Disease control and management

Globally, the main contributors to morbidity and mortality are chronic conditions, including cardiovascular disease and diabetes. Chronic disease is costly and partially avoidable, with around 60% of deaths and nearly 50% of the global disease burden attributable to these conditions. By 2020, chronic illnesses will likely be the leading cause of disability worldwide. Existing healthcare systems that focus on acute episodic health conditions, both national and international, cannot address the worldwide transition to chronic illness; nor are they appropriate for the ongoing care and management of those already dealing with chronic diseases. As such, chronic disease management requires integrated approaches that incorporate interventions targeted at both individuals and populations, and emphasise the shared risk factors of different conditions. International and Australian strategic planning documents articulate similar elements to manage chronic disease, including the need for aligning sectoral policies for health, forming partnerships, and engaging communities in decision-making. Infectious diseases are also a common and significant contributor to ill health throughout the world. In many countries, this impact has been minimised by the combined efforts of preventative health measures and improved treatment methods. However, in low-income countries, infectious diseases remain the dominant cause of death and disability. The World Health Organization (WHO) estimates that infectious diseases (including respiratory infections) still account for around 23% (or around 14 million) of all deaths each year, and result in over 4.6 billion episodes of diarrhoeal disease and 243 million cases of malaria each year (Lozano et al. 2012, WHO 2009). In addition to the high level of mortality, infectious diseases disable many hundreds of millions of people each year, mainly in developing countries, with the global burden of disease from infectious diseases estimated to be around 300 million DALYs (disability-adjusted life years) (WHO 2012). The aim of this chapter is to outline the impact that infectious diseases and chronic diseases have on the health of the community, describe the public health strategies used to reduce the burden of those diseases, and discuss the historic and emerging disease risks to public health. This chapter examines the comprehensive approaches implemented to prevent both chronic and infectious diseases, and to manage and care for communities with these conditions.

Individual and social determinants of multiple chronic disease behavioural risk factors in Canadian children and adolescents

