome research planned for rural regions, will contribute to the development of more comprehensive CDSM programs for Aboriginal communities generally.

Health literacy and the determinants of obesity: a population-based survey of sixth grade school children in Taiwan

BACKGROUND: Health literacy has become an important health policy and health promotion agenda item in recent years. It had been seen as a means to reduce health disparities and a critical empowerment strategy to increase people's control over their health. So far, most of health literacy studies mainly focus on adults with few studies investigating associations between child health literacy and health status. This study aimed to investigate the association between health literacy and body weight in Taiwan's sixth grade school children.

METHODS: Using a population-based survey, 162,209 sixth grade (11-12 years old) school children were assessed. The response rate at school level was 83%, with 70% of all students completing the survey. The Taiwan child health literacy assessment tool was applied and information on sex, ethnicity, self-reported health, and health behaviors were also collected. BMI was used to classify the children as underweight, normal, overweight, or obese. A multinomial logit model with robust estimation was used to explore associations between health literacy and the body weight with an adjustment for covariates.

RESULTS: The sample consisted of 48.9% girls, 3.8% were indigenous and the mean BMI was 19.55 (SD = 3.93). About 6% of children self-reported bad or very bad health. The mean child health literacy score was 24.03 (SD = 6.12, scale range from 0 to 32). The overall proportion of obese children was 15.2%. Children in the highest health literacy quartile were less likely to be obese (12.4%) compared with the lowest quartile (17.4%). After controlling for gender, ethnicity, self-rated health, and health behaviors, children with higher health literacy were less likely to be obese (Relative Risk Ratio (RRR) = 0.94, p < 0.001) and underweight (RRR = 0.83, p < 0.001). Those who did not have regular physical activity, or had sugar-sweetened beverage intake (RRR > 1.10, p < 0.0001) were more likely to report being overweight or obese.

CONCLUSIONS: This study demonstrates strong links between health literacy and obesity, even after adjusting for key potential confounders, and provides new insights into potential intervention points in school education for obesity prevention. Systematic approaches to integrating a health literacy curriculum into schools may mitigate the growing burden of disease due to obesity.

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

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

Prejudicial evaluation: bias in self-and-peer-assessments of teamwork contributions to design

This chapter considers a simple but important question: can students fairly assess each other’s individual contribution to team designs? The chapter focuses on a key problem when using online self-and-peerassessment to individualising design grades for team assignments, namely rater bias – the possibility of students being biased when assessing their own and their peers’ contributions. Three rater-bias issuesare considered in depth: (1) self-overmarking; (2) gender bias and gender differences; and (3) out-group bias in the peer assessment of international students in multicultural cohorts. Each issue is explored viathe analysis of eight years of quantitative data from the use of an online self-and-peer assessment tool. Evidence is found of self-overmarking and of out-group bias in nonhomogeneous cohorts. However, no evidence is found of gender bias. The chapter concludes with recommendations for design teachers around the assessment of individual contributions to teamwork using self-and-peer assessment.

Assessment as a strategic tool for enhancing learning in teacher education: a case study

This small exploratory case study describes an attempt to integrate the academic and practical aspects of a teacher education course in order to promote deep understanding of children's ways of understanding mathematics. The assessment regime of the course was used as a strategic tool for engaging students, and the assessment tasks themselves were used as the means of generating genuine integration, or case knowledge, of the content of the course. The results indicate that the approach was effective in achieving the aims of the course, and student reaction to the approach was extremely positive.

Producing a GIS based multiple criteria analysis tool for regional sustainability assessment: the problem of weighting

Decision support tools will be useful in guiding regions to sustainability. These need to be simple but effective at identifying, for regional managers, areas most in need of initiatives to progress sustainability. Multiple criteria analysis (MCA) is often used as a decision support tool for a wide range of applications. This method allows many criteria to be considered at one time. It does this by giving a ranking of possible options based on how closely each option meets the criteria. Thus, it is suited to the assessment of regional sustainability as it can consider a number of indicators simultaneously and demonstrates how sustainability can vary at small scales across the region. Coupling MCA with GIS to produce maps, allows this analysis to become visual giving the manager a picture of sustainability across the region. To do this each indicator is standardised to a common scale so that it can be compared to other indicators. A weighting is then applied to each indicator to calculate weighted summation for each area in the region. This paper argues that this is the critical step in developing a useful decision support tool. A study being conducted in south west Victoria demonstrates that the weights chosen can have a dramatic impact on the results of the sustainability assessment. It is therefore imperative that careful consideration be given to determining indicator weights in a way that is objective and fully considers the impact of that indicator on regional sustainability.

Equity-focused health impact assessment: a tool to assist policy makers in addressing health inequalities.

In Australasia (Australia and New Zealand) the use of health impact assessment (HIA) as a tool for improved policy development is comparatively new. The public health workforce do not routinely assess the potential health and equity impacts of proposed policies or programs. The Australasian Collaboration for Health Equity Impact Assessment was funded to develop a strategic framework for equity-focused HIA (EFHIA) with the intent of strengthening the ways in which equity is addressed in each step of HIA. The collaboration developed a draft framework for EFHIA that mirrored, but modified the commonly accepted steps of HIA; tested the draft framework in six different health service delivery settings; analysed the feedback about application of the draft EFHIA framework and modified it accordingly. The strategic framework shows promise in providing a systematic process for identifying potential differential health impacts and assessing the extent to which these are avoidable and unfair. This paper presents the EFHIA framework and discusses some of the issues that arose in the case study sites undertaking equity-focused HIA.