Hormones down under: Hormone therapy use after the Women's Health Initiative

Aims:  The primary objective was to describe the usage pattern of hormone therapy (HT) in a sample of urban Australian women in 2001 and to assess the characteristics of users vs. non-users. The second objective was to determine whether there had been any change in usage since the publication of the results of the combined oestrogen plus progestagen arm of the Women's Health Initiative (WHI) in 2002. Methods:  A cohort of 374 postmenopausal women aged 50–80 years participated in this substudy of the LAW (Longitudinal Assessment of Ageing in Women) project: a 5-year multidisciplinary, observational study. Participants completed an annual medical assessment including details of the use of HT and the reasons for use, as well as demographic and psychosocial data. Results:  In December 2001, 30.8% of the participants were using HT, whereas 55.4% were ever users. The management of vasomotor symptoms and mood disturbance were the primary reasons for use. Of those who had been using HT in December 2001 (24.4%) women ceased using HT in the 3 months following publication of the WHI results. The percentage of women using HT in December 2003 (13.9%) was less than half of that of December 2001. Conclusion:  The rate of HT use and the reasons for use, in 2001 in Brisbane was similar to that of other Australian regions. Usage of HT decreased since the publication of the WHI results in 2002 which may reflect changing attitudes by patients and practitioners regarding HT.

Intensive Case Management: A Critical Re-Appraisal of the Scientific Evidence for Effectiveness

Intensive Case Management (ICM) is widely claimed to be an evidence-based and cost effective program for people with high levels of disability as a result of mental illness. However, the findings of recent randomized controlled trials comparing ICM with ‘usual services’ suggest that both clinical and cost effectiveness of ICM may be weakening. Possible reasons for this, including fidelity of implementation, researcher allegiance effects and changes in the wider service environment within which ICM is provided, are considered. The implications for service delivery and research are discussed.

Using participatory action research in a community-based initiative addressing complex mental health needs

Objective: This paper describes the first phase of a larger project that utilizes participatory action research to examine complex mental health needs across an extensive group of stakeholders in the community. Method: Within an objective qualitative analysis of focus group discussions the social ecological model is utilized to explore how integrative activities can be informed, planned and implemented across multiple elements and levels of a system. Seventy-one primary care workers, managers, policy-makers, consumers and carers from across the southern metropolitan and Gippsland regions of Victoria, Australia took part in seven focus groups. All groups responded to an identical set of focusing questions. Results: Participants produced an explanatory model describing the service system, as it relates to people with complex needs, across the levels of social ecological analysis. Qualitative themes analysis identified four priority areas to be addressed in order to improve the system's capacity for working with complexity. These included: (i) system fragmentation; (ii) integrative case management practices; (iii) community attitudes; and (iv) money and resources. Conclusions: The emergent themes provide clues as to how complexity is constructed and interpreted across the system of involved agencies and interest groups. The implications these findings have for the development and evaluation of this community capacity-building project were examined from the perspective of constructing interventions that address both top-down and bottom-up processes.

Caregiving attachment in mothers with schizophrenia: Child and Youth Mental Health Service, Mater Misericordiae Health Services, South Brisbane, Australia

The assessment of parenting capacity and appropriate provision of services to assist parents with mental illness requires improved understanding of how a mental illness may affect the parent-child relationship. Mothers with mental illness may be defensive when providing self-report accounts of their parenting. Within the framework of attachment theory, this study developed a methodology for investigating the quality and characteristics of caregiving through exploration of the mothers' perceptions and strategies in managing her child at bedtime. Utilising questions derived from caregiving attachment research, five mothers with schizophrenia participated in a semi-structured interview concerning bedtime separation. In addition the mothers completed a modified standardised measure of attachment style, the Parent Bonding Instrument, to provide information regarding how they perceived their parenting style. The mothers demonstrated very poor understanding of their child's bedtime anxiety. They described difficulty being effective with bedtime strategies and attributed it to medication-induced fatigue. The interview data contrasted significantly with the Parent Bonding Instrument data in which the mothers did not identify concerns in themselves as caregivers. This study demonstrated the feasibility of a novel approach to gathering information regarding parenting from mothers with a diagnosis of schizophrenia.