Contexte: Les facteurs de risque comportementaux, notamment l’inactivité physique, le comportement sédentaire, le tabagisme, la consommation d’alcool et le surpoids sont les principales causes modifiables de maladies chroniques telles que le cancer, les maladies cardiovasculaires et le diabète. Ces facteurs de risque se manifestent également de façon concomitante chez l’individu et entraînent des risques accrus de morbidité et de mortalité. Bien que les facteurs de risque comportementaux aient été largement étudiés, la distribution, les patrons d’agrégation et les déterminants de multiples facteurs de risque comportementaux sont peu connus, surtout chez les enfants et les adolescents. Objectifs: Cette thèse vise 1) à décrire la prévalence et les patrons d’agrégation de multiples facteurs de risque comportementaux des maladies chroniques chez les enfants et adolescents canadiens; 2) à explorer les corrélats individuels, sociaux et scolaires de multiples facteurs de risque comportementaux chez les enfants et adolescents canadiens; et 3) à évaluer, selon le modèle conceptuel de l’étude, l’influence longitudinale d’un ensemble de variables distales (c’est-à-dire des variables situées à une distance intermédiaire des comportements à risque) de type individuel (estime de soi, sentiment de réussite), social (relations sociales, comportements des parents/pairs) et scolaire (engagement collectif à la réussite, compréhension des règles), ainsi que de variables ultimes (c’est-à-dire des variables situées à une distance éloignée des comportements à risque) de type individuel (traits de personnalité, caractéristiques démographiques), social (caractéristiques socio-économiques des parents) et scolaire (type d’école, environnement favorable, climat disciplinaire) sur le taux d’occurrence de multiples facteurs de risque comportementaux chez les enfants et adolescents canadiens. Méthodes: Des données transversales (n = 4724) à partir du cycle 4 (2000-2001) de l’Enquête longitudinale nationale sur les enfants et les jeunes (ELNEJ) ont été utilisées pour décrire la prévalence et les patrons d’agrégation de multiples facteurs de risque comportementaux chez les jeunes canadiens âgés de 10-17 ans. L’agrégation des facteurs de risque a été examinée en utilisant une méthode du ratio de cas observés sur les cas attendus. La régression logistique ordinale a été utilisée pour explorer les corrélats de multiples facteurs de risque comportementaux dans un échantillon transversal (n = 1747) de jeunes canadiens âgés de 10-15 ans du cycle 4 (2000-2001) de l’ELNEJ. Des données prospectives (n = 1135) à partir des cycle 4 (2000-2001), cycle 5 (2002-2003) et cycle 6 (2004-2005) de l’ELNEJ ont été utilisées pour évaluer l’influence longitudinale des variables distales et ultimes (tel que décrit ci-haut dans les objectifs) sur le taux d’occurrence de multiples facteurs de risque comportementaux chez les jeunes canadiens âgés de 10-15 ans; cette analyse a été effectuée à l’aide des modèles de Poisson longitudinaux. Résultats: Soixante-cinq pour cent des jeunes canadiens ont rapporté avoir deux ou plus de facteurs de risque comportementaux, comparativement à seulement 10% des jeunes avec aucun facteur de risque. Les facteurs de risque comportementaux se sont agrégés en de multiples combinaisons. Plus précisément, l’occurrence simultanée des cinq facteurs de risque était 120% plus élevée chez les garçons (ratio observé/attendu (O/E) = 2.20, intervalle de confiance (IC) 95%: 1.31-3.09) et 94% plus élevée chez les filles (ratio O/E = 1.94, IC 95%: 1.24-2.64) qu’attendu. L’âge (rapport de cotes (RC) = 1.95, IC 95%: 1.21-3.13), ayant un parent fumeur (RC = 1.49, IC 95%: 1.09-2.03), ayant rapporté que la majorité/tous de ses pairs consommaient du tabac (RC = 7.31, IC 95%: 4.00-13.35) ou buvaient de l’alcool (RC = 3.77, IC 95%: 2.18-6.53), et vivant dans une famille monoparentale (RC = 1.94, IC 95%: 1.31-2.88) ont été positivement associés aux multiples comportements à risque. Les jeunes ayant une forte estime de soi (RC = 0.92, IC 95%: 0.85-0.99) ainsi que les jeunes dont un des parents avait un niveau d’éducation postsecondaire (RC = 0.58, IC 95%: 0.41-0.82) étaient moins susceptibles d’avoir de multiples facteurs de risque comportementaux. Enfin, les variables de type social distal (tabagisme des parents et des pairs, consommation d’alcool par les pairs) (Log du rapport de vraisemblance (LLR) = 187.86, degrés de liberté = 8, P < 0,001) et individuel distal (estime de soi) (LLR = 76.94, degrés de liberté = 4, P < 0,001) ont significativement influencé le taux d’occurrence de multiples facteurs de risque comportementaux. Les variables de type individuel ultime (âge, sexe, anxiété) et social ultime (niveau d’éducation du parent, revenu du ménage, structure de la famille) ont eu une influence moins prononcée sur le taux de cooccurrence des facteurs de risque comportementaux chez les jeunes. Conclusion: Les résultats suggèrent que les interventions de santé publique devraient principalement cibler les déterminants de type individuel distal (tel que l’estime de soi) ainsi que social distal (tels que le tabagisme des parents et des pairs et la consommation d’alcool par les pairs) pour prévenir et/ou réduire l’occurrence de multiples facteurs de risque comportementaux chez les enfants et les adolescents. Cependant, puisque les variables de type distal (telles que les caractéristiques psychosociales des jeunes et comportements des parents/pairs) peuvent être influencées par des variables de type ultime (telles que les caractéristiques démographiques et socioéconomiques), les programmes et politiques de prévention devraient également viser à améliorer les conditions socioéconomiques des jeunes, particulièrement celles des enfants et des adolescents des familles les plus démunies.

