The Pacific OPIC Project (Obesity Prevention In Communities) : action plans and interventions

Background: The Pacific OPIC Project (Obesity Prevention In Communities) includes whole-of-community intervention programs in four countries (Fiji, Tonga, New Zealand, Australia) aimed at reducing the prevalence of overweight and  obesity in youth.

Development of Action Plans: At each intervention site, preliminary interviews  were conducted with youth to identify the potential socio-cultural barriers and  facilitators to healthy eating and regular physical activity in order to attain and sustain a healthy body size. This and other information was presented at a 2-day workshop with community stakeholders, including youth. The participants then prioritised the components for a draft action plan which was later consolidated through further community consultation.

Action Plan objectives: Each action plan had two overall aims: to build  community capacity and to promote healthy weight. The first three objectives in each action plan were on capacity building, social marketing messages, and evaluation. Next were a set of four to five behavioural objectives with associated strategies involving programs, events, social marketing and environmental  change. Lastly, each site had one or two innovative or developmental objectives.

Progress: Interventions began in all sites from 2005, with the action plans guiding implementation priorities. The initial behavioural objective for targeting in Fiji was eating regular breakfast and meals throughout the day, for Tonga it was physical activity, and for Australia and New Zealand it was increasing water consumption and decreasing consumption of sweet drinks.

Conclusions: The action plans have provided the basis for community engagement in the project, the guide to the implementation of activities and the template for the evaluation plan.

Falls prevention in rural general practice: what stands the test of time and where to from here?

Objective: General practitioner recall of the 1992–96 'Stay on Your Feet' (SOYF) program and its influence on practice were surveyed five years post-intervention to gauge sustainability of the SOYF General Practice (GP) component.

Methods: A survey assessed which SOYF components were still in existence, current practice related to falls prevention, and interest in professional development. All general practitioners (GPs) situated within the boundaries of a rural Area Health Service were mailed a survey in late 2001.

Results: Response rate was 66.5% (139/209). Of 117 GPs in practice at the time of SOYF, 80.2% reported having heard of SOYF and 74.4% of those felt it had influenced practice. Half (50.9%) still had a copy of the SOYF GP resource and of those, 58.6% used it at least 'occasionally'. Three-quarters of GPs surveyed (75.2%) checked medications 'most/almost all' of the time with patients over 60 years; 46.7% assessed falls risk factors; 41.3% gave advice; and 22.6% referred to allied health practitioners. GPs indicated a strong interest in falls prevention-related professional development. There was no significant association between use of the SOYF resource package and any of the current falls prevention practices (all χ² >0.05).

Conclusions and implications: There was high recall of SOYF and a general belief that it influenced practice. There was little indication that use of the resource had any lasting influence on GPs' practices. In future, careful thought needs to go into designing a program that has potential to affect long-term change in GPs' falls prevention practice.

Economic analysis of a community-based falls prevention program

Objectives: To undertake a cost–benefit analysis of ‘Stay on Your Feet’, a community-based falls prevention program targeting older people at all levels of risk in New South Wales, Australia. Hospital separations were monitored in the intervention region, a control region and for the state of New South Wales as a whole. Changing admission patterns over the intervention period were used to assess the impact of the program.

Methods: Cost–benefit analysis compared the costs of the program with two estimates of savings from avoided hospital admissions. The first compared the cost of hospital admissions in the intervention region to a control region of similar demographics, while the second compared hospital utilization in the intervention region with the state of New South Wales as a whole using falls-related hospital diagnosis related group (DRG) codes.

Results: The total direct costs of the program were estimated at A$781 829. Both methods identified clear overall net benefits ranging from A$5.4 million for avoided hospitalizations alone to A$16.9 million for all avoided direct and indirect costs. The confidence intervals around these estimates were small. The average overall benefit to cost ratio for the intervention as a whole was 20.6:1.

Conclusions: These findings suggest that well-designed community-based interventions targeting falls prevention among older people are highly cost effective and a wise investment for all levels of government. The models used are conservative and are likely to underestimate the real benefit of the intervention, which may have lasted for some time beyond the life of the program.

