Regional and urban Victorian diabetic youth: clinical and quality-of-life outcomes

Objectives: To compare groups of urban and regional Victorian diabetic children and assess their quality of life, diabetes knowledge, access to services and metabolic control.

Methods: Forty-seven children from three regional Victorian communities (Horsham, Warrnambool and Sale; n = 16, 18 and 13, respectively) were compared with 120 age-, sex- and duration of diabetes-matched children attending the Royal Children's Hospital (RCH) diabetes clinic in Melbourne. Quality of life, diabetes knowledge, use of services, and metabolic control were assessed using the child health questionnaire (CHQ PF-50/CF-80); a diabetes-knowledge questionnaire; access to a diabetes nurse educator (DNE), dietitian and complication screening; and indices of mean HbA1C (values are taken every 3 months in the 'yearly HbA1C'), respectively.

Results: Comparisons of CHQ data showed that regional diabetic youth scored significantly lower on most subscales. The greatest deficits were seen in areas of mental health, self-esteem, parent impact (emotional) and family cohesion. Diabetes knowledge and median yearly HbA1C for patients were not significantly different between the regional and urban centres (8.1%, 8.9%, 8.4% and 8.6% at RCH, Horsham, Warrnambool and Sale, respectively). Patients in regional centres had reportedly less access to team-based diabetes care.

Conclusions: Regional youth in Victoria, with similar levels of metabolic control and diabetes knowledge as their urban counterparts, have a markedly lower quality of life, implying a negative synergy between diabetes and the demands of regional lifestyles.

Flora Fit street : a qualitative evaluation

This report summaries a qualitative evauation of the Flora Fit Street community based health living initiative.

Changing lifestyles: a major responsibility for physical education

Nutritionists, physical and health educators and the medical profession have all expressed concern about the eating habits and sedentary lifestyle of Australian children and the short and long term consequences if we do not change our ways, states the author. Can schools solve the problem? The author examines the effort to strengthen physical education in Australian schools and considers why the subject remains marginal in the curriculum.

The infant feeding activity and nutrition trial (INFANT) an early intervention to prevent childhood obesity : cluster-randomised controlled trial

Background : Multiple factors combine to support a compelling case for interventions that target the development of obesity-promoting behaviours (poor diet, low physical activity and high sedentary behaviour) from their inception. These factors include the rapidly increasing prevalence of fatness throughout childhood, the instigation of obesity-promoting behaviours in infancy, and the tracking of these behaviours from childhood through to adolescence and adulthood. The Infant Feeding Activity and Nutrition Trial (INFANT) aims to determine the effectiveness of an early childhood obesity prevention intervention delivered to first-time parents. The intervention, conducted with parents over the infant's first 18 months of life, will use existing social networks (first-time parent's groups) and an anticipatory guidance framework focusing on parenting skills which support the development of positive diet and physical activity behaviours, and reduced sedentary behaviours in infancy.

Methods/Design : This cluster-randomised controlled trial, with first-time parent groups as the unit of randomisation, will be conducted with a sample of 600 first-time parents and their newborn children who attend the first-time parents' group at Maternal and Child Health Centres. Using a two-stage sampling process, local government areas in Victoria, Australia will be randomly selected at the first stage. At the second stage, a proportional sample of first-time parent groups within selected local government areas will be randomly selected and invited to participate. Informed consent will be obtained and groups will then be randomly allocated to the intervention or control group.

Discussion : The early years hold promise as a time in which obesity prevention may be most effective. To our knowledge this will be the first randomised trial internationally to demonstrate whether an early health promotion program delivered to first-time parents in their existing social groups promotes healthy eating, physical activity and reduced sedentary behaviours. If proven to be effective, INFANT may protect children from the development of obesity and its associated social and economic costs.

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.

Support needs of parents of sick and/or preterm infants admitted to a neonatal unit

The sudden unexpected delivery of a preterm infant elicits many emotional responses from parents, with studies confirming the importance of providing parents with nursing support. The purpose of this study was to measure parents' perception of the type and level of support that nurses provided in an Australian neonatal unit, and to determine the extent to which parents were satisfied with the support currently provided. A convenience sample of 112 parents in an Australian tertiary neonatal unit were invited to complete the nurse parent support tool (NPST), which is a 21-item questionnaire used to measure the level of nursing support. The NPST consists of four domains -emotional, informational, appraisal and instrumental support. A second tool was used to assess parent satisfaction with nurse-to-parent support. A total of 62 parents completed the NPST and satisfaction tool.