The application of medical informatics to the veterinary management programs at companion animal practices in Alberta, Canada: a case study.

Companion animals closely share their domestic environment with people and have the potential to, act as sources of zoonotic diseases. They also have the potential to be sentinels of infectious and noninfectious, diseases. With the exception of rabies, there has been minimal ongoing surveillance of, companion animals in Canada. We developed customized data extraction software, the University of, Calgary Data Extraction Program (UCDEP), to automatically extract and warehouse the electronic, medical records (EMR) from participating private veterinary practices to make them available for, disease surveillance and knowledge creation for evidence-based practice. It was not possible to build, generic data extraction software; the UCDEP required customization to meet the specific software, capabilities of the veterinary practices. The UCDEP, tailored to the participating veterinary practices', management software, was capable of extracting data from the EMR with greater than 99%, completeness and accuracy. The experiences of the people developing and using the UCDEP and the, quality of the extracted data were evaluated. The electronic medical record data stored in the data, warehouse may be a valuable resource for surveillance and evidence-based medical research.

Roadmap for implementing the Chronic Care Model for weight management: Healthcare Institution's Response to Obesity (HIRO)

Background. Excess weight and obesity are at epidemic proportions in the United States and place individuals at increased risk for a variety of chronic conditions. Rates of diabetes, high blood pressure, coronary artery disease, stroke, cancer, and arthritis are all influenced by the presence of obesity. Small reductions in excess weight can produce significant positive clinical outcomes. Healthcare organizations have a vital role to play in the identification and management of obesity. Currently, healthcare providers do not adequately diagnose and manage excess weight in patients. Lack of skill, time, and knowledge are commonly cited as reasons for non-adherence to recommended standards of care. The Chronic Care Model offers an approach to healthcare organizations for chronic disease management. The model consists of six elements that work together to empower both providers and patients to have more productive interactions: the community, the health system itself, self-management support, delivery system design, decision support, and clinical information systems. The model and its elements may offer a framework through which healthcare organizations can adapt to support, educate, and empower providers and patients in the management of excess weight and obesity. Successful management of excess weight will reduce morbidity and mortality of many chronic conditions. Purpose. The purpose of this review is to synthesize existing research on the effectiveness of the Chronic Care Model and its elements as they relate to weight management and behaviors associated with maintaining a healthy weight. Methods: A narrative review of the literature between November 1998 and November 2008 was conducted. The review focused on clinical trials, systematic reviews, and reports related to the chronic care model or its elements and weight management, physical activity, nutrition, or diabetes. Fifty-nine articles are included in the review. Results. This review highlights the use of the Chronic Care Model and its elements that can result in improved quality of care and clinical outcomes related to weight management, physical activity, nutrition, and diabetes. Conclusions. Healthcare organizations can use the Chronic Care Model framework to implement changes within their systems to successfully address overweight and obesity in their patient populations. Specific recommendations for operationalizing the Chronic Care Model elements for weight management are presented.^

Kidney and related chronic disease profiles and risk factors in three remote Australian Aboriginal communities

Morbidities and deaths from noncommunicable chronic diseases are greatly increased in remote Australian Aboriginal communities, but little is known of the underlying community-based health profiles. We describe chronic-disease profiles and their risk factors in 3 remote communities in the Northern Territory. Consenting adults (18+ years of age) in 3 communities participated in a brief history and examination between 2000 and mid-2003 as part of a systematic program to improve chronic-disease awareness and management. Participation was 67%,128%, and 62% in communities A, B, and C, respectively with a total of 1070 people examined. Current smokers included 41% of females and 72% of males. Most men were current drinkers, but most women were not. Parameters of body weight differed markedly by community, with mean body mass index (BMC) varying from 21.4 to 27.9 kg/m(2). Rates of chronic diseases were excessive but differed markedly; an almost threefold difference in the likelihood of any morbidity existed between communities A and C. Rates increased with age, but the greatest numbers of people with morbidities were in the middle-aged group. Most people had multiple morbidities with tremendous overlap. Hypertension and kidney disease appear to be early manifestations of the integrated chronic-disease syndrome, while diabetes is a late manifestation or complication. Substantial numbers of new cases of disease were identified by testing, and blood pressure improved in treated people with hypertension. Wide variations occur in body habitus, risk factors, and chronic-disease rates among communities, but an overwhelming need for effective smoking interventions exists in all. Systematic screening is useful in identifying high-risk individuals, most at early treatable stages there. Findings are very important for estimating current treatment needs, future burdens of disease, and for needs-based health services planning. Resources required will vary according to the burden of disease. (C) 2005 by the National Kidney Foundation, Inc.

