Dyslipidaemia in rural Australia : prevalence, awareness, and adherence to treatment guidelines in the Greater Green Triangle risk factor study

Objectives: To determine population lipid profiles, awareness of hyperlipidaemia and adherence to Australian lipid management guidelines.
Design and setting: Population survey in rural south-eastern Australia, 2004–2006.
Participants: Stratified random sample from the electoral roll. Data from 1274 participants (40%) aged 25–74 years were analysed.
Main outcome measures: Population mean total, low-density lipoprotein and high-density lipoprotein cholesterol (TC, LDL-C and HDL-C) and triglyceride (TG) concentrations, prevalence of dyslipidaemia, and treatment according to 2001 and 2005 Australian guideline target levels.
Results: Population-adjusted mean TC, TG, LDL-C and HDL-C concentrations were 5.38 mmol/L (95% CI, 5.30–5.45), 1.50 mmol/L (95% CI, 1.43–1.56), 3.23 mmol/L (95% CI, 3.16–3.30) and 1.46 mmol/L (95% CI, 1.44–1.49), respectively. Prevalence of hypercholesterolaemia (TC > 5.5 mmol/L or on treatment) was 48%. Lipid-lowering medication use was reported by 12%. Seventy-seven of 183 participants with established cardiovascular disease (CVD) or diabetes were untreated, and of the 106 treated, 59% reached the target LDL-C. Of those without CVD or diabetes already treated, 38% reached target LDL-C, and 397 participants at high absolute risk did not receive primary prevention. Ninety-five per cent of treated individuals with CVD or diabetes and 86% of others treated had cholesterol measured in the previous year. Sixty-nine per cent of individuals at low risk aged over 45 years had their cholesterol measured within the previous 5 years.
Conclusions: A comprehensive national strategy for lowering mean population cholesterol is required, as is better implementation of absolute risk management guidelines — particularly in rural populations.