Measuring the economic impact of falls prevention interventions

The objective of this paper is to assess the appropriateness of available health economic models and concepts in the development of a best practice model to assess community based multifactorial falls prevention programs. To this end, a critical review and synthesis of contemporary published and unpublished  methodological approaches to economic evaluation of health initiatives in general and falls prevention initiatives in particular, has been carried out. The review  indicates that costs, time and utility all need to be taken into consideration when economically evaluating a falls prevention program.

A recommended approach that takes into account a full consideration of relevant costs and benefits associated with falls prevention programs is outlined. This approach can help demonstrate the true relative efficacy of preventing falls over the treatment of their consequences.

Obesity prevention in children and adolescents

Childhood and adolescent obesity has been increasing in most middle- and high-income countries, and, as with adult obesity, this has been driven by increasingly obesogenic environments, especially the food environment. This constitutes a “market failure,” signaling the need for government interventions with policies, programs, and social marketing. Population prevention strategies are critical, and children and adolescents should be the priority populations. Food marketing to children is a central policy issue for governments to address, and comprehensive regulations are needed to provide substantive protection for children. Community-based intervention programs show some real promise in reducing childhood obesity, but the 2 big challenges ahead are to ensure that there is substantial ongoing funding so that the community capacity to promote healthy weights can be scaled up to a national level and to ensure that policies are in place to support these efforts. The social and cultural shifts that support healthy eating and physical activity occur differentially, and special efforts are needed to reduce the socioeconomic gradients associated with childhood obesity. A positive public health approach encompassing environmental, regulatory, sociocultural, and educational strategies offer the best chance of reducing obesity without increasing disordered eating patterns.

Creating community action plans for obesity prevention using the ANGELO (Analysis Grid for Elements Linked to Obesity) framework

Community-based interventions are an important component of obesity prevention efforts. The literature provides little guidance on priority-setting for obesity prevention in communities, especially for socially and culturally diverse populations. This paper reports on the process of developing prioritized, community-participatory action plans for obesity prevention projects in children and adolescents using the ANGELO (Analysis Grid for Elements Linked to Obesity) Framework. We combined stakeholder engagement processes, the ANGELO Framework (scans for environmental barriers, targeted behaviours, gaps in skills and knowledge) and workshops with key stakeholders to create action plans for six diverse obesity prevention projects in Australia (n = 3), New Zealand, Fiji and Tonga from 2002 to 2005. Some sites included sociocultural contextual analyses in the environmental scans. Target groups were under-5-year-olds (Australia), 4–12-year-olds (Australia) and 13–18-year-olds (all four countries). Over 120 potential behavioural, knowledge, skill and environmental elements were identified for prioritization leading into each 2-day workshop. Many elements were common across the diverse cultural communities; however, several unique sociocultural elements emerged in some cultural groups which informed their action plans. Youth were actively engaged in adolescent projects, allowing their needs to be incorporated into the action plans initiating the process of ownership. A common structure for the action plan promoted efficiencies in the process while allowing for community creativity and innovation. The ANGELO is a flexible and efficient way of achieving an agreed plan for obesity prevention with diverse communities. It is responsive to community needs, combines local and international knowledge and creates stakeholder ownership of the action plan.

Laboratory and non-laboratory-based risk prevention models for secondary prevention of cardiovascular disease : the LIPID study

Aims : The aims of this study were to examine whether risk prediction models for recurrent cardiovascular disease (CVD) events have prognostic value, and to particularly examine the performance of those models based on non-laboratory data. We also aimed to construct a risk chart based on the risk factors that showed the strongest relationship with CVD.

Methods and results : Cox proportional hazards models were used to calculate a risk score for each recurrent event in a CVD patient who was enrolled in a very large randomized controlled clinical trial. Patients were then classified into groups according to quintiles of their risk score. These risk models were validated by calibration and discrimination analyses based on data from patients recruited in New Zealand for the same study. Non-laboratory-based risk factors, such as age, sex, body mass index, smoking status, angina grade, history of myocardial infarction, revascularization, stroke, diabetes or hypertension and treatment with pravastatin, were found to be significantly associated with the risk of developing a recurrent CVD event. Patients who were classified into the medium and high-risk groups had two-fold and four-fold the risk of developing a CVD event compared with those in the low-risk group, respectively. The risk prediction models also fitted New Zealand data well after recalibration.