Prolonged effects of a home-based intervention in patients with chronic illness

Background: Data on the long-term benefits of nonspecific disease management programs are limited. We performed a long-term follow-up of a previously published randomized trial. Methods: We compared all-cause mortality and recurrent hospitalization during median follow-up of 7.5 years in a heterogeneous cohort of patients with chronic illness initially exposed to a multidisciplinary, homebased intervention (HBI) (n = 260) or to usual postdischarge care (n = 268). Results: During follow-up, HBI had no impact on all-cause mortality (relative risk, 1.04; 95% confidence interval, 0.80-1.35) or event-free survival from death or unplanned hospitalization (relative risk, 1.03; 95% confidence interval, 0.86-1.24). Initial analysis suggested that HBI had only a marginal impact in reducing unplanned hospitalization, with 677 readmissions vs 824 for the usual care group (mean +/- SD rate, 0.72 +/- 0.96 vs 0.84 +/- 1.20 readmissions/patient per year; P = .08). When accounting for increased hospital activity in HBI patients with chronic obstructive pulmonary disease during follow-up for 2 years, post hoc analyses showed that HBI reduced readmissions by 14% within 2 years in patients without this condition (mean +/- SD rate, 0.54 +/- 0.72 vs 0.63 +/- 0.88 readmission/patient per year; P =. 04) and by 21% in all surviving patients within 3 to 8 years (mean +/- SD rate, 0.64 +/- 1.26 vs 0.81 +/- 1.61 readmissions/ patient per year; P =. 03). Overall, recurrent hospital costs were significantly lower ( 14%) in the HBI group (mean +/- SD, $ 823 +/- $ 1642 vs $ 960 +/- $ 1376 per patient per year; P =. 045). Conclusion: This unique study suggests that a nonspecific HBI provides long-term cost benefits in a range of chronic illnesses, except for chronic obstructive pulmonary disease.

Mobile Clinics & Bundled Healthcare: An Exploration of Patient Perceptions of the SughaVazhvu Approach to Chronic Care Management

As the burden of non-communicable diseases increases worldwide, it is imperative that health systems adopt delivery approaches that will enable them to provide accessible, high-quality, and low-cost care to patients that need consistent management of their lifelong conditions. This is especially true in low- and middle-income country settings, such as India, where the disease burden is high and the health sector resources to address it are limited. The subscription-based, managed care model that SughaVazhvu Healthcare—a non-profit social enterprise operating in rural Thanjavur, Tamil Nadu—has deployed demonstrates potential for ensuring continuity of care among chronic care patients in resource-strained areas. However, its effectiveness and sustainability will depend on its ability to positively impact patient health status and patient satisfaction with the care management they are receiving. Therefore, this study is not only a program appraisal to aid operational quality improvement of the SughaVazhvu Healthcare model, but also an attempt to identify the factors that affect patient satisfaction among individuals with chronic conditions actively availing services.