Guideline-based programs in the treatment of complex PTSD

The term “post-traumatic stress disorder” (PTSD) is a relatively new diagnostic label, being formally recognized in 1980 in the Diagnostic Statistical Manual for Psychiatric Illness – Third Edition (DSM-III) of the American Psychiatric Association (APA, 1980). Complex Post-Traumatic Stress Disorder (CP) is a more recently discussed, and newly-classified, phenomenon, initially discussed in the early 1990s (Herman, 1992a). Thus, as research into effective treatments for CP is sparse, the treatment of CP is the topic of this study, in which a guideline-based treatment program developed by the researcher for the treatment of CP is implemented and evaluated. Ten individuals participated in this study, undertaking individualized, guideline-based treatment programs spanning a period of six months. In providing background information relevant to this study, an explanation is provided regarding the nature of CP, and the reasons for its consideration as a separate phenomenon to PTSD. The adequacy of the PTSD formulation in enabling effective assessment and treatment of CP is also explored, with endorsement of previous researchers’ conclusions that the CP construct is more useful than the PTSD construct for assessing and treating survivors of long-term and multiple forms of abuse. The PTSD classification is restrictive, and not necessarily appropriate for certain forms of trauma (such as prolonged trauma, or multiple forms of trauma), as such trauma experiences may lead to specific effects that lay outside those formerly associated with PTSD. Such effects include alterations in affect regulation, consciousness, self-perception, interpersonal relationships, and in systems of meaning. Following discussion regarding the PTSD/CP classification, an examination of treatment methods currently used in the treatment of PTSD, and a review of treatment outcome studies, takes place. The adequacy of primary treatment methods in treating CP symptoms is then examined, with the conclusion that a range of treatment methods could potentially be useful in the treatment of CP symptoms. Individuals with a diagnosis of CP may benefit from the adoption of an eclectic approach, drawing on different treatment options for different symptoms, and constantly evaluating client progress and re-evaluating interventions. This review of treatment approaches is followed by details of an initial study undertaken to obtain feedback from individuals who had suffered long-term/multiple trauma and who had received treatment. Participants in this initial study were asked open-ended questions regarding the treatment approach they had experienced, the most useful aspect of the treatment, the least useful aspect, and other strategies/treatment approaches that may have been useful – but which were not used. The feedback obtained from these individuals was used to inform the development of treatment guidelines for use in the main study, as were recommendations made by Chu (1998). The predominant focus of the treatment guidelines was “ego strengthening”, a term coined by Chu (1998) to describe the “initial (sometimes lengthy) period of developing fundamental skills in maintaining supportive relationships, developing self-care strategies, coping with symptomatology, improving functioning, and establishing a positive self identity” (p.75). Using a case study approach, data are then presented relating to each of the ten individuals involved in the treatment program: details of his/her trauma experience(s)and the impact of the trauma (as perceived by each individual); details of each individual’s treatment program (as planned, and as implemented); post-treatment evaluation of the positive and negative aspects of the treatment program (from the therapist’s perspective); and details of the symptoms reported by the individual post-treatment, via psychometric assessment and also during interview. Analysis and discussion of the data relating to the ten participants in the study are the focal point of this study. The evaluation of the effectiveness of each individual’s treatment has been based predominantly on qualitative data, obtained from an analysis of language (discourse analysis) used by participants to describe their symptoms pre- and post-treatment. Both blatant and subtle changes in the language used by participants to describe themselves, their behaviour, and their relationships pre- and post-treatment have provided an insight into the possible changes that occurred as a result of the treatment program. The language used by participants has been a rich source of data, one that has enabled the researcher to obtain information that could not be obtained using psychometric assessment methods. Most of the participants in this study portrayed notable changes in many of the CP symptoms, including being more stable and having improved capacity to explore their early abuse. Although no direct cause-effect relationship between the participants’ treatment program and the improvements described can be established from this study, the participants’ perception that the program assisted them with their symptoms, and reported many aspects of “ego strengthening”, is of major importance. Such self-perception of strength and empowerment is important if an individual is going to be able to deal with past trauma experiences. In fact, abreactive work may have a greater chance of succeeding if those who have experienced long-term or multiple trauma are feeling more empowered, and more stable, as were the participants in this study (post-intervention). In concluding this study, recommendations have been made in regard to the use of guideline-based treatment programs in the responsible treatment of CP. Strengths and limitations of this study have also been highlighted, and recommendations have been made regarding possibilities for future research related to CP treatment. On the whole, this study has supported strongly other research that highlights the importance of focusing on “ego strengthening” in assisting those who have suffered long-term/multiple trauma experiences. Thus, a guideline-based program focusing on assisting sufferers of long-term trauma with some, or all, of the symptoms of CP, is recommended as an important first stage of any treatment of individuals who have experienced long-term/multiple trauma, allowing them to develop the emotional and psychological strength required to deal with past traumatic events. Clinicians who are treating patients whose history depicts long-term or multiple trauma experiences (either from their childhood, or at some stage in their adult life) need, therefore, to be mindful of assessing individuals for symptoms of CP – so that they can treat these symptoms prior to engaging in any work associated directly with the past traumatic experiences.

Provision of meals on wheels to the elderly : case studies in the era of local government reform

