Can a disease-specific education program augment self-management skills and improve Health-Related Quality of Life in people with hip or knee osteoarthritis?

Background: Patient education and self-management programs are offered in many countries to people with chronic conditions such as osteoarthritis (OA). The most well-known is the disease-specific Stanford Arthritis Self-Management Program (ASMP). While Australian and international clinical guidelines promote the concept of self-management for OA, there is currently little evidence to support the use of the ASMP. Several meta-analyses have reported that arthritis self-management programs had minimal or no effect on reducing pain and disability. However, previous studies have had methodological shortcomings including the use of outcome measures which do not accurately reflect program goals. Additionally, limited cost-effectiveness analyses have been undertaken and the cost-utility of the program has not been explored.

Methods/design: This study is a randomised controlled trial to determine the efficacy (in terms of Health-Related Quality of Life and self-management skills) and cost-utility of a 6-week group-based Stanford ASMP for people with hip or knee OA.

Six hundred participants referred to an orthopaedic surgeon or rheumatologist for hip or knee OA will be recruited from outpatient clinics at 2 public hospitals and community-based private practices within 2 private hospital settings in Victoria, Australia. Participants must be 18 years or over, fluent in English and able to attend ASMP sessions. Exclusion criteria include cognitive dysfunction, previous participation in self-management programs and placement on a waiting list for joint replacement surgery or scheduled joint replacement.

Eligible, consenting participants will be randomised to an intervention group (who receive the ASMP and an arthritis self-management book) or a control group (who receive the book only). Follow-up will be at 6 weeks, 3 months and 12 months using standardised self-report measures. The primary outcome is Health-Related Quality of Life at 12 months, measured using the Assessment of Quality of Life instrument. Secondary outcome measures include the Health Education Impact Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (pain subscale and total scores), Kessler Psychological Distress Scale and the Hip and Knee Multi-Attribute Priority Tool. Cost-utility analyses will be undertaken using administrative records and self-report data. A subgroup of 100 participants will undergo qualitative interviews to explore the broader potential impacts of the ASMP.

Discussion: Using an innovative design combining both quantitative and qualitative components, this project will provide high quality data to facilitate evidence-based recommendations regarding the ASMP.

Change of perspective: a measurable and desired outcome of chronic disease self-management intervention programs that violates the premise of preintervention/postintervention assessment

Objective: To determine if participants in chronic disease self-management courses have a change of perspective of their health status (a response shift), and if this is measurable with a paper-based questionnaire.

Methods: Nine items were developed to measure potential benefits of self-management courses. These were based on the constructs of a previous questionnaire, the Health Education Impact Questionnaire (HEI-Q). Cognitive interviews elicited spontaneous statements about the reasons for paper-based answers. Sensitivity, specificity, and overall accuracy of items were calculated using the interview as a relative gold standard. Response shift can be negative (i.e., after the course, participants realize that, before the course, they were worse than they thought they were), positive (i.e., participants now realize they were better than they thought they were), or absent (no change).

Results: Interviews (n = 39) reflected that true response shift occurred in approximately half the replies to questionnaire items. Of these, 31% were negative response shift, 20% were positive response shift. Response shift was absent in 32% of replies. Presence or absence of response shift could not be determined in 17% of replies across items. Significant concordance between questionnaires and cognitive interviews (average overall accuracy 0.79) indicated that the HEI-Q Perspective questionnaire detects response shift in participants of self-management courses. The questionnaire revealed that 87% of participants had response shift in at least 1 item.

Conclusion: This study suggests that preintervention/postintervention assessments of interventions such as self-management courses are confounded by a change in perspective of a large proportion of respondents. It also indicates response shift is a valuable outcome of self-management courses that can be measured with a paper-based questionnaire.

Investigating the factors of professional development programs that effect change in the classroom

This paper reports on the implementation of two professional development programs designed to support ICT based pedagogies in Victorian (Australia) schools. In both programs the teachers participated in an intensive program of professional development designed to assist them in embedding ICT into their classroom practice. There was a large diversity of circumstances experienced by the schools, not only in terms of ICT availability and use, and teacher experience, but also in issues of cultures of curriculum planning and integration, size, communication, and pedagogical presumptions. Both projects were successful in implementing change; however there were teachers in both projects who failed to take advantage of the PD. Some of the limitations with both studies include the high expectations of time comittment by the teachers – who are already fully committed with full teaching loads, and the high expectations of the change that will occur in the teaching and
learning as a result of the PD, wthout consideration of the time needed to learn and adopt new pedagogical practice. In some cases, teachers and the school did not appreciate the necessary commitment to take full advantage of the opportunity being provided. This was compounded by the lack of support and recognition by school management.