Sources of stress experienced by occupational therapists and social workers in mental health settings

This study examined the sources of stress experienced by occupational therapists and social workers employed in Australian public mental health services and identified the demographic and work-related factors related to stress using a cross-sectional survey design. Participants provided demographic and work-related information and completed the Mental Health Professionals Stress Scale. The overall response rate to the survey was 76.6%, consisting of 196 occupational therapists and 108 social workers. Results indicated that lack of resources, relationships and conflicts with other professionals, workload, and professional self-doubt were correlated with increased stress. Working in case management was associated with stress caused by client-related difficulties, lack of resources, and professional self-doubt. The results of this study suggest that Australian occupational therapists and social workers experience stress, with social workers reporting slightly more overall stress than occupational therapists.

Managing medical advice seeking in calls to Child Health Line

Child Health Line is a 24-hour Australian helpline that offers information and support for parents and families on child development and parenting. The helpline guidelines suggest that nurses should not offer medical advice, however they regularly receive calls seeking such advice. This paper examines how the service guidelines are talked into being through the nurses’ management of caller’s requests for medical advice and information, and shows how nurses orient to the boundaries of their professional role and institutionally regulated authority. Three ways in which the child health nurses manage medical advice and information seeking are discussed: using membership as a nurse to establish boundaries of expertise, privileging parental authority regarding decision making about seeking treatment for their child, and respecifying a ‘medical’ problem as a child development issue. The paper contributes to research on medical authority, and nurse authority in particular, by demonstrating the impact of institutional roles and guidelines on displays of knowledge and expertise. More generally, it contributes to an understanding of the interactional enactment and consequences of service guidelines for telehealth practice, with implications for training, policy and service delivery.

Non-pharmacological interventions for breathlessness management in patients with lung cancer : A systematic review

The aim is to review the published scientific literature for studies evaluating nonpharmacological interventions for breathlessness management in patients with lung cancer. The following selection criteria were used to systematically search the literature: studies were to be published research or systematic reviews; they were to be published in English and from 1990 to 2007; the targeted populations were adult patients with dyspnoea/breathlessness associated with lung cancer; and the study reported on the outcomes from use of non-pharmacological strategies for breathlessness. This review retrieved five studies that met all inclusion criteria. All the studies reported the benefits of non-pharmacological interventions in improving breathlessness regardless of differences in clinical contexts, components of programmes and methods for delivery. Analysis of the available evidence suggests that tailored instructions delivered by nurses with sufficient training and supervision may have some benefits over other delivery approaches. Based on the results, non-pharmacological interventions are recommended as effective adjunctive strategies in managing breathlessness for patients with lung cancer. In order to refine such interventions, future research should seek to explore the core components of such approaches that are critical to achieving optimal outcomes, the contexts in which the interventions are most effective, and to evaluate the relative benefits of different methods for delivering such interventions.

Editoral : Correspondence regarding Anker SD, Koehler F, Abraham WT. Telemedicine and remote management of patients with heart failure. The Lancet 2011; 378: 731–39. Published 20 August 2011.

We read the excellent review of telemonitoring in chronic heart failure (CHF)1 with interest and commend the authors on the proposed classification of telemedical remote management systems according to the type of data transfer, decision ability and level of integration. However, several points require clarification in relation to our Cochrane review of telemonitoring and structured telephone support2. We included a study by Kielblock3. We corresponded directly with this study team specifically to find out whether or not this was a randomised study and were informed that it was a randomised trial, albeit by date of birth. We note in our review2 that this randomisation method carries a high risk of bias. Post-hoc metaanalyses without these data demonstrate no substantial change to the effect estimates for all cause mortality (original risk ratio (RR) 0·66 [95% CI 0·54, 0·81], p<0·0001; revised RR 0·72 [95% CI 0·57, 0·92], p=0·008), all-cause hospitalisation (original RR 0·91 [95% CI 0·84, 0·99] p=0·02; revised RR 0.92 [95% CI 0·84, 1·02], p=0·10 ) or CHF-related hospitalisation (original RR 0·79 [95% CI 0·67, 0·94] p=0·008; revised RR 0·75 [95% CI 0·60, 0·94] p=0·01). Secondly, we would classify the Tele-HF study4, 5 as structured telephone support, rather than telemonitoring. Again, inclusion of these data alters the point-estimate but not the overall result of the meta-analyses4. Finally, our review2 does not include invasive telemonitoring as the search strategy was not designed to capture these studies. Therefore direct comparison of our review findings with recent studies of these interventions is not recommended.