Results showed that instrumental support had the highest mean score for both nurse-to-parent support 4.51 (out of 5) and 4.36 for satisfaction. The mean score for nursing support was 4.21 followed by satisfaction with nurse-to-parent support at 4.16. In contrast, emotional support had the lowest mean score for both nurse-to-parent support at 3.94 and 3.97 for satisfaction. Parents indicated that they needed further support with lactation, breastfeeding and assistance with parenting skills. Overall, results indicated that parent perception of nursing support was positive and that parents were highly satisfied with the nursing support provided in the neonatal unit. However, some attention needs to be given to providing more support and information on breastfeeding and parenting skills.

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.

Intersection of autonomy and social control : negotiating teenage motherhood

Contrary to popular belief, teenage mothers are a declining proportion of birthing women; however they receive much negative public attention. Of particular public concern is the high cost of supporting teenage mothers, in terms of financial, health and welfare resources. Historically, the typical founding mother of white Australia was single, but post-war changes in the family structure incorporated the expectation that children be born into two-parent households with the male as the breadwinner. Policy changes in the seventies saw the introduction of the Sole Parents Pension which meant that many birthing teenage women could choose to keep their infants rather than have a clandestine adoption or an enforced marriage. The parenting practices of teenage mothers have been criticised for being less than optimal, and mother and child are reported as being disadvantaged cognitively, psychosocially, and educationally. One widespread nursing service which provides support for new mothers in Victoria is the Maternal and Child Health Service; however, teenage mothers appear reluctant to use such services. Why this should be so became an important question for this research, since little is known about the parenting practices of teenage mothers. This study therefore sought to explore mothering from the perspective of five sole supporting teenage mothers each of whom had a child over six months of age. The research methodology took an interpretive ethnographic approach and was guided by feminist principles. The data were collected through repeated interviewing, participant observation, informal discussions with key informants, field notes and journalling. Data analysis was aided by the use of the software, program NUD-IST. It was found that the young women in this study each chose to give birth with full realisation that their existence was dependent on the Welfare State. Unanticipated, however, were the many structural barriers which made their lives cataclysmic, but these reinforced their determination to prove themselves worthy and capable mothers. The young women negotiated motherhood through a range of social supports and through maternal practice. Unquestionably, their social dependency on the welfare system forced them into marginal citizen status. Moreover, absolute and intrinsic poverty levels were experienced, brought about by inadequate welfare payments. Formal support agencies, such as the Maternal and Child Health nurses were rarely approached to provide childrearing support beyond the initial months following birthing, since the teenagers' basic needs such as shelter, food and clothing took precedence over their parenting needs. Additionally, some nurses were perceived to hold judgmental attitudes towards teenage mothers. It was far easier to forestall confrontation with nurses and the other 'older' women clientele by avoiding them. Thus XI they turned to charitable agencies who provided a safety net in the form of emergency supplies of money, food, or equipment. Informal networks of friends provided alternative modes of support when family help failed to materialise. The children, however, provided the young women with an opportunity to transform their lives by breaking free of the past, and by creating a new, mature existence for themselves. Despite being abandoned by family, friends, lovers and society, in the privacy and isolation of their own homes, they attempted to provide a more nurturing environment for their children than they themselves had received. Each bestowed unconditional maternal love on the child and were rewarded through the pleasures of watching their children grow and develop into worthwhile individuals. The children became the focus of their attention and their reason for living. In the course of their welfare dependency, the young women became public property, targets of surveillance, and were subjected to stigmatising and condescending public attitudes wherever they went. In this way, it was evident that they were an oppressed group, but each found ways of resisting. Rather than focussing on their oppressive or disabling lives, or dwelling on their disadvantaged status, the young women sought their identities as mature women through motherhood and by demonstrating that they could do this important job well. Through motherhood their lives had meaning and a sense of purpose. The thesis concludes that motherhood in the teenage years is difficult. However, if appropriate supports are made available, teenage mothers need be no different from non-teenage mothers. But with state resources shrinking, and their own resources limited, teenage mothers are disadvantaged. In some ways, this study showed that all levels of support were inadequate, although those provided through the charitable organizations were seen to be the most appropriate. This reflects the current policy of economic rationalism adopted by most Western liberal democracies in the 1980s and 1990s and no less by the former Keating Labor Government in Australia.