Resilience in chronic disease : the relationships among risk factors, protective factors, adaptive outcomes, and the level of resilience in adults with diabetes

Background: There are innumerable diabetes studies that have investigated associations between risk factors, protective factors, and health outcomes; however, these individual predictors are part of a complex network of interacting forces. Moreover, there is little awareness about resilience or its importance in chronic disease in adulthood, especially diabetes. Thus, this is the first study to: (1) extensively investigate the relationships among a host of predictors and multiple adaptive outcomes; and (2) conceptualise a resilience model among people with diabetes. Methods: This cross-sectional study was divided into two research studies. Study One was to translate two diabetes-specific instruments (Problem Areas In Diabetes, PAID; Diabetes Coping Measure, DCM) into a Chinese version and to examine their psychometric properties for use in Study Two in a convenience sample of 205 outpatients with type 2 diabetes. In Study Two, an integrated theoretical model is developed and evaluated using the structural equation modelling (SEM) technique. A self-administered questionnaire was completed by 345 people with type 2 diabetes from the endocrine outpatient departments of three hospitals in Taiwan. Results: Confirmatory factor analyses confirmed a one-factor structure of the PAID-C which was similar to the original version of the PAID. Strong content validity of the PAID-C was demonstrated. The PAID-C was associated with HbA1c and diabetes self-care behaviours, confirming satisfactory criterion validity. There was a moderate relationship between the PAID-C and the Perceived Stress Scale, supporting satisfactory convergent validity. The PAID-C also demonstrated satisfactory stability and high internal consistency. A four-factor structure and strong content validity of the DCM-C was confirmed. Criterion validity demonstrated that the DCM-C was significantly associated with HbA1c and diabetes self-care behaviours. There was a statistical correlation between the DCM-C and the Revised Ways of Coping Checklist, suggesting satisfactory convergent validity. Test-retest reliability demonstrated satisfactory stability of the DCM-C. The total scale of the DCM-C showed adequate internal consistency. Age, duration of diabetes, diabetes symptoms, diabetes distress, physical activity, coping strategies, and social support were the most consistent factors associated with adaptive outcomes in adults with diabetes. Resilience was positively associated with coping strategies, social support, health-related quality of life, and diabetes self-care behaviours. Results of the structural equation modelling revealed protective factors had a significant direct effect on adaptive outcomes; however, the construct of risk factors was not significantly related to adaptive outcomes. Moreover, resilience can moderate the relationships among protective factors and adaptive outcomes, but there were no interaction effects of risk factors and resilience on adaptive outcomes. Conclusion: This study contributes to an understanding of how risk factors and protective factors work together to influence adaptive outcomes in blood sugar control, health-related quality of life, and diabetes self-care behaviours. Additionally, resilience is a positive personality characteristic and may be importantly involved in the adjustment process among people living with type 2 diabetes.

Manufacturing management programs : are developing economies bridging the strategic gap?

Over the past decade there have been a large number of significant innovations in manufacturing which have resulted in more flexible and cost efficient methods and higher quality products, as manufacturers have set about upgrading their processes, systems and performance. This study compares the use of technologies and improvement programs between OECD and Non-OECD countries, and also between small and large firms, and examines differences in the use and outcomes across the economies and different sized firms. The empirical analysis provides an opportunity to test whether the ‘capabilities’ or strengths of a firm can be linked to these activities and examines if developing economies are using technology or management programs such as quality management and business process re-engineering to catch up to manufacturers in developed economies. The analysis utilises data from the second International Manufacturing Strategy Survey (IMSS), which encompasses 703 firms in 23 countries.

