Dusting off the epidemiological triad: could it work with obesity

The search for effective ways of dealing with obesity has centred on biological research and clinical management. However, obesity needs to be conceptualized more broadly if the modern pandemic is to be arrested. The epidemiological triad (hosts, agent/vectors and environments) has served us well in dealing with epidemics in the past, and may be worth re-evaluating to this end. Education, behaviour change and clinical practices deal predominantly with the host, although multidisciplinary practices such as shared-care might also be expected to impact on other corners of the triad. Technology deals best with the agent of obesity (energy imbalance) and it's vectors (excessive energy intake and/or inadequate energy expenditure), and policy and social change are needed to cope with the environment. The value of a broad model like this, rather than specific isolated approaches, is that the key players such as legislators, health professionals, governments and industry can see their roles in attenuating and eventually reversing the epidemic. It also highlights the need to intervene at all levels in obesity control and reduces the relevance of arguments about nature vs. nurture.


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The MOA framework and behavioural response

This paper discusses the application of a conceptual social marketing model, the MOA (motivation, opportunity and ability) framework, in the context of an environmental management case study relating to land management. The main objectives involved examination of the relationships between the MOA constructs and the relationships between these constructs and socially desirable behaviour. Structural Equation Modelling was chosen to examine the relationships in data collected from a telephone survey. The results from the analysis of the data revealed that the relationships between the MOA components could be used to explain changes in durable socially desirable behaviour. In particular, intrinsic motivation is more likely than extrinsic motivation to produce a durable socially desirable behaviour change.

Key behavioural and cognitive employee outcomes : a social exchange model

This paper serves to integrate social exchange with organisational justice and performance theory. Social exchange relationships are represented by employees’ perceptions of workplace inequity and evaluated using justice rules. Employees are expected to have in-role and extra-role behavioural responses and cognitive responses to inequity. It is theorised that behavioural and cognitive responses are moderated by the employee’s perceptions of organisational justice. Much employee performance, commitment, engagement, retention and turnover may be explained by this comprehensive model.

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.

The application of the transtheoretical model to offender populations : some critical issues

Purpose : Over the past two decades, the transtheoretical model (TTM) of change has become perhaps the most widely used model of behaviour change in the treatment of addictive and/or problem behaviours. More recently, the stages of change component of the TTM has been adopted for use in forensic settings. This paper aims to review the application of the TTM model to offender populations.

Arguments : The application of the TTM to offenders raises a number of issues regarding the process of behaviour change for offenders attending treatment programmes. It is argued that while the TTM has been designed to account for high frequency behaviour (e.g. smoking, alcohol misuse), offending behaviour may be less frequent and the process of change less cyclical. Moreover, it is suggested that the most important issue in a treatment context is the proper integration of the TTM constructs. There have been few empirical tests of this aspect of the model.

Conclusion : While the TTM may have some value in explaining how rehabilitation programmes help offenders to change their behaviour, the stages of change construct is, by itself, unlikely to adequately explain the process by which offenders desist from offending.

CLTS: Lessons learnt from a pilot project in Timor Leste

Timor Leste, emerging from conflict ridden independence is one of the poorest countries in Asia, with major challenges in rebuilding infrastructure, particularly water and sanitation in rural areas. Community Led Total Sanitation is a relatively new approach to eliminate open defecation through community mobilisation and behaviour change, rather than subsidy and latrine construction. This paper discusses CLTS in the Timorese context, and highlights some key challenges in assessing the potential of CLTS to address sanitation issues. Some problems identified include a lack of coherence between the integration of water supply and sanitation, and the promotion of CLTS in isolation of any project activities that utilise any form of incentive or subsidy. The knock- on effect of the long term sustainability of latrine usage and maintenance CLTS is questioned unless further research clarifies the demand responsiveness of CLTS in conjunction with subsidy driven water supply.

Model of behavioural response in social marketing

This thesis contributes to the expanding area of non-profit and social marketing research. The research developed a new conceptual model that was applied to environmental management and provides an understanding of the components that contribute to durable behaviour change in social marketing applications.