Australia’s ageing population is on the increase. It is predicted that by 2021 one quarter of Victoria’s elderly population will be aged 60 and over. Not only are people living longer, but they also wish to remain living in the community. The Home and Community Care (HACC) Program was established in 1985 to facilitate and assist the elderly and disabled to remain in their home. In Victoria around 51% of HACC funds are managed by local governments, a level of government that has recently undergone major reforms, which ultimately impacted on the manner in which services were provided. The HACC program funds Meals on Wheels, a service that provides meals for those elderly who no longer can prepare their own meals. The aim of this study was to assess the Meals on Wheels service provided by two Melbourne councils with different service philosophies. The study has four main components: (1) Menu analysis by food and variety; (2) Analysis of actual meals; (3) Clients assessment of Food Services; and (4) Client assessment of the organoleptic qualities of Meals on Wheels. Two Melbourne councils were chosen for their different approaches to service delivery. The City of South tendered out both meal production and delivery, while the City of North maintained its MOW service in-house. The case study method of research allowed for each council’s service to be assessed objectively and without comparison. Several methodologies were used for collecting data in this study. Menu analysis was carried out by comparing the MOW menus with the HACC menu planning guidelines together with general menu planning principles. Analysis of actual meals was in two stages. The weights of the meals were recorded and compared with the HACC recommended food serving portions and meal combinations over a five-day period were analysed for their nutrient contents. Face to face interviews were conducted with clients for their assessment of MOW and the assessment of the organoleptic qualities of the meals was carried out over a five-day period. The results concluded that both councils menus were based on sound menu planning principles, but did not conform with Home and Community Care menu planning guidelines fully and did not include a serve of bread, fruit and milk. The weight analysis of the meal combinations revealed some discrepancies between actual meals and Home and Community Care guidelines by not meeting the recommended serving sizes. Meal combinations generally met Home and Community Care standard for kilojoule and protein, but other nutrients, such as thiamin, riboflavin, magnesium, calcium and zinc were generally below the recommended levels for Meals On Wheels. The majority of study group lived alone and received four to five meals per week. Delivery times of meals, selective menus and food quality were issues raised by clients. Whilst the quality and variety of vegetables was raised by clients they generally rated the organoleptic qualities of the meals as satisfactory. This study examined the four components of the service. A simple method of evaluation the service was developed, which highlight discrepancies with HACC standards and encouraged the councils to set a customer satisfaction standard. A number of recommendations are made to ensure that meals are aesthetically pleasing, including a list of different methods for preparing vegetables. The provision of additional foods, such as a “snack pack” is recommended to improve the supply of essential nutrients that were below the Home and Community Care standards. Meals on Wheels is a vital support service for the elderly living in the community and as such should aim to provide a high quality service that meets the needs of its clients.

Investigative interviewing of children with intellectual disabilities

This research was designed to examine two broad issues in relation to the investigative interviewing of children (aged 9 to 13 years) with mild and moderate intellectual disabilities. First, how do children with intellectual disabilities perform (relative to children matched for chronological and mental age) when recalling an event in response to various questions? Second, what question types and interview strategies do police officers and caregivers use to elicit accurate and detailed accounts about an event from children with intellectual disabilities? The rationale for exploring each of these issues was to determine possible ways of improving the elicitation of evidence from children with intellectual disabilities. While children with intellectual disabilities constitute a high proportion of all child victims of abuse (Conway, 1994; Goldman, 1994; Morse, et ah, 1970), they rarely provide formal reports of abuse and of those incidents that are reported, few cases progress to court (Henry & Gudjonsson, 1999). Study 1 used a standard interview protocol containing a variety of questions and an interview structure commonly used in investigative interviews. Specifically, the memory and suggestibility of eighty children with either a mild and moderate intellectual disability (M age = 10.85 years) was examined when recalling an innocuous event that was staged at their school. The children's performance was compared with that of two control groups; a group of mainstream children matched for mental age and a group of mainstream children matched for chronological age. Overall, this study showed that children with both mild and moderate intellectual disabilities can provide accurate and highly specific event-related information hi response to questions recommended in best-practice guidelines. However, their recall was less complete and less clear in response to free-narrative prompts and less accurate in response to specific questions when compared to both mainstream age-matched groups. Study 2 provided an in-depth analysis of the types of questions and strategies used by twenty-eight police officers and caregivers when interviewing children with either mild or moderate intellectual disabilities (M age = 11.13 years) about a repeated event that was staged at their school. The results revealed that while the approach used by the police officers was generally consistent with best-practice recommendations (i.e., their interviews contained few leading, coercive or negative strategies), there were many ways in which their approach could be improved. This study also showed that the caregivers used a high proportion of direct and negative strategies to elicit information from their children. Even when caregivers used open-ended questions, their children provided less event-related information than they did to police interviewers. The results of both studies were discussed in relation to current 'best-practice' guidelines for interviewing children and recommendations were offered for improving the quality of field interviews with children who have intellectual disabilities.