Facilitating needs based cancer care for people with a chronic disease : evaluation of an intervention using a multi-centre interrupted time series design

Background: Palliative care should be provided according to the individual needs of the patient, caregiver and family, so that the type and level of care provided, as well as the setting in which it is delivered, are dependent on the complexity and severity of individual needs, rather than prognosis or diagnosis. This paper presents a study designed to assess the feasibility and efficacy of an intervention to assist in the allocation of palliative care resources according to need, within the context of a population of people with advanced cancer. ---------- Methods/design: People with advanced cancer and their caregivers completed bi-monthly telephone interviews over a period of up to 18 months to assess unmet needs, anxiety and depression, quality of life, satisfaction with care and service utilisation. The intervention, introduced after at least two baseline phone interviews, involved a) training medical, nursing and allied health professionals at each recruitment site on the use of the Palliative Care Needs Assessment Guidelines and the Needs Assessment Tool: Progressive Disease - Cancer (NAT: PD-C); b) health professionals completing the NAT: PD-C with participating patients approximately monthly for the rest of the study period. Changes in outcomes will be compared pre-and post-intervention.---------- Discussion: The study will determine whether the routine, systematic and regular use of the Guidelines and NAT: PD-C in a range of clinical settings is a feasible and effective strategy for facilitating the timely provision of needs based care.

Exporting educational services : an Australian university’s experience in delivering offshore project management programs

Increasingly, Australian universities are facing the challenges of global education. While overseas students studying in Australia provide the primary source of export earnings for educational institutions, a number of institutions, including QUT, are also involved in international trade in educational services by providing services offshore. This paper discusses driving forces behind moves by Australian universities to enter the international education market. It then briefly describes Queensland University of Technology’s internationalisation strategy. The paper concludes with a case study describing how the School of Construction Management has pioneered the development of offshore courses at QUT. The introduction of the Master of Project Management and Graduate Diploma of Project Management programs in Singapore in November 1993 represented QUT’s first experience in this area. With the experience of 18 months of operation, the School now has the opportunity to reflect on the outcomes of this venture and consider future options.

Factors influencing health promotion activities in midlife and older Australian women with a chronic disease

Background: Chronic diseases including type 2 diabetes are a leading cause of morbidity and mortality in midlife and older Australian women. There are a number of modifiable risk factors for type 2 diabetes and other chronic diseases including smoking, nutrition, physical activity and overweight and obesity. Little research has been conducted in the Australian context to explore the perceived barriers to health promotion activities in midlife and older Australian women with a chronic disease. Aims: The primary aim of this study was to explore women’s perceived barriers to health promotion activities to reduce modifiable risk factors, and the relationship of perceived barriers to smoking behaviour, fruit and vegetable intake, physical activity and body mass index. A secondary aim of this study was to investigate nurses’ perceptions of the barriers to action for women with a chronic disease, and to compare those perceptions with those of the women. Methods: The study was divided into two phases where Phase 1 was a cross sectional survey of women, aged over 45 years with type 2 diabetes who were attending Diabetes clinics in the Primary and Community Health Service of the Metro North Health Service District of Queensland Health (N = 22). The women were a subsample of women participating in a multi-model lifestyle intervention, the ‘Reducing Chronic Disease among Adult Australian Women’ project. Phase 2 of the study was a cross sectional online survey of nurses working in Primary and Community Health Service in the Metro North Health Service District of Queensland Health (N = 46). Pender’s health promotion model was used as the theoretical framework for this study. Results: Women in this study had an average total barriers score of 32.18 (SD = 9.52) which was similar to average scores reported in the literature for women with a range of physical disabilities and illnesses. The leading five barriers for this group of women were: concern about safety; too tired; not interested; lack of information about what to do; with lack of time and feeling I can’t do things correctly the equal fifth ranked barriers. In this study there was no statistically significant difference in average total barriers scores between women in the intervention group and those is the usual care group of the parent study. There was also no significant relationship between the women’s socio-demographic variables and lifestyle risk factors and their level of perceived barriers. Nurses in the study had an average total barriers score of 44.48 (SD = 6.24) which was higher than all other average scores reported in the literature. The leading five barriers that nurses perceived were an issue for women with a chronic disease were: lack of time and interferes with other responsibilities the leading barriers; embarrassment about appearance; lack of money; too tired and lack of support from family and friends. There was no significant relationship between the nurses’ sociodemographic and nursing variables and the level of perceived barriers. When comparing the results of women and nurses in the study there was a statistically significant difference in the median total barriers score between the groups (p < 0.001), where the nurses perceived the barriers to be higher (Md = 43) than the women (Md = 33). There was also a significant difference in the responses to the individual barriers items in fifteen of the eighteen items (p < 0.002). Conclusion: Although this study is limited by a small sample size, it contributes to understanding the perception of midlife and older women with a chronic disease and also the perception of nurses, about the barriers to healthy lifestyle activities that women face. The study provides some evidence that the perceptions of women and nurses may differ and argues that these differences may have significant implications for clinical practice. The study recommends a greater emphasis on assessing and managing perceived barriers to health promotion activities in health education and policy development and proposes a conceptual model for understanding perceived barriers to action.