Promoting social support and social networks among Irish pensioners in South London, UK

This paper explores the activities of an Irish-led voluntary sector project that sought to minimise social isolation and build social networks among Irish elderly people living in a socio-economically deprived borough in South London, UK. The study from which this paper is drawn aimed to explore the nature and extent of unmet mental health needs among Irish pensioners. Using a naturalistic and exploratory design, data were collected through 19 semi-structured interviews, observation of project activities and analysis of members' case files. The paper presents findings in relation to the significant themes that emerged from the data analysis, which used a grounded theory approach. It discusses the social support systems within the project and examines the ways in which they maintained the mental wellbeing of the projects' members and interconnected with other areas of the project's activities. The study's findings demonstrated that the project provided space for social interaction among otherwise isolated Irish pensioners, many of whom experienced multiple morbidity. The project worked successfully to overcome the sense of stigma that prevented many of its members accessing statutory services; it also identified needs among carers. There was an Irish cultural ambience at the project centre, which generated a sense of belonging among members, and assisted in the development of social networks. The project initiated other forms of social support through the use of volunteers and developed befriending and telephone support services. The project developed partnership working with other agencies, particularly community mental health services, in order to provide support to elderly people who might otherwise have been institutionalised. The project engaged with the cultural norms of this marginalised white minority ethnic community to promote both social interaction and social networks. It offered a model of good practice for agencies working with isolated elderly members of minority ethnic communities.

Effects of parental perception of neighbourhood deprivation and family environment characteristics on pro-social behaviours among 4-12 year old children

Objective : To assess the effect family environment stressors (e.g. poor family functioning and parental psychological distress) and neighbourhood environment on child prosocial behaviour (CPB) and child difficulty behaviour (CDB) among 4-to-12 year old children.

Methods : Analysis of the 2006 Victorian Child Health and Wellbeing Survey (VCHWS) dataset derived from a statewide cross-sectional telephone survey, with a final total sample of 3,370 children.

Results : Only family functioning, parental psychological distress, child gender, and age were associated with CPB, explaining a total of 8% of the variance. Children from healthily functioning families and of parents without any psychological distress exhibited greater prosocial behaviours than those from poorly functioning families and of parents with mental health problems. Neighbourhood environment was not found to contribute to CPB. A total of eight variables were found to predict CDB, explaining a total of 16% of the variance. Poor family and parental psychological functioning as well as poor access to public facilities in the neighbourhood were associated with conduct problems in children.

Conclusion : Our results point to the importance of the family environment in providing a context that fosters the development of empathic, caring and responsible children; and in buffering children in exhibiting behaviour difficulties during the formative years of life. Programs aimed at promoting prosocial behaviours in children need to target stressors on the family environment.

A descriptive interview with 64 patients discharged from an acute-psyciatric-inpatient service

Background Acute-mental-health services receive hundreds of admissions every year. Some of these patients will continue to be case-managed by community mental-health teams on discharge from the acute unit while others will not remain in contact with the mental-health service. This study compares the findings of comprehensive interviews conducted with current and past patients of the community mental-health service 3 or more years following case closure from the community ambulatory service.
Methods Between 1 July 1999 and 30 June 2001, there were 2245 closed cases identified at Barwon Health. Letters of invitation to participate in a research project were sent to people who had suffered from psychotic illnesses, and had been case-closed by community mental-health services between the above dates and had not been in contact with the Community and Mental Health Service for at least 6 months. A second group of participants was recruited from people who had also been case-closed by community mental health teams in Barwon Health during the 1999–2001 2-year-time window but whose cases had been re-opened and who were in case management with Barwon Health at the time of the study. All participants were interviewed using the Diagnostic Interview for Psychosis.
Results Letter responses were received from 17 men and 18 women, aged 40.7 ± 12.0 (mean ± SD), who were interviewed. A second group of 17 men and 12 women, aged 40.9 ± 9.6 (mean ± SD) of currently case-managed patients was interviewed. All interviewees reported a detailed history of mental illness. Persistent social dysfunction and impaired quality of life were reported in both groups.
Conclusion Patients suffering from psychotic disorders who had been case-closed by community mental-health teams and had been discharged to the care of their general practitioners or elsewhere continued to show evidence of significant impairment due to mental illness 3 years after being case-closed.

Maternal self-efficacy regarding children's eating and sedentary behaviours in the early years : Associations with children's food intake and sedentary behaviours

Introduction. This cross-sectional study aimed to describe parents' views regarding self-efficacy to influence children's eating and sedentary behaviours at two time points in early childhood, and to examine associations between these views and children's eating and sedentary behaviours.

Methods. Mothers of 1-year (n=60) and 5-year-old children (n=80) were recruited through Maternal and Child Health Centres and kindergartens in Victoria, Australia. Mothers reported children's dietary intake, television viewing and perceptions of their self-efficacy regarding children's eating and sedentary behaviours.