‘We should change ourselves, but we can’t’: accounts of food and eating practices amongst British Pakistanis and Indians with type 2 diabetes

Objective(s). To look at food and eating practices from the perspectives of Pakistanis and Indians with type 2 diabetes, their perceptions of the barriers and facilitators to dietary change, and the social and cultural factors informing their accounts.

Method. Qualitative, interview study involving 23 Pakistanis and nine Indians with type 2 diabetes. Respondents were interviewed in their first language (Punjabi or English) by a bilingual researcher. Data collection and analysis took place concurrently with issues identified in early interviews being used to inform areas of investigation in later ones.

Results. Despite considerable diversity in the dietary advice received, respondents offered similar accounts of their food and eating practices following diagnosis. Most had continued to consume South Asian foods, especially in the evenings, despite their perceived concerns that these foods could be 'dangerous' and detrimental to their diabetes control. Respondents described such foods as 'strength-giving', and highlighted a cultural expectation to participate in acts of commensality with family/community members. Male respondents often reported limited input into food preparation. Many respondents attempted to balance the perceived risks of eating South Asian foodstuffs against those of alienating themselves from their culture and community by eating such foods in smaller amounts. This strategy could lead to a lack of satiation and is not recommended in current dietary guidelines.

Conclusions. Perceptions that South Asian foodstuffs necessarily comprise 'risky' options need to be tackled amongst patients and possibly their healthcare providers. To enable Indians and Pakistanis to manage their diabetes and identity simultaneously, guidelines should promote changes which work with their current food practices and preferences; specifically through lower fat recipes for commonly consumed dishes. Information and advice should be targeted at those responsible for food preparation, not just the person with diabetes. Community initiatives, emphasising the importance of healthy eating, are also needed.

Investigative interviewing of children : barriers to adopting 'best-practice' guidelines

This research examined the global difficulties of investigative interviewers in adhering to best-practice guidelines (i.e. open-ended questions) when interviewing children about abuse. It demonstrated that the importance of, and rationale for, using open-ended questions is not well understood by investigative interviewers, nor are they adequately reinforced with police organisations.

Implementation of clinical practice guidelines using simulation in education

Background: Underpinning the Department of Human Services (DHS) “Future directions for Victoria’s maternity services” strategy in Victoria, are the principles of achieving the right balance between primary level care and access to appropriate levels of medical care by making the best use of the complementary skills of midwives, GPs and obstetricians. Planning new models of care have exposed a need to upskill many clinicians in providing evidence based pregnancy care. A statewide education program conducts 1 day workshops to multidisciplinary forums in Victoria. The program content is developed with each service and simulation activities are incorporated in the workshop to provide a realistic environment for practising skills related to the implementation of clinical practice guidelines.

Method: Post workshop surveys are completed anonymously by participants using a five point Likert scale to evaluate their experiences in peer learning, the use of simulation, reflective practice and communication skills training. Open ended responses were analysed thematically.

Results: In 2007, 14 workshops were conducted with 254 clinicians attending. The survey response rate was 80%. Participants responded ‘strongly agree’ or ‘agree’ that the workshop: enhanced their ability to access current pregnancy care research and information 193/ 204(95%), challenged them to think more broadly 192/204(94%), provided an opportunity to reflect on their communication skills during the simulation actives 197/201 (96%) and provided a valuable opportunity for observing the communication skills of their peers 197/ 201(98%).