The relationship between parents’ self-efficacy beliefs, outcome expectations, child behaviour, and management of atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin condition, characterized by intense pruritis, with a complex aetiology comprising multiple genetic and environmental factors. It is a common chronic health problem among children, and along with other allergic conditions, is increasing in prevalence within Australia and in many countries worldwide. Successful management of childhood AD poses a significant and ongoing challenge to parents of affected children. Episodic and unpredictable, AD can have profound effects on children’s physical and psychosocial wellbeing and quality of life, and that of their caregivers and families. Where concurrent child behavioural problems and parenting difficulties exist, parents may have particular difficulty achieving adequate and consistent performance of the routine management tasks that promote the child’s health and wellbeing. Despite frequent reports of behaviour problems in children with AD, past research has neglected the importance of child behaviour to parenting confidence and competence with treatment. Parents of children with AD are also at risk of experiencing depression, anxiety, parenting stress, and parenting difficulties. Although these factors have been associated with difficulty in managing other childhood chronic health conditions, the nature of these relationships in the context of child AD management has not been reported. This study therefore examined relationships between child, parent, and family variables, and parents’ management of child AD and difficult child behaviour, using social cognitive and self-efficacy theory as a guiding framework. The study was conducted in three phases. It employed a quantitative, cross-sectional study design, accessing a community sample of 120 parents of children with AD, and a sample of 64 child-parent dyads recruited from a metropolitan paediatric tertiary referral centre. In Phase One, instruments designed to measure parents’ self-reported performance of AD management tasks (Parents’ Eczema Management Scale – PEMS) and parents’ outcome expectations of task performance (Parents’ Outcome Expectations of Eczema Management Scale – POEEMS) were adapted from the Parental Self-Efficacy with Eczema Care Index (PASECI). In Phase Two, these instruments were used to examine relationships between child, parent, and family variables, and parents’ self-efficacy, outcome expectations, and self-reported performance of AD management tasks. Relationships between child, parent, and family variables, parents’ self-efficacy for managing problem behaviours, and reported parenting practices, were also examined. This latter focus was explored further in Phase Three, in which relationships between observed child and parent behaviour, and parent-reported self-efficacy for managing both child AD and problem behaviours, were explored. Phase One demonstrated the reliability of both PEMS and POEEMS, and confirmed that PASECI was reliable and valid with modification as detailed. Factor analyses revealed two-factor structures for PEMS and PASECI alike, with both scales containing factors related to performing routine management tasks, and managing the child’s symptoms and behaviour. Factor analysis was also applied to POEEMS resulting in a three-factor structure. Factors relating to independent management of AD by the parent, involving healthcare professionals in management, and involving the child in management of AD were found. Parents’ self-efficacy and outcome expectations had a significant influence on self-reported task performance. In Phase Two, relationships emerged between parents’ self-efficacy and self-reported performance of AD management tasks, and AD severity, child behaviour difficulties, parent depression and stress, conflict over parenting issues, and parents’ relationship satisfaction. Using multiple linear regressions, significant proportions of variation in parents’ self-efficacy and self-reported performance of AD management tasks were explained by child behaviour difficulties and parents’ formal education, and self-efficacy emerged as a likely mediator for the relationships between both child behaviour and parents’ education, and performance of AD management tasks. Relationships were also found between parents’ self-efficacy for managing difficult child behaviour and use of dysfunctional parenting strategies, and child behaviour difficulties, parents’ depression and stress, conflict over parenting issues, and relationship satisfaction. While significant proportions of variation in self-efficacy for managing child behaviour were explained by both child behaviour and family income, family income was the only variable to explain a significant proportion of variation in parent-reported use of dysfunctional parenting strategies. Greater use of dysfunctional parenting strategies (both lax and authoritarian parenting) was associated with more severe AD. Parents reporting lower self-efficacy for managing AD also reported lower self-efficacy for managing difficult child behaviour; likewise, less successful self-reported performance of AD management tasks was associated with greater use of dysfunctional parenting strategies. When child and parent behaviour was directly observed in Phase Three, more aversive child behaviour was associated with lower self-efficacy, less positive outcome expectations, and poorer self-reported performance of AD management tasks by parents. Importantly, there were strong positive relationships between these variables (self-efficacy, outcome expectations, and self-reported task performance) and parents’ observed competence when providing treatment to their child. Less competent performance was also associated with greater parent-reported child behaviour difficulties, parent depression and stress, parenting conflict, and relationship dissatisfaction. Overall, this study revealed the importance of child behaviour to parents’ confidence and practices in the contexts of child AD and child behaviour management. Parents of children with concurrent AD and behavioural problems are at particular risk of having low self-efficacy for managing their child’s AD and difficult behaviour. Children with more severe AD are also at higher risk of behaviour problems, and thus represent a high-risk group of children whose parents may struggle to manage the disease successfully. As one of the first studies to examine the role and correlates of parents’ self-efficacy in child AD management, this study identified a number of potentially modifiable factors that can be targeted to enhance parents’ self-efficacy, and improve parent management of child AD. In particular, interventions should focus on child behaviour and parenting issues to support parents caring for children with AD and improve child health outcomes. In future, findings from this research will assist healthcare teams to identify parents most in need of support and intervention, and inform the development and testing of targeted multidisciplinary strategies to support parents caring for children with AD.