Results. Overall, 5-year-old children consumed significantly more energy-dense food and drink and spent significantly more time viewing TV/DVD and video. Mothers of 1-year-olds were significantly more likely to report they felt confident to limit child's consumption of non-core foods/drinks, and to limit screen access (p<0.001). Measures of maternal self-efficacy were directly associated with 5-year-old children's water (p<0.05), and fruit and vegetable consumption (p<0.005), and with 1-year-old children's vegetable consumption (p<0.05), and were inversely associated with cordial and cake consumption (p<0.05). Maternal self-efficacy to limit viewing time was inversely associated with screen-time exposure in both age groups (p<0.01).

Conclusion. This study suggests that mother's self-efficacy regarding limiting non-core foods/drinks and limiting screen-time exposures may decline during the first few years of a child's life. Higher maternal self-efficacy was associated with children having more obesity protective eating and sedentary behaviours at both ages. Interventions to support the development of healthy lifestyle behaviours may be most effective if they target mothers' self-efficacy in these domains early in their child's life.

Experiences of engagement in occupations and assertive outreach services

Aim: The purpose of this study was to describe the experience and meaning of engagement for staff and clients of assertive outreach teams.
Method: Interpretative phenomenological analysis was selected for its flexibility and transparency. Data were collected by semi-structured interviews from a sample of five client and five staff participants (n = 10). The interviews were analysed idiographically, inductively and interrogatively.
Findings: Four themes identified by both staff and client participants emerged: engagement as an interpersonal relationship, engagement in and through time, enabling and disabling factors and engagement in occupation. In addition, clients developed a theme around engagement as a means to self-actualisation. Staff also raised a specific theme around the role of engagement in mental health services.
Conclusion: Staff and clients experienced engagement in broadly similar ways, but with differing emphases. Although all participants described it as both an invisible 'means' and a visible 'end', the staff related engagement only to mental health services whereas the clients experienced it in the context of both mental health services and occupations.
Relevance: This study is relevant to all occupational therapists who work with people experiencing mental health problems.

Screening children with developmental coordination disorder : the development of the caregiver assessment of movement participation

This study investigated the psychometric properties of the Caregiver Assessment of Movement Participation (CAMP), which was developed to measure and identify children with movement participation problems in home contexts. The test-retest reliability, as well as the concurrent and contrast-group validity of the 35-item parent-proxy CAMP, was examined on 312 children aged 5 to 8 years using intraclass correlation, factor analysis, and the Rasch model. Initial findings on the CAMP appeared to support its validity. Testing on other properties from a practical perspective, such as finding the best rating scale structure and cutpoints, are recommended before using the instrument for child health surveillance screening.

An exploratory cluster randomised controlled trial of knowledge translation strategies to support evidence-informed decision-making in local governments (The KT4LG study)

Background: Childhood overweight and obesity is the most prevalent and, arguably, politically complex child health problem internationally. Governments, communities and industry have important roles to play, and are increasingly expected to deliver an evidence-informed system-wide prevention program. However, efforts are impeded by a lack of organisational access to and use of research evidence. This study aims to identify feasible, acceptable and ideally, effective knowledge translation (KT) strategies to increase evidence-informed decision making in local governments, within the context of childhood obesity prevention as a national policy priority.
Methods/Design: This paper describes the methods for KT4LG, a cluster randomised controlled trial which is exploratory in nature, given the limited evidence base and methodological advances. KT4LG aims to examine a program of KT strategies to increase the use of research evidence in informing public health decisions in local governments. KT4LG will also assess the feasibility and acceptability of the intervention. The intervention program comprises a facilitated program of evidence awareness, access to tailored research evidence, critical appraisal skills development, networking and evidence summaries and will be compared to provision of evidence summaries alone in the control program. 28 local governments were randomised to intervention or control, using computer generated numbers, stratified by budget tertile (high, medium or low). Questionnaires will be used to measure impact, costs, and outcomes, and key informant interviews will be used to examine processes, feasibility, and experiences. Policy tracer studies will be included to examine impact of intervention on policies within relevant government policy documents.
Discussion: Knowledge translation intervention studies with a focus on public health and prevention are very few in number. Thus, this study will provide essential data on the experience of program implementation and evaluation of a system-integrated intervention program employed within the local government public health context. Standardised programs of system, organisational and individual KT strategies have not been described or rigorously evaluated. As such, the findings will make a significant contribution to understanding whether a facilitated program of KT strategies hold promise for facilitating evidence-informed public health decision making within complex multisectoral government organisations.