Conclusion : A simpler non-laboratory-based risk prediction model performed equally as well as the more comprehensive laboratory-based risk prediction models. The risk chart based on the further simplified Score Model may provide a useful tool for clinical cardiologists to assess an individual patient's risk for recurrent CVD events.

Family food environments as determinants of children's eating : implications for obesity prevention

The prevalence of childhood obesity is escalating rapidly and it considered to be a major public health problem. Diet is a recognised precursor of fatness, and current evidence supports the premise that in Westernised countries, the dietary intakes of children are likely to be important in obesity genesis. However, we have a relatively poor understanding of the environments in which a child’s eating is learnt and maintained. Much of the existing work in this area is based on small-scale or experimental studies, or has been derived from homogeneous populations within the USA. Despite these limitations, there is evidence that aspects of the child’s family environment are likely to be important in determining obesity risk in children. This thesis examines the impact of the family food environment on a child’s eating through two related studies. The first study, titled the Children and Family Eating (CAFÉ) study comprised three phases. Phase one involved qualitative interviews with 17 parents of 5-6 year-old children to explore parental perceptions regarding those factors in a child’s environment believed to influence the development of their child’s eating habits. These interviews were used to inform the development of quantitative measures of the family food environment. The second phase involved the development of a Food Frequency Questionnaire (FFQ) to assess dietary intake in 5-6 year-olds. The FFQ was informed by analysis of 1995 Australian National Nutrition Survey data. In the final phase the relationships between dietary intakes of 5-6 year-old children, and potential predictors of dietary intake were examined in a cross-sectional study of 560 families. Predictors included measures of: parental perceptions of the adequacy of their child’s diet; food availability and accessibility; child-feeding; the opportunities for parental modelling of food intake; a child’s television exposure; maternal Body Mass Index; and maternal education. Analysis of the CAFÉ data provides unique information regarding the relationships between a child’s family food environment and their food consumption. Models developed for a range of dietary outcomes considered to be predictive of increased risk for obesity, including total energy and fat intakes, vegetable variety, vegetable consumption, and high-energy (non-dairy) fluid consumption, explained between 11 and 20 percent of the variance in dietary intake. Two aspects of the family food environment, parental perception of a child’s dietary adequacy, and the total minutes of television viewed per day, were frequently found to be predictive of dietary outcomes likely to promote fatness in these children. The second study, titled the Parent Education and Support (PEAS) Feeding Intervention Study, was a prospective pre/post non-randomised intervention trial that assessed the impact of a feeding intervention to 240 first-time mothers of one-year-old children. This intervention focused on one aspect of the family food environment, child-feeding, which has been proposed as influential in the development of obesogenic eating behaviours. In this study, Maternal and Child Health Nurses (MCHNs), using a ‘Division of Responsibility’ model of feeding, taught parents to provide nutritious food at regular intervals and to let children decide if to eat and how much to eat. Thus parents were encourages to food their child without exerting pressure, or employing coercion or rewards (controlling behaviours). The aim was to influence parental attitudes and beliefs regarding child-feeding. Through the use of these feeding techniques, this intervention also aimed to increase the variety of fruits and vegetables a child consumed by teaching parents to persist with offering these foods, over the year of the intervention, in non-emotive environments. Fruits and vegetables were chosen in this intervention because they are likely to be protective in the development of obesity. Analysis of the PEAS data suggests that this low-level feeding intervention, delivered through existing Maternal and Child Health services, was modestly effective in changing parental attitudes and beliefs regarding the feeding of young children. Further, the validity of fruits offered to intervention group children increased. This thesis expands the existing knowledge base by providing a comprehensive analysis of the relative impact of aspects of the family environment on dietary intakes of 5-6 year-olds. Further, the analysis of a feeding intervention in first-time parents provides important insights regarding the potential to influence child-feeding and the impact this may have on the promotion of eating behaviours protective against obesity.