Is dietary management a responsibility of general practitioners? The views of Victorian general practitioners

Rationale : Australia is experiencing an evolving healthcare system, resulting in an aim of systematic managed care for patients with chronic disease. One outcome has been debate on doctors' dietary management responsibilities.
Aim : To identify general practitioners' perceptions of their dietary management responsibilities for adult cardiac patients.
Methods : A Two phase study was conducted. First, semi-structured interviews with 30 Melbourne general practitioners were conducted to gather preliminary information about dietary management. The results informed a questionnaire for the second phase. This was completed by 248 general practitioners (30%) in Victoria.
Principal findings : Themes arising in interviews, and also supported by cross-sectional survey showed that doctors perceive themselves as filling one or more of three roles. The majority (87.4%) endorsed an 'Influencing' role, 27.4% endorsed 'Dietary Educator' and 44.0% a 'Coordinator' role. The Influencer role was characterised by encouragement of dietary behaviour change, such as discussing benefits and consequences of inaction to dietary change. The Educator role was characterised by the provision of a range of behaviour change strategies- 'how to' achieve change. 'Coordinators' reported the provision of dietary counselling belonged to dietitians alone.
Implications : The results indicate doctors' awareness of need for patients' dietary education should be increased. This could be accomplished by one-on-one education. Patients' access to dietary education should also be facilitated by doctors' referring on. Embedding dietary management protocols in doctors' managed care templates could improve patients' access to dietary education and enhance doctor's collaborative roles.
Presentation type : Paper
Session theme : Getting Evidence into Practice 2

Diabetes risk reduction behaviours of rural postpartum women with a recent history of gestational diabetes

Introduction: For most women, gestational diabetes is temporary; however, an episode of gestational diabetes mellitus (GDM) confers an approximately seven-fold increased risk of developing type 2 diabetes mellitus. Objective: To examine readiness to adopt diabetes risk reduction behaviours and the prevalence of these behaviours among rural women with GDM during their last pregnancy.
Methods: The study design was a self-administered mailed questionnaire seeking information about demographics, stage of change, physical activity level and dietary fat intake. Setting: Regional outpatient context. Participants: Women with a single episode of GDM between 1 July 2001 and 31 December 2005 (n = 210). Main outcome measures: Stage of change for physical activity, weight loss and reducing dietary fat behaviour; meeting activity targets, body mass index (BMI) and dietary fat score.
Results: Eighty-four women returned completed questionnaires (40% response rate). Of the 77 women eligible (mean age 35 ± 3.8 years), 58% met recommended activity targets. Sixty-three percent of women were overweight or obese: mean BMI 29.6 kg/m2 (± 7.30). Women reported a high level of preparedness to engage in physical activity, weight loss and reduction of fat intake. Thirty-nine percent of women had not had any postpartum follow-up glucose screening. Women who remembered receiving diabetes prevention information were significantly more likely to meet physical activity targets (p<0.05).
Conclusions: Readiness to engage in behaviour change was high among this group of rural women for all three diabetes risk reduction behaviours measured. However, despite a high proportion of women meeting activity targets and reducing fat intake, the majority of women remained overweight or obese. Postpartum follow-up glucose testing needs to be improved and the impact of diabetes prevention information provided during pregnancy warrants further study.

Understanding the concept of elasticity in supply chain relationships : an agency theory perspective

The issue of flexibility in supply chains has been receiving heightened attention by scholars and practitioners especially as business environment becoming more turbulent and uncertain. Notwithstanding, one of the important aspects of flexibility – relationship flexibility – which has the potential to proliferate responsiveness and postpone bifurcation in buyer -supplier relationships has not been well understood and researched. Identifying this gap within the literature, this paper proposes a concept of elasticity as an important element of relationship flexibility in supply chains. It is argued that the tolerance threshold of coopering parties in presence of their sudden behaviour change will determine their state of relationship elasticity (i.e. elastic or inelastic). The theoretical development of this paper has been primarily based on review of the literature and insights from agency perspective. It is proposed that relationship governance mechanisms advocated by agency theory has the potential to influence elasticity status of principal agent relationships.

Health beliefs - what role do they play in outcomes research?