Conclusion: Providing opportunities for peer learning in pregnancy education is valuable and the use of simulation can play an important role in overcoming barriers to implementing guidelines.

Race-day carbohydrate intakes of elite triathletes contesting olympic-distance triathlon events

The aim of this study was to investigate the prerace and during-race carbohydrate intakes of elite-level triathletes contesting draft-legal Olympic-distance triathlon (ODT) events. Self-reported prerace and during-race nutrition data were collected at 3 separate ODT events from 51 elite senior and under-23 triathletes. One hundred twenty-nine observations of food and fluid intake representing actual prerace (n = 62) and during-race (n = 67) nutrition practices from 36 male and 15 female triathletes were used in the final analysis of this study. Female triathletes consumed significantly more carbohydrate on the morning before race start when corrected for body mass and race start time than their male counterparts (p < .05). Male and female triathletes consumed 26% more energy (kJ/kg) and 24% more carbohydrate (g/kg) when commencing a race after midday (1:00-1:30 p.m.) than for a late morning (11:00-11:15 a.m.) race start. During the race, triathletes consumed less than 60 g of carbohydrate on 66% of occasions, with average total race intakes of 48 ± 25 and 49 ± 25 g carbohydrate for men and women, respectively. Given average race times of 1:57:07 hr and 2:08:12 hr, hourly carbohydrate intakes were ∼25 g and ∼23 g for men and women, respectively. Although most elite ODT triathletes consume sufficient carbohydrate to meet recommended prerace carbohydrate intake guidelines, during-race carbohydrate intakes varied considerably, with many failing to meet recommended levels.

Assessing physical activity during recess using accelerometry

Background : Physical activity guidelines recommend children should engage in 60 min of moderate-to-vigorous physical activity (MVPA) a day. School recess presents an opportunity for children to be physically active during the school day. Limited research has investigated children's activity levels during recess and its contribution to physical activity recommendations. Moreover, no target for physical activity during recess has been set.

Methods : One hundred sixteen boys and 112 girls (aged 5–10 years) from 23 schools had their physical activity during recess quantified using a uniaxial accelerometer during three recess breaks on one school day. The percentage of time spent engaged in moderate, high, and very high intensity activity was calculated using existing thresholds.

Results : Boys engaged in more moderate, high, and very high intensity activity than girls. On average, boys and girls spent 32.9% and 23% of recess engaged in physical activity, respectively.

Conclusions : Boys engaged in higher intensity activities than girls. The results suggest that recess can contribute 28 min for boys and 21.5 min for girls toward the accumulation of recommended daily physical activity. However, the physical activity intensities that children engaged in were low during recess. On average, children in this study did not achieve 50% of recess time in physical activity. Interventions for increasing the physical activity of children in the playground are warranted.

Physical activity levels of children during school playtime

School represents a suitable setting for intervention programmes aiming to promote physical activity to benefit health. During the school day, physical education and school playtime offer children regular opportunities to engage in physical activity. However, there is growing concern that, internationally, curricular time allocated to physical education is not meeting statutory guidelines. The effectiveness of the playground environment to promote physical activity has been considered as a complementary setting to physical education.

Physical activity guidelines state that children should engage in at least 1 hour of moderate intensity physical activity a day. Currently no empirically tested guidelines exist for physical activity levels during playtime. However, studies cited in this article indicate that playtime can contribute between 5-40% of recommended daily physical activity levels when no interventions have been utilised.

The limited school-based investigations that have been reported in the literature suggest that boys engage in more physical activity during playtime than girls. Studies that have implemented intervention strategies in order to promote physical activity levels indicate that playtime can substantially contribute towards daily optimal physical activity guidelines. Energy expenditure and physical activity levels have increased during playtime following the implementation of playtimebased interventions. In order to advance knowledge of children's physical activity during playtime, a number of key issues for consideration in future research are detailed. Research on children's use of playtime to be physically active and the extent of the contribution of playtime to daily physical activity guidelines is warranted.