Evolving nature of fraud investigation and prevention

This thesis is concerned with the evolution of fraud investigation and prevention in light of the advances in computing technology. These recent advances have impacted upon traditional fraud offences as well as creating a range of new crimes. The financial significance of fraud is growing whereas law enforcement and the judicial system appear to be unable to meet the demands of these emerging crimes and its victims. This research compares the responses of our present and future investigators with those of our current business leaders from the government and the commercial sectors. This research establishes the needs of corporate decision-makers and the attitudes of police with regard to fraud. Data relating to persons arrested and convicted of fraud was also analysed to identify the issues that may be responsible for the non-reporting of offences to police by victims. The research found that victims are seeking solutions that are not available through law enforcement, for example financial compensation. Law enforcement also under-utilises the potential of proactive responses to prevent offences and they are reluctant to acknowledge the benefits of preventative measures and to incorporate this strategy within criminal investigation training programmes. The lack of deterrence offered by the judicial system does not make the situation any better. The police function is still primarily a reactive one. In order to overcome fraud and to be able to adapt to changes there needs to be collaboration between stakeholders. This requires a joint effort from the police, government, commerce and the victims of fraud. An innovative model involving stakeholders has been formulated that represents an alternative to the current system. This approach utilises the financial resources and expertise from the commercial sector as well as the skills of criminal investigators from the police. This means adopting a combined package of both reactive and proactive measures in order to minimise the impact of fraud. This model will be adaptive and will be able to accommodate any future requirements arising out of further inevitable advances in computer technology.

Prevention of body concerns and risk behaviours in adolescent boys

Overall, this thesis was designed to explore the nature of adolescent boys' body image, the effects of body image on body change strategies and psychological adjustment, and the factors that influence body image. The first study examined body image in 362 adolescent boys. Body image was considered in terms of attitudes to different body parts and attributes, including, lower, middle and upper body, as well as weight, shape and muscles. The relationships between Body Mass Index (BMI), body image, sociocultural messages, psychological adjustment and body change strategies, including strategies to decrease weight and increase muscles using food and exercise, drive for thinness, bulimic attitudes and behaviour, excessive exercise, food supplements to lose weight, increase muscles and steroids, were also investigated. Multiple regression analyses were used to examine the role of body image, sociocultural messages and psychological adjustment to predict satisfaction with different body attributes and body change strategies. The findings from study one led to the development of a program aimed at preventing the development of unhealthy attitudes and behaviours among adolescent boys. Study two involved the implementation and evaluation of this prevention program. One hundred and twenty one boys participated in the program. The program was based on social-cognitive theory, and included a focus on accepting differences and the development of self-esteem. The boys who participated in the program indicated some change in existing attitudes and showed less development of risk behaviours relative to the control group. The implications of the findings from this thesis in relation to future research, as well as the prevention of adolescent boys' body image problems are discussed.

Fall incidence and fall prevention practices at acute care hospitals in Singapore : a retrospective audit

Objective To investigate the incidence of falls and explore fall prevention practices at acute care hospitals in Singapore.

Design A retrospective audit to collect baseline data on (1) incidence of falls (patient fall rates and fall injury rates) and (2) fall prevention practices, was conducted in five acute care hospitals in Singapore from December 2004 to March 2005.

Study participants Medical record data (n = 6000) of patients admitted into the medical, surgical and geriatric units in the five hospitals.

Outcome measures Fall incidence was obtained from the hospital's fall databases and incident reports for the period of June 2003 to May 2004. In total, 6000 medical records from five hospitals were randomly selected, retrieved and reviewed to determine whether falls, fall assessments and interventions were being initiated and documented.

Results The number of fallers for all hospitals was 825. Analysis showed that patient fall rates ranged from 0.68 to 1.44 per 1000 patient days, and the proportion of falls associated with injury ranged from 27.4% to 71.7%. The use of a fall risk assessment tool by nurses was recorded in 77% of all the nursing records.

Conclusion This study has laid the foundation for further research for fall prevention in Singapore by describing current fall rates, fall-associated injury rates and the status of fall prevention practices in acute care settings. The results will be used to inform the development of a tailored multifaceted strategy to facilitate the implementation of Fall Prevention Clinical Practice Guidelines to reduce the burden of falls and fall injuries in hospitals in Singapore.

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

Background

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.
Methods

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.
Results

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.
Conclusion

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.