The Health Education Impact Questionnaire (heiQ): An outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions

Objective: This paper describes the development and validation of the Health Education Impact Questionnaire (heiQ). The aim was to develop a user-friendly, relevant, and psychometrically sound instrument for the comprehensive evaluation of patient education programs, which can be applied across a broad range of chronic conditions.

Methods: Item development for the heiQ was guided by a Program Logic Model, Concept Mapping, interviews with stakeholders and psychometric analyses. Construction (N = 591) and confirmatory (N = 598) samples were drawn from consumers of patient education programs and hospital outpatients. The properties of the heiQ were investigated using item response theory and structural equation modeling.

Results: Over 90 candidate items were generated, with 42 items selected for inclusion in the final scale. Eight independent dimensions were derived: Positive and Active Engagement in Life (five items, Cronbach's alpha (α) = 0.86); Health Directed Behavior (four items, α = 0.80); Skill and Technique Acquisition (five items, α = 0.81); Constructive Attitudes and Approaches (five items, α = 0.81); Self-Monitoring and Insight (seven items, α = 0.70); Health Service Navigation (five items, α = 0.82); Social Integration and Support (five items, α = 0.86); and Emotional Wellbeing (six items, α = 0.89).

Conclusion:The heiQ has high construct validity and is a reliable measure of a broad range of patient education program benefits.

Practice Implications: The heiQ will provide valuable information to clinicians, researchers, policymakers and other stakeholders about the value of patient education programs in chronic disease management.

Designing and delivering clinical risk management education for graduate nurses : an Australian study

In order to enhance their capabilities in clinical risk management (CRM) and to be integrated into safe and effective patient safety organisational processes and systems, neophyte graduate nurses need to be provided with pertinent information on CRM at the beginning of their employment. What and how such information should be given to new graduate nurses, however, remains open to question and curiously something that has not been the subject either of critique or systematic investigation in the nursing literature. This article reports the findings of the third and final cycle of a 12 month action research (AR) project that has sought to redress this oversight by developing, implementing and evaluating a CRM education program for neophyte graduate nurses. Conducted in the cultural context of regional Victoria, Australia, the design, implementation and evaluation of the package revealed that it was a useful resource, served the intended purpose of ensuring that neophyte graduate nurses were provided with pertinent information on CRM upon the commencement and during their graduate nurse year, and enabled graduate nurses to be facilitated to translate that information into their everyday practice.

The sustainable farm families project: changing farmer attitudes to health

Farm health and safety has focussed on strategies such as injury prevention, audits and fulfilling legislative responsibilities. We know farmer injuries mask deeper health issues such as higher rates of cancer, suicides, cardiovascular disease and stress. The relationship between occupational health and safety and farming family health has not been investigated by other researchers either nationally or internationally. The Sustainable Farm Families (SFF) project attempts to make this connection in order to address the unacceptable rates of premature death, higher morbidity and injury on Australian farms.

The SFF focuses on the human resource in the triple bottom line and is working with farmers, families, industry, and university to collaboratively address and improve the health and well being of farming families. Based on a model of extension that engages farming families as active learners where they commit to healthy living and safe working practices the SFF is proving to be an effective model for engaging communities in learning and change. Health education and information is delivered to farming families using a workshop format with participants reporting positive impacts on their farming business. The SFF project sits across generations and sexes and has a high level of support with the overwhelming majority of participants saying they would recommend the program to others.

This paper discusses the progress of the research outlining the design of the project, the delivery and extension processes used to engage 321 farming families to date. The paper presents key learning’s on intersectoral collaboration, engaging farmers and families in health and the future for this project extending into agricultural industries across the nation.

Three key learnings: (1) The increased health risks faced by farmers and their families need social and political attention. (2) Joint ownership and collaborative partnerships where all partners have a key role within the development and delivery of the project to their relevant representative groups enables resources to be shared and encourages greater in-kind support to augment funding received. (3) Farming families are keen to understand more about their health and farmers who participate in health education programs based around industry collaboration with high levels of individual participation will engage with health professionals and obtain an improved health status if programs are presented to them in personally engaging and relevant ways

Innovative model for clinical education in dietetics

Aim: Professional practice placement programs in dietetics face a number of challenges in respect of quantity, quality and sustainability. The aim of the present study is to report on the development of an innovative placement model based on a variety of training and supervision approaches to address these aforementioned challenges.

Methods: The model was developed following an investigation of existing practice and the literature with approaches that were identified as important to the requirements and constraints of dietetics clinical training incorporated into the model.

Results: Although one-on-one supervision is the predominant approach in Australian dietetic education, the educational literature and the authors' experience showed that a variety of approaches are represented