Markers of chronic disease in offenders in a high secure correctional centre in Queensland

This study aimed to gauge the presence of markers of chronic disease, as a basis for food and nutrition policy in correctional facilities. One hundred and twenty offenders, recruited from a Queensland Correctional Centre, provided informed consent and completed both dietary interviews and physical measurements. Mean age of the sample was 35.5 ± 12 years (range = 19–77 yrs); mean age of the total population (n = 945) was 32.8 ± 10 years (range = 19–80 yrs). Seventy-nine participants also provided fasting blood samples. The mean body mass index (BMI) was 27 ± 3.5 kg/m2; 72% having a BMI > 25 kg/m2. Thirty-three percent were classified overweight or obese using waist circumference (mean = 92 ± 10 cm). Mean blood pressure measurement was systolic = 130 ± 14 mmHg and diastolic = 73 ± 10 mmHg. Twenty-four percent were classified as hypertensive of whom three were on antihypertensive medication. Eighteen percent had elevated triglycerides, and 40% unfavourable total cholesterol to HDL ratios. Homeostatic Model Assessment (HOMA scores) were calculated from glucose and insulin. Four participants were insulin resistant, two of whom had known diabetes. Metabolic syndrome, based on waist circumference (adjusted for ethnicity), blood lipids, blood pressure and plasma glucose indicated that 25% (n = 20) were classified with metabolic syndrome. Eighty-four percent (n = 120) reported some physical activity each day, with 51 percent participating ≥two times daily. Fifty-four percent reported smoking with an additional 20% having smoked in the past. Findings suggest that waist circumference rather than weight and BMI only should be used in this group to determine weight status. The data suggest that markers of chronic disease are present and that food and nutrition policy must reflect this. Further analysis is being completed to determine relevant policy initiatives.