New Evidence for Structured Telephone Support in the Management of Patients with Heart Failure [Letter to Editor]

Letter to the Editor of New England Journal of Medicine on behalf of the Cochrane Systematic Review team.

Weight management and its role in breast cancer rehabilitation

Overweight and obesity are risk factors for post-menopausal breast cancer, and many women diagnosed with breast cancer, irrespective of menopausal status, gain weight after diagnosis. Weight management plays an important role in rehabilitation and recovery since obesity and/or weight gain may lead to poorer breast cancer prognosis, as well as prevalent co-morbid conditions (e.g. cardiovascular disease and diabetes), poorer surgical outcomes (e.g., increased operating and recovery times, higher infection rates, and poorer healing), lymphedema, fatigue, functional decline, and poorer health and overall quality of life. Health care professionals should encourage weight management at all phases of the cancer care continuum as a means to potentially avoid adverse sequelae and late effects, as well as to improve overall health and possibly survival. Comprehensive approaches that involve dietary and behavior modification, and increased aerobic and strength training exercise have shown promise in either preventing weight gain or promoting weight loss, reducing biomarkers associated with inflammation and co-morbidity, and improving lifestyle behaviors, functional status, and quality of life in this high-risk patient population.

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.

Preliminary study on bridge health prediction using Dynamic Objective Oriented Bayesian Network (DOOBN)

The availability of bridges is crucial to people’s daily life and national economy. Bridge health prediction plays an important role in bridge management because maintenance optimization is implemented based on prediction results of bridge deterioration. Conventional bridge deterioration models can be categorised into two groups, namely condition states models and structural reliability models. Optimal maintenance strategy should be carried out based on both condition states and structural reliability of a bridge. However, none of existing deterioration models considers both condition states and structural reliability. This study thus proposes a Dynamic Objective Oriented Bayesian Network (DOOBN) based method to overcome the limitations of the existing methods. This methodology has the ability to act upon as a flexible unifying tool, which can integrate a variety of approaches and information for better bridge deterioration prediction. Two demonstrative case studies are conducted to preliminarily justify the feasibility of the methodology

Engaging law students to promote psychological health

Recent empirical evidence suggests that concern for the psychological health of law students is well justified. Traditionally, the legal curriculum has focused on the provision of substantive legal doctrinal knowledge. This approach has not always engaged students positively with their learning of law. This article considers some strategies that can be adopted by Law Faculties to better engage students with their legal education in order to promote their psychological health. These strategies are: ensuring that active learning occurs in lectures, demonstrating concern for students and their learning and skillful management of student expectations and the learning environment. Further, some self-help strategies that students can adopt for themselves are discussed. Combined, these strategies will enable students to engage more positively with their legal education.

Information accountability with policy languages for e-Health

ICT is becoming a prominent part of healthcare delivery but brings with it information privacy concerns for patients and competing concerns by the caregivers. A proper balance between these issues must be established in order to fully utilise ICT capabilities in healthcare. Information accountability is a fairly new concept to computer science which focuses on fair use of information. In this paper we investigate the different issues that need to be addressed when applying information accountability principles to manage healthcare information. We briefly introduce an information accountability framework for handling electronic health records (eHR). We focus more on digital rights management by considering data in eHRs as digital assets and how we can represent privacy policies and data usage policies as these are key factors in accountability systems.