Methods for exploring implementation variation and local context within a cluster tandomised community intervention trial

Insignificant or modest findings in intervention trials may be attributable to poorly designed or theorised interventions, poorly implemented interventions, or inadequate evaluation methods. The pre-existing context may also account for the effects observed. A combination of qualitative and quantitative methods is outlined that will permit the determination of how context level factors might modify intervention effectiveness, within a cluster randomised community intervention trial to promote the health of mothers with new babies. The methods include written and oral narratives, key informant interviews, impact logs, and inter-organisational network analyses. Context level factors, which may affect intervention uptake, success, and sustainability are the density of inter-organisational ties within communities at the start of the intervention, the centrality of the primary care agencies expected to take a lead with the intervention, the extent of context-level adaptation of the intervention, and the amount of local resources contributed by the participating agencies. Investigation of how intervention effects are modified by context is a new methodological frontier in community intervention trial research.

The extent and breadth of benefits from participating in chronic disease self-management courses: a national patient-reported outcomes survey

Objective
To quantify the benefits that people receive from participating in self-management courses and identify subgroups that benefit most.

Methods
People with a wide range of chronic conditions attending self-management courses (N = 1341 individuals) were administered the Health Education Impact Questionnaire (heiQ). Baseline and follow-up data were collected resulting in 842 complete responses. Outcomes were categorized as substantial improvement (effect size, ES ≥ 0.5), minimal/no change (ES −0.49 to 0.49) and substantial decline (ES ≤ −0.5).

Results
On average, one third of participants reported substantial benefits at the end of a course and this ranged from 49% in the heiQ subscale Skill and technique acquisition to 27% in the heiQ subscale Health service navigation. Stratification by gender, age and education showed that younger participants were more likely to benefit, particularly young women. No further subgroup differences were observed.

Conclusion
While the well-being of people with chronic diseases tends to decline, about one third of participants from a wide range of backgrounds show substantial improvements in a range of skills that enable them to self-manage.

Practice implications
These data support the application of self-management courses indicating that they are a useful adjunct to usual care for a modest proportion of attendees.

Prevention of type 2 diabetes in a primary health care setting interim results from the Greater Green Triangle (GGT) Diabetes Prevention Project

Although clinical trials have shown that lifestyle modifications reduce the risk of type 2 diabetes, translating lessons from trials to primary care remains a challenge. The aim of the study was to evaluate efficacy and feasibility of primary care-based diabetes prevention model with modest resource requirements in rural Australia. Three hundred and eleven subjects with at least a moderate risk of type 2 diabetes participated in a combined dietary and physical activity intervention. Clinical measurements and fasting blood samples were taken at the baseline and after intervention. After 3 months intervention, total (change −3.5%, p < 0.001) and LDL cholesterol (−4.8%, p < 0.001) plasma levels as well as body mass index (−2.5%, p < 0.001), weight (−2.5%, p < 0.001), and waist (−1.6%, p < 0.001) and hip (−2.7%, p < 0.001) circumferences reduced significantly. A borderline reduction was found in triglyceride levels (−4.8%, p = 0.058) while no changes were observed in HDL cholesterol (+0.6%, p = 0.525), glucose (+0.06%, p = 0.386), or systolic (−0.98%, p = 0.095) or diastolic (−1.06%, p = 0.134) blood pressure levels. In conclusion, a lifestyle intervention improved health outcomes – especially obesity and blood lipids – in a population at high risk of developing type 2 diabetes. Our results suggest that the present model is effective and feasible to carry out in primary care settings.

Neighborhood walkability and the walking behavior of Australian adults

Background
The physical attributes of residential neighborhoods, particularly the connectedness of streets and the proximity of destinations, can influence walking behaviors. To provide the evidence for public health advocacy on activity-friendly environments, large-scale studies in different countries are needed. Associations of neighborhood physical environments with adults’ walking for transport and walking for recreation must be better understood.

Method
Walking for transport and walking for recreation were assessed with a validated survey among 2650 adults recruited from neighborhoods in an Australian city between July 2003 and June 2004, with neighborhoods selected to have either high or low walkability, based on objective measures of connectedness and proximity derived from geographic information systems (GIS) databases. The study design was stratified by area-level socioeconomic status, while analyses controlled for participant age, gender, individual-level socioeconomic status, and reasons for neighborhood self-selection.

Results
A strong independent positive association was found between weekly frequency of walking for transport and the objectively derived neighborhood walkability index. Preference for walkable neighborhoods moderated the relationship of walkability with weekly minutes, but not the frequency of walking for transport—walkability was related to higher frequency of transport walking, irrespective of neighborhood self-selection. There were no significant associations between environmental factors and walking for recreation.

Conclusions
Associations of neighborhood walkability attributes with walking for transport were confirmed in Australia. They accounted for a modest but statistically significant proportion of the total variation of the relevant walking behavior. The physical environment attributes that make up the walkability index are potentially important candidate factors for future environmental and policy initiatives designed to increase physical activity.

Does walking in the neighbourhood enhance local sociability?

The walkability of urban neighbourhoods has emerged as a strong component in policy and design models for active, liveable communities. This paper examines the proposition that more walkable neighbourhoods encourage local social interaction, a sense of community, informal social control and social cohesion; and that the relationship is explained by walking for transport or for recreation. Multilevel analyses of data from an Australian sample showed a modest association between the walkability of a neighbourhood and sense of community only. Walking for transport, but not recreation, mediated this relationship although the effect was small. These results support contentions that 'walkability' is more complex than usually defined and that factors influencing neighbourhood sociability extend beyond issues of urban form.

An individualized psychosocial approach for "treatment resistant" behavioral symptoms of dementia among aged care residents

Background: Behavioral symptoms of dementia are common among residents in mainstream aged care settings, and have a substantial impact on residents and professional caregivers. This study evaluated the impact of individualized psychosocial interventions for behavioral symptoms through a small preliminary study.
Method: Interventions were delivered to a patient group of 31 psychogeriatric aged care residents who presented with behavioral symptoms of dementia that had failed to respond to pharmacological treatment approaches. Outcome data on severity of behaviors, health service utilization and staff burden of care were collected.
Results: A modest but significant reduction in staff ratings of the severity of aggressive and verbally agitated behavioral symptoms was found, with an associated reduction in their perceptions of the burden of caring for these patients. Reduced behavioral disturbance was associated with a reduction in the requirement for primary care consultations, and all participants were able to continue to reside in mainstream aged care facilities, despite an increase in the severity of dementia.
Conclusions: This study supported the use of individualized psychological strategies for behavioral symptoms at all stages of dementia. Methodological limitations of this preliminary study are discussed.

Benefits of a year-long workplace weight loss program on cardiovascular risk factors

Objective: To assess the effectiveness of a year-long workplace weight loss program in reducing risk factors of coronary heart disease.

Design: A randomised, controlled study of low fat (25% of dietary energy) diet- and/or moderate exercise-induced weight loss interventions in free-living, middle-aged men. Compliance was monitored from food and activity diaries at monthly blood pressure measurement sessions. Blood was sampled and body composition determined from dual energy X-ray absorptiometry before and after 12 months.

Subjects and setting: Fifty-eight overweight men (mean [+ or -] SD age: 43.4 [+ or -] 5.7 years; BMI 29.0 [+ or -] 2.6 kg/[m.sup.2]), recruited from a national corporation, were instructed into diet (n = 18) exercise (a 21) or control (n = 19) groups over 12 months; 16 control subjects combined diet and exercise (n = 16) for the subsequent 12 months.

Main outcome measures: At 12 months, weight, total and regional fat and lean mass, dietary energy and percentage dietary fat intake, physical activity indices, systolic and diastolic blood pressure, serum insulin, blood lipids and lipoproteins.

Statistical analyses: Differences between groups were tested using analysis of variance with Scheffe post hoc test. Differences between pre- and post-intervention variables were tested using Students' paired t-tests. Pearson's correlation coefficient and univariate linear regression identified association between dependent variables, multiple stepwise regression identified specific predictors.

Results: Weight loss with either diet or exercise resulted in a reduction in systolic blood pressure (-3.3 [+ or -] 1.7%), diastolic blood pressure (-4.8 [+ or -] 1.3%) and LDL cholesterol (-3.9 [+ or -] 2.8%), a rise in HDL cholesterol (+10.0 [+ or -] 3.8%) and a change in the LDL/HDL ratio (-8.9 [+ or -] 3.5%). Abdominal fat loss (-26.8 [+ or -] 3.6% after diet; -16.6 [+ or -] 4.5% after exercise; -21.0 [+ or -] 4.7% after diet and exercise) was the strongest predictor of change in blood pressure: twenty percent abdominal fat loss predicted a percentage fall of 2.4 [+ or -] 0.05% in systolic blood pressure and 5.4 [+ or -] 0.07% in diastolic blood pressure. Greater abdominal fat loss was associated with the greatest decrease in serum insulin (P < 0.05).

Conclusion: Modest changes in diet and exercise effected by a low cost workplace-based education program achieved weight loss, loss of abdominal fat, reduced blood pressure and serum insulin and improved blood lipid concentrations. (Nutr Diet 2002;59:87-96)

Assessing cost-effectiveness of drug interventions for schizophrenia

Objective: To assess from a health sector perspective the incremental cost-effectiveness of eight drug treatment scenarios for established schizophrenia.

Method: Using a standardized methodology, costs and outcomes are modelled over the lifetime of prevalent cases of schizophrenia in Australia in 2000. A two-stage approach to assessment of health benefit is used. The first stage involves a quantitative analysis based on disability-adjusted life years (DALYs) averted, using best available evidence. The robustness of results is tested using probabilistic uncertainty analysis. The second stage involves application of 'second filter' criteria (equity, strength of evidence, feasibility and acceptability) to allow broader concepts of benefit to be considered.

Results: Replacing oral typicals with risperidone or olanzapine has an incremental costeffectiveness ratio (ICER) of A$48 000 and A$92 000/DALY respectively. Switching from low-dose typicals to risperidone has an ICER of A$80 000. Giving risperidone to people experiencing side-effects on typicals is more cost-effective at A$20 000. Giving clozapine to people taking typicals, with the worst course of the disorder and either little or clear deterioration, is cost-effective at A$42 000 or A$23 000/DALY respectively. The least costeffective intervention is to replace risperidone with olanzapine at A$160 000/DALY.

Conclusions: Based on an A$50 000/DALY threshold, low-dose typical neuroleptics are indicated as the treatment of choice for established schizophrenia, with risperidone being reserved for those experiencing moderate to severe side-effects on typicals. The more expensive olanzapine should only be prescribed when risperidone is not clinically indicated. The high cost of risperidone and olanzapine relative to modest health gains underlie this conclusion. Earlier introduction of clozapine however, would be cost-effective. This work is limited by weaknesses in trials (lack of long-term efficacy data, quality of life and consumer satisfaction evidence) and the translation of effect size into a DALY change. Some stakeholders, including SANE Australia, argue the modest health gains reported in the literature do not adequately reflect perceptions by patients, clinicians and carers, of improved quality of life with these atypicals.

The development impact of remittances to Nicaragua

Workers' remittances represent a resource flow from rich to poor countries. The global value of remittances has risen sharply to over US$100 billion a year. This represents the second largest external income source for developing countries behind foreign direct investment (FDI), and far outstrips official development assistance (ODA) (Orozco 2003a). Remittances to developing countries are becoming increasingly important as other sources of external income decline. The impact of remittances on development, however, is inadequately reflected in the literature. Latin America and the Caribbean (LAC) is the world's largest remittance-receiving region. With 9 per cent of the world's population, the region receives approximately 32 per cent of the world's remittances. It is appreciably greater than tourist revenues in many countries, and in five countries in this region, remittances account for over 10 per cent of GNP (World Bank 2003). Within LAC, Nicaragua stands out from other countries. While the US dollar value of remittances to Nicaragua, estimated at US$610 million in 2001, is quite modest compared with the US$10 billion flowing into Mexico, for example, the relative volume of this resource compared with other income flows, and the potential for the country's development, makes Nicaragua's case exceptional. Representing almost 24 per cent of its GNP, remittances to Nicaragua have a significant social and economic impact. The value of known remittances is greater than total export earnings, on a par with the country's ODA, and almost five times that of FDI. As such, remittances currently represent the second largest single resource flow into the country. This is a recent phenomenon.

The health watch case - control study of leukemia and benzene:the story so far

A case–control study nested in the Health Watch cohort of petroleum industry workers, investigated whether the excess of lymphohematopoetic cancers, identified among male members of the Health Watch cohort, was associated with benzene exposure. Cases of non-Hodgkin’s lymphoma (n=31),multiple myeloma (n=15), and leukemia (n=33)were identified between 1981 and 1999. Cases were age-matched to five controls. Exposure was retrospectively estimated for each occupational history using an algorithm in a relational database. Benzene exposure measurements, supplied by Australian petroleum companies, were used to estimate exposure for specific tasks. The tasks carried out within the job, the products handled, and the technology used,were identified from interviews with contemporary colleagues. More than half of the subjects started work after 1965 and had an average exposure period of 20 years. Exposure was low, 85% of the cumulative exposure estimates were<10 ppm years. Matched analyses showed that non-Hodgkin’s lymphoma and multiple myeloma were not associated with benzene exposure. Leukemia risk, however, was significantly increased for the subjects with greater than 16 ppm years cumulative exposure, odds ratio (OR) 51.9 (5.6–477) or with greater than 0.8 ppm intensity of highest exposed job. Cumulative exposures were similar to those found in comparable studies.The inclusion of occasional high exposures, for example, as a result of spillages, reduced the ORs, when the exposure was treated as either a continuous or a categorical variable. Our data demonstrate a strong association between leukemia and modest benzene exposure. The choice of cut-point and reference group has a marked effect on the ORs, but does not change the overall conclusions.

Towards universal and statistical-driven heuristics for automatic classification of sports video events

Researchers worldwide have been actively seeking for the most robust and powerful solutions to detect and classify key events (or highlights) in various sports domains. Most approaches have employed manual heuristics that model the typical pattern of audio-visual features within particular sport events To avoid manual observation and knowledge, machine-learning can be used as an alternative approach. To bridge the gaps between these two alternatives, an attempt is made to integrate statistics into heuristic models during highlight detection in our investigation. The models can be designed with a modest amount of domain-knowledge, making them less subjective and more robust for different sports. We have also successfully used a universal scope of detection and a standard set of features that can be applied for different sports that include soccer, basketball and Australian football. An experiment on a large dataset of sport videos, with a total of around 15 hours, has demonstrated the effectiveness and robustness of our
aIlgorithms.

Strength of faith and body image in Muslim and non-Muslim women

A questionnaire was completed by 98 Muslim and 91 non-Muslim Australian  women to examine the relationship between Islam and body image. Path analyses revealed that for Muslim women (but not non-Muslim women) strength of religious faith was inversely related to body dissatisfaction, body self-objectification, and dietary restraint. These relationships were mediated by increased use of modest clothing and by reduced media consumption. These results are consistent with the proposition that adherence to Islam can indirectly protect women's body image from appearance-based public scrutiny and from exposure to Western media.

Selective reduction in body fat mass and plasma leptin induced by angiotensin-converting enzyme inhibition in rats

Objective: There is emerging evidence that angiotensin stimulates adipocyte differentiation and lipogenesis. This study tested the hypothesis that inhibition of angiotensin II by treatment with an angiotensin-converting enzyme inhibitor, perindopril, would reduce fat mass in rats. Design: After a 12-day baseline, rats were divided into two groups: one was untreated and the other received perindopril (1.2 mg kg⁻¹ per day) in drinking water for 26 days.Subjects: In total, 16 male Sprague–Dawley rats aged 10 weeks at the start of the study. Measurements: Plasma leptin was measured in samples collected at baseline, half-way through and at the end of treatment. Body weight, food and water intake were measured daily throughout the experiment. Body fat mass, bone and lean mass were determined by dual energy X-ray absorptiometry (DEXA) at the end of the treatment period. Results: Daily food intake was the same in both groups throughout the study. By the end of treatment, animals receiving perindopril showed a modest reduction in weight gain relative to the untreated animals (62.4±5.0 g vs 73.0±4.0 g; P<0.05). DEXA analysis showed that body composition was greatly altered and the perindopril-treated group had 26% less body fat mass than the untreated group (61.0±5.2 g vs 44.4±4.2 g; P<0.01). The reduction in body fat mass was correlated with reductions in the weight of both the epididymal and retroperitoneal fat pads (P<0.001). Similarly, plasma leptin was reduced by perindopril treatment (4.64±0.56 ng ml⁻¹) compared to the untreated group (8.27±1.03 ng ml⁻¹; P<0.001). In contrast, there were no differences in lean or bone mass between the two groups.Conclusion: Oral treatment with perindopril selectively reduced body fat mass without influencing daily food intake. In contrast, there were no differences in lean or bone mass between the two groups

Why do medical graduates choose rural careers?

Introduction: This study is based on the metaphor of the ‘rural pipeline’ into medical practice. The four stages of the rural
pipeline are: (1) contact between rural secondary schools and the medical profession; (2) selection of rural students into medical
programs; (3) rural exposure during medical training; and (4) measures to address retention of the rural medical workforce.
Methods: Using the rural pipeline template we conducted a literature review, analysed the selection methods of Australian
graduate entry medical schools and interviewed 17 interns about their medical career aspirations.
Results: Literature review: The literature was reviewed to assess the effectiveness of selection practices to predict successful
gradation and the impact of rural pipeline components on eventual rural practice. Undergraduate academic performance is the
strongest predictor of medical course academic performance. The predictive power of interviews is modest. There are limited data
on the predictive power of other measures of non-cognitive performance or the content of the undergraduate degree. Prior rural
residence is the strongest predictor of choice of a rural career but extended rural exposure during medical training also has a
significant impact. The most significant influencing factors are: professional support at national, state and local levels; career
pathway opportunities; contentedness of the practitioner’s spouse in rural communities; preparedness to adopt a rural lifestyle;
educational opportunities for children; and proximity to extended family and social circle. Analysis of selection methods: Staff
involved in student selection into 9 Australian graduate entry medical schools were interviewed. Four themes were identified:
(1) rurality as a factor in student selection; (2) rurality as a factor in student selection interviews; (3) rural representation on student
selection interview panels; (4) rural experience during the medical course. Interns’ career intentions: Three themes were identified:
(1) the efficacy of the rural pipeline; (2) community connectedness through the rural pipeline; (3) impediments to the effect of the
rural pipeline, the most significant being a partner who was not committed to rural life
Conclusion: Based on the literature review and interviews, 11 strategies are suggested to increase the number of graduates
choosing a career in rural medicine, and one strategy for maintaining practitioners in rural health settings after graduation.

Untitled. Conundrum, September 2004

Conundrum is about improvisation as a performance practice. Conundrum is a hybrid event with dancers, actors, and musicians participating in a format that is informal, maintains modest production values and is rooted in the performers desire to practice improvisation in performance. Conundrum is the defining event, a lighthouse to pinpoint and illuminate a range of improvisation and body practices which constellate around the space known as Cecil Street Studio located in Fitzroy, Melbourne.