Lay beliefs about health and illness are individual and social, influenced by prevailing social and medical ideologies. Health beliefs clearly influence self-care motivation and have an effect on health-promoting behaviour (e.g. attendance at a screening program, food choices, adherence to prescribed medication). Further, the beliefs and attributions that people hold can directly affect physiological systems (e.g. the immune system). Health beliefs have been shown to influence a variety of patient-reported outcomes, including medication adherence, satisfaction and health-related quality of life. It is widely acknowledged that when the patient's beliefs are acknowledged and incorporated, rather than ignored, optimal biomedical patient-reported outcomes are more likely to be achieved. Several psychological models have been developed to predict health behaviours and may be utilised to identify the beliefs that inform such behaviours. These models consider the social milieu, personality, demographic, political and economic predictors of health beliefs. They demonstrate the impact of beliefs such as the causes of illness, effectiveness of healthcare and acceptability of health services, and how manipulating these can result in actual or intended behaviour change. This workshop will introduce health beliefs and discuss the psychological models that underpin the translation of belief into behaviour. The session is interactive, with participants defining health beliefs and their impact on behaviour. Participants will be invited to critique the models and apply their chosen model to a health indication of their choice.

Introducing the D4 Diagnostic Quadrant as a targeting tool: developing a framework for the effectiveness of HIV/AIDS interventions in Tanzania and beyond

The current study develops and evaluates a tool to distinguish four different categories of educators for the effective delivery of HIV/AIDS health education using data from 548 randomly selected participants aged 16 years. The D4 Diagnostic Quadrant is based on HIV knowledge and sexual practice behaviours and indicates four distinct typologies of educator. The discerning educator has high HIV/AIDS knowledge and healthy sexual practices. The dissolute educator has high HIV/AIDS knowledge but employs unhealthy or risky sexual practices. The decorous educator has low HIV/AIDS knowledge but practices healthy sexual practices. The disempowered educator has low HIV/AIDS knowledge and employs unhealthy or risky sexual practices. The study found that the two categories that will result in the most effective behaviour-change interventions are those that target ‘discerning’ and ‘decorous’ individuals as the educators. Both these categories have underlying healthy practices that minimise the risk of HIV transmission. The D4 Diagnostic Quadrant tool provides information as to existing knowledge and beliefs about HIV/AIDS that can inform decisions relating to the allocation of scarce resources. The tool will be very useful in the selection process of would-be educators particularly in health-promotion interventions.

Scaling up diabetes prevention in Victoria, Australia: policy development, implementation and evaluation

Objective
The Australian lifestyle intervention program Life! is only the second reported, large-scale diabetes prevention program. This paper describes the genesis and the successful establishment of Life! and its key outcomes for participants and implementation.

Research
Design and Methods Life!, a behavior change intervention, comprises six group sessions over eight months. The Victorian Department of Health funded Diabetes Australia-Victoria to implement the program. Experience of the Greater Green Triangle diabetes prevention implementation trial was used for intervention design, workforce development, training and infrastructure. Clinical and anthropometric data from participants, used for program evaluation, was recorded on a central database.

Results
Life! has a state-wide workforce of 302 trained facilitators within 137 organizations. 29,000 Victorians showed interest in Life! and 15,000 individuals have been referred to the program. In total, 8,412 participants commenced a Life! program between October 2007 and June 2011. 37% of the original participants completed the eight month program. Participants completing sessions one to five lost an average of 1·4 kg weight (p<0·001) and waist circumference of 2·5cm (p<0.001). Those completing six sessions lost an average of 2·4 kg weight (p<0·001) and waist circumference of 3·8 cm (p<0·001). The weight loss of 2.4 kg represents 2.7% of participants’ starting body weight.

Conclusion
The impact of Life! is attributable to applying available evidence for the systems design of the intervention, and collaboration between policy makers, implementers and evaluators using the principles of continuous quality improvement to support successful, large scale recruitment and implementation.

Underestimation of risk perception in patients at risk of heart disease

Accurate perception of cardiovascular risk is important if people with established, or at high risk of, coronary heart disease are to engage in risk-reducing behaviours.