Fat, rich and beautiful: changing socio-cultural paradigms associated with obesity risk, nutritional status and refugee children from sub-Saharan Africa

There has been an increase in Australia's intake of refugees and migrants from sub-Saharan Africa over the last two decades. These refugees have been exposed to nutritional risks prior to migration, which, together with changes associated with acculturation, impact on their health and nutritional status post-migration. However, there is a paucity of data in Australia that has examined the health and nutritional status of this ethnic minority in Australia. Despite basic research assessing the nutritional status of children, none have specifically concentrated on the health and nutritional situation of sub-Saharan refugee children. In the absence of such studies, this paper explores issues relating to obesity in sub-Saharan African refugee children within a cultural and public health framework. We begin by outlining the history of obesity and its cultural meaning. We then move to a consideration of predisposing factors for obesity and how these factors translate into obesity risk contexts of sub-Saharan refugees post-migration. We argue there are a number of key challenges related to culture and the relationship between socio-economic factors post-migration that require addressing by health professionals, dieticians and health educators to ensure the delivery of successful health outcomes.

Clinical decisions using the National Triage Scale: how important is postgraduate education?

Triage is the formal nursing assessment of all patients who present to an Emergency Department (ED). The National Triage Scale (NTS) is used in most Australian EDs. Triage decision making involves the allocation of every patient presenting to an ED to one of the five NTS categories. The NTS directly relates a triage category to illness or injury severity and need for emergency care. Triage nurses’ decisions not only have the potential to impact on the health outcomes of ED patients, they are also used, in part, to evaluate ED performance and allocate components of ED funding. This study was a correlational study that used survey methods. Triage decisions were classified as ‘expected triage’, ‘overtriage’ or ‘undertriage’ decisions. Participant’s qualifications were allocated to five categories: ‘nil’; ‘emergency nursing’; ‘critical care nursing’; ‘midwifery’; and ‘tertiary’ qualifications. There was no correlation between triage decisions and length of experience in emergency nursing or triage. ‘Expected triage’ decisions were more common when the predicted triage category was Category 3 (P< 0.001) and ‘overtriage’ decisions were less common when the predicted triage category was Category 2 (P< 0.0010). The frequency of ‘undertriage’ decisions decreased significantly when the predicted triage category was Category 3 (P< 0.001) or Category 4 (P< 0.001). There was no correlation between triage decisions and qualifications in the ‘nil’, ‘emergency nursing’ or ‘critical care nursing’ categories. A midwifery qualification demonstrated a positive correlation with ‘expected triage’ decisions (P = 0.048) and a negative correlation with ‘undertriage’ decisions (P = 0.012). There was also a positive correlation between a tertiary qualification and ‘expected triage’ decisions (P = 0.012).

Regional variations in walking for different purposes : the south east Queensland quality of life study

Where people are located can influence behavioral choices and health outcomes through the effects of place on health. Walking is the most commonly reported form of nonoccupational and nonhousehold physical activity for adults. It is a behavior of particular interest to those in the transportation, urban planning, and public health fields. Researchers have examined patterns of walking from both an individual perspective (psychological and social factors) and from a broader community focus (location and built environment factors). The majority of studies have examined walking in the context of urban environments. Variations within regions (urban, periurban, and rural, for example) in walking have not been previously described. We use data from a regionally based quality of life survey to examine subregional variations in walking for particular purposes. Both the social and contextual variations that may underlie these differences are considered. This is useful in helping identify particular factors that may be further investigated in disaggregated analyses using GIS methods to identify specific differences in objective attributes between subregions that may influence peoples' choices to walk, such as walking infrastructure and the availability of destinations.

Extent of heart failure self-care as an endpoint to patient education: a literature review

Background: In western countries the number of chronic heart failure (CHF) management programs has escalated in recent times. One key component of them is to teach self-care behaviours that enable affected individuals to monitor themselves and engage in lifestyles that improve their health status.
Aim: The aim of this article is to describe CHF self-care management and to review the literature which examines the effectiveness of patient education on patients’ performance of self-care behaviours.
Design/method: bibliographical databases were searched for papers published in English between 1982 to 2006. The search used the key words: heart failure, education, self-care and measures. Only randomized controlled trials (RCTs) were selected.
Results: Ten randomized controlled trials were selected that used education as an intervention and, in total, 1064 patients with CHF participated in these studies. The studies were heterogenous as to the sample population, the health outcomes measured, the education interventions, the expertise of the educator, and the length of time that was spent on teaching patients. No consistent patterns of implementation and specific evaluation of its impact were found, although three respective groups of investigators reported signifi cant differences in recurrent hospitalisation rates and mortality rates which were relative to usual care.
Conclusions: Teaching patients appropriate CHF self-care behaviours can significantly improve their health outcomes. Improvements in self-care were demonstrated in seven studies but only three had used validated instruments to measure such changes. This suggests that no firm conclusions can be drawn about changes in self-care practices.

Attachment bonding and the receipt of care in the face of chronic illness

The relationship between social support and the mental health outcomes of chronic illness sufferers is regarded as complex with inconsistent findings across studies. More recently, researchers have argued that that these inconsistencies may be explained by attachment theory. In this preliminary study, we explored how attachment bonds with three distinct attachment figures – parents, best friends and romantic partners influenced arthritic young adults’ seeking of care. Forty-one arthritis sufferers aged between 18 and 33 years were administered an online questionnaire which included measures of attachment and the receipt of emotional and instrumental care. Significant differences were found in young adults’ attachment avoidance and anxiety ratings, and seeking of instrumental care across parents, best friends and romantic partners. These differences were associated with differences in the frequency and type of care received by young arthritis sufferers across the three attachment figures. Furthermore, arthritis severity was associated with the receipt of care from attachment figures however this relationship was partially mediated by attachment anxiety.

Rural sports and recreational injuries in Australia: what do we know?

Objective: It is widely recognised that individuals residing in regional or rural areas have poorer health outcomes than those from metropolitan areas. Factors associated with these poorer health outcomes include geographical isolation, population declines, limited health care provision and higher levels of inactivity compared to urban areas. The mental, social and physical health of individuals and communities in rural areas can be improved through active participation in sport and recreation activities. Unfortunately, participation in such activities can potentially lead to injury. There is a suggestion that there is an increased risk of sports injuries in rural areas due to the lack of health professionals and coaching personnel, fewer available volunteers to organise and deliver sport, and the general attitude towards injuries in rural settings.

Results: There is very limited information about the number and types of injuries sustained during participation in sports activities in rural and regional settings. This is largely related to a lack of formal sporting structures and support mechanisms including research funding and trained personnel.

Conclusion: A range of factors need to be implemented to improve safety for sporting and recreational participants in these areas. These include improved monitoring of injury occurrence, stronger promotion of safety initiatives and wider implementation of education strategies.

Injury profiles of Indigenous and non-Indigenous people in New South Wales

Objectives:
To compare the injury profiles of the Indigenous population in New South Wales with that of the non-Indigenous population.
Design and setting:
Descriptive analysis of NSW Health data obtained from the Health Outcomes Information and Statistical Toolkit (HOIST) database. Hospitalisation data were collected for the period 1 July 1999 to 30 June 2003. Mortality data were collected for the period 1 January 1999 to 31 December 2002.
Main outcome measures:
Hospitalisation and death rates due to injury by age, sex, injury mechanism and Indigenous status. Rate ratios for comparison between Indigenous and non-Indigenous populations.
Results:
Rates of death from injury were higher for all age groups in the Indigenous population, except people older than 65 years. Indigenous people aged 25–44 years were twice as likely to be hospitalised as their non-Indigenous counterparts (rate ratio [RR], 2.09; 95% CI, 2.03–2.14), and five times as likely to be hospitalised for interpersonal violence (RR, 5.19; 95% CI, 4.98–5.40).
Conclusion:
The higher rates of injury-related hospitalisation and death in the Indigenous population in NSW are consistent with data reported for other parts of Australia. Of particular concern is the number of Indigenous deaths and hospitalisations due to interpersonal violence.

Cost-effectiveness analysis of screening for lung cancer with low dose spiral CT (computed tomography) in the Australian setting

Introduction:
Low dose spiral computed tomography (CT) is a sensitive screening tool for lung cancer that is currently being evaluated in both non-randomised studies and randomised controlled trials.
Methods:
We conducted a quantitative decision analysis using a Markov model to determine whether, in the Australian setting, offering spiral CT screening for lung cancer to high risk individuals would be cost-effective compared with current practice. This exploratory analysis was undertaken predominantly from the perspective of the government as third-party funder. In the base-case analysis, the costs and health outcomes (life-years saved and quality-adjusted life years) were calculated in a hypothetical cohort of 10,000 male current smokers for two alternatives: (1) screen for lung cancer with annual CT for 5 years starting at age 60 year and treat those diagnosed with cancer or (2) no screening and treat only those who present with symptomatic cancer.
Results:
For male smokers aged 60–64 years, with an annual incidence of lung cancer of 552 per 100,000, the incremental cost-effectiveness ratio was $57,325 per life-year saved and $105,090 per QALY saved. For females aged 60–64 years with the same annual incidence of lung cancer, the cost-effectiveness ratio was $51,001 per life-year saved and $88,583 per QALY saved. The model was used to examine the relationship between efficacy in terms of the expected reduction in lung cancer mortality at 7 years and cost-effectiveness. In the base-case analysis lung cancer mortality was reduced by 27% and all cause mortality by 2.1%. Changes in the estimated proportion of stage I cancers detected by screening had the greatest impact on the efficacy of the intervention and the cost-effectiveness. The results were also sensitive to assumptions about the test performance characteristics of CT scanning, the proportion of lung cancer cases overdiagnosed by screening, intervention rates for benign disease, the discount rate, the cost of CT, the quality of life in individuals with early stage screen-detected cancer and disutility associated with false positive diagnoses. Given current knowledge and practice, even under favourable assumptions, reductions in lung cancer mortality of less than 20% are unlikely to be cost-effective, using a value of $50,000 per life-year saved as the threshold to define a “cost-effective” intervention.
Conclusion:
The most feasible scenario under which CT screening for lung cancer could be cost-effective would be if very high-risk individuals are targeted and screening is either highly effective or CT screening costs fall substantially.

Interventions for educating children who have attended the emergency room for asthma (Review)

Background: Asthma is one of the most common reasons for paediatric admissions to hospital, with substantial cost to the community. There is some evidence to suggest that many hospital admissions could be prevented with effective education about asthma and its management.
Objectives: To conduct a systematic review of the literature in order to identify whether asthma education leads to improved health outcomes in children who have attended the emergency department for asthma.
Search strategy: We searched the Cochrane Airways Group trials register, including MEDLINE, EMBASE, and CINAHL databases, and reference lists of trials and review articles.
Selection criteria: Randomised controlled trials or controlled clinical trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months. Data collection and analysis:Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.
Main results: Eight trials involving 1407 patients were included, in all the education was provided by nurses or researchers. Compared to control (usual care or lower intensity education) education did not reduce subsequent emergency department (ED) visits [4 trials; relative risk (RR)= 0.87, 95% confidence interval (CI) 0.37 to 2.08], hospital admissions [5 trials; RR=0.74, 95% CI 0.38 to 1.46] and unscheduled doctor visits [5 trials; RR= 0.74, 95% CI 0.49 to 1.12). Each analysis showed evidence of heterogeneity among the studies (P<0.01). Subgroup analyses by the overall difference in scale of intervention between treatment and control groups (comprehensive programme versus information only) or the timing of the intervention/recruitment (early versus delayed) gave similar results to the main analysis and still revealed significant heterogeneity between trials. Authors' conclusions: On the basis of the published trials, there is no firm evidence to support the use of asthma education for children who have attended the emergency department for asthma as a means of reducing subsequent ED visits, hospital admissions or unscheduled doctor visits. Some trials appeared to show clear evidence of benefit, but reasons for differences between these and the negative studies is not clear. More research is required.

Heterogeneity in service delivery and inequity in access are common characteristics of chronic heart failure management programs

Background: The prevalence of heart failure in Australia is similar to that of Europe. In Australia, chronic heart failure management programs (CHF-MPs) have become part of standard care for patients with Chronic Heart Failure (CHF). However, heterogeneity among programs is common which can result in variable patient outcomes.

Method: A national survey was undertaken of 59 post-discharge CHF-MPs identified from within the Australian health care system. Two had ceased operating and one centre declined to participate in the study. A 33-item investigator-developed questionnaire, examining the characteristics and interventions used within each CHF-MP, was sent to the remaining 56 CHF-MPs. A response rate of 100% was achieved.

Results: Our survey revealed a disproportional distribution of CHF-MPs across the Australian continent: the State of Victoria had 3.6 CHF-MPs/million population, New South Wales had 3.7 CHF-MPs/million population, Queensland had 1 program/million population, South Australia had 0.3 CHF-MPs/million population and Western Australia had 1 program/million population.Overall, 8000 postdischarge CHF pts (median: 126; IQR: 26-260) were managed via CHF-MPs. Approximately 40,000 CHF pts are discharged from metropolitan institutions nationally, this represents only 22% of the potential caseload for these cost-effective CHF-MPs. Only 8% of these programs were located within rural regions. The majority of CHF-MPs were located within an acute metropolitan hospital (52%) and 36% were community based (all associated with a hospital). Heterogeneity of CHF-MPs in applied models of care was evident with 75% of CHF-MPs offering CHF outpatient clinics and 77% conducting home visits. Of the programs offering home visits 78% were funded by regional government (p<0.048). There were no nurse-led CHF outpatient clinics. A hybrid approach to CHF-MPs was common with many CHF-MPs comprising an outpatient clinic, home visits and inpatient visits. Various medications were titrated by nurses in 43% of CHF-MPs. In the programs that allowed nurses to titrate medications 79% were located in an acute hospital (p<0.011).

Conclusion: Variability of service availability is of concern within the context of universal coverage. In addition, heterogeneity between programs and the diversity in models of care delivery highlights the inconsistency and questions the quality of health related outcomes. We are currently analysing health outcome data from the 1015 patients managed in these CHF-MPs to describe the relationship between quality of care and health outcomes.

Fuzzy logic in clinical practice decision support systems

Computerized clinical guidelines can provide significant benefits to health outcomes and costs, however, their effective implementation presents significant problems. Vagueness and ambiguity inherent in natural (textual) clinical guidelines is not readily amenable to formulating automated alerts or advice. Fuzzy logic allows us to formalize the treatment of vagueness in a decision support architecture. This paper discusses sources of fuzziness in clinical practice guidelines. We consider how fuzzy logic can be applied and give a set of heuristics for the clinical guideline knowledge engineer for addressing uncertainty in practice guidelines. We describe the specific applicability of fuzzy logic to the decision support behavior of Care Plan On-Line, an intranet-based chronic care planning system for General Practitioners.

Dietary patterns of adolescents and risk of obesity and hypertension

Increasingly, measures of dietary patterns have been used to capture the complex nature of dietary intake and investigate its association with health. Certain dietary patterns may be important in the prevention of chronic disease; however, there are few investigations in adolescents. The aim of this study was to describe the dietary patterns of adolescents and their associations with sociodemographic factors, nutrient intakes, and behavioral and health outcomes. Analysis was conducted using data collected in the 1995 Australian National Nutrition Survey of participants aged 12–18 y who completed a 108-item FFQ (n = 764). Dietary patterns were identified using factor analysis and associations with sociodemographic factors and behavioral and health outcomes investigated. Factor analysis revealed 3 dietary patterns labeled a fruit, salad, cereals, and fish pattern; a high fat and sugar pattern; and a vegetables pattern, which explained 11.9, 5.9, and 3.9% of the variation in food intakes, respectively. The high fat and sugar pattern was positively associated with being male (P < 0.001), the vegetables pattern was positively associated with rural region of residence (P = 0.004), and the fruit, salad, cereals, and fish pattern was inversely associated with age (P = 0.03). Dietary patterns were not associated with socioeconomic indicators. The fruit, salad, cereals, and fish pattern was inversely associated with diastolic blood pressure (P = 0.0025) after adjustment for age, sex, and physical activity in adolescents ≥16 y. This study suggests that specific dietary patterns are already evident in adolescence and a dietary pattern rich in fruit, salad, cereals, and fish pattern may be associated with diastolic blood pressure in older adolescents.

Cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children

Objective
 To assess from a societal perspective the incremental cost-effectiveness of a family-based GP-mediated intervention targeting overweight and moderately obese children. The intervention was modelled on the LEAP (live, eat and play) trial, a randomised controlled trial conducted by the Centre for Community Child Health, Melbourne, Australia in 2002–2003. This study was undertaken as part of the assessing cost-effectiveness (ACE) in obesity project which evaluated, using consistent methods, 13 interventions targeting unhealthy weight gain in children and adolescents.
Method
A logic pathway was used to model the effects of the intervention compared to no intervention on body mass index (BMI) and health outcomes (disability-adjusted life years—DALYs). Disease costs and health benefits were tracked until the cohort of eligible children reached the age of 100 years or death. Simulation-modelling techniques were used to present a 95% uncertainty interval around the cost-effectiveness ratio. The intervention was also assessed against a series of filters (‘equity’, ‘strength of evidence’, ‘acceptability’, ‘feasibility’, sustainability’ and ‘side-effects’) to incorporate additional factors that impact on resource allocation decisions.
Results
The intervention, as modelled, reached 9685 children aged 5–9 years with a BMI z-score of ≥3.0, and cost $AUD6.3M (or $AUD4.8M excluding time costs). It resulted in an incremental saving of 2300 BMI units which translated to 511 DALYs. The cost-offsets stemming from the intervention totalled $AUD3.6M, resulting in a net cost per DALY saved of $AUD4670 (dominated; $0.1M) (dominated means intervention costs more for less effect).
Conclusion
Compared to a ‘no intervention’ control group, the intervention was cost-effective under current assumptions, although the uncertainty intervals were wide. A key question related to the long-term sustainability of the small incremental weight loss reported, based on the 9-month follow-up results for LEAP.

The meaning of leisure for well-elderly Italians in an Australian community : implications for occupational therapy

Aim: This paper documents a study that aimed to discover the meaning of leisure experiences for an ageing Italian community in a large regional centre in Victoria, Australia.
Methods: This qualitative investigation used a phenomenological study design, and data were collected through semistructured interviews with 10 well-elderly Australian Italians.
Results: Participants engaged in numerous leisure occupations that were meaningful to them and directly impacted on positive subjective experiences and health outcomes.
Conclusion: This paper adds to an understanding of how leisure impacts on the health of well-elderly Australians and how occupational therapists can use leisure effectively in interventions for successful ageing.

Conceptualising the policy practice and behavioural research relationship

Background
Policy is frequently identified in the behavioural nutrition and physical activity research literature as a necessary component of effective research and practice. The purpose of this commentary is to promote a dialogue to contribute towards the further development of conceptual understandings and theories of the relationship between policy practice and behavioural research and how these two activities might work synergistically to improve public health outcomes.

Methods
Drawing on policy and public health literature, this commentary presents a a conceptual model of the interaction and mediation between nutrition and physical activity-relevant policy and behavioural nutrition and physical activity research, environments, behaviours and public health implications. The selling of food in school canteens in several Australian states is discussed to illustrate components of the relationship and the interactions among its components.

Results
The model depicts a relationship that is interdependent and cyclic. Policy contributes to the relationship through its role in shaping environmental and personal-cognitive determinants of behaviours and through these determinants it can induce behaviour change. Behavioural research describes behaviours, identifies determinants of behaviour change and therefore helps inform policy development and monitor and evaluate its impact.

Conclusion
The model has implications for guiding behavioural research and policy practice priorities to promote public health outcomes. In particular, we propose that policy practice and behavioural research activities can be strengthened by applying to each other the theories from the scientific disciplines informing these respective activities. Behavioural science theories can be applied to help understand policy-making and assist with disseminating research into policy and practice. In turn, policy science theories can be applied to support the 'institutionalisation' of commitments to ongoing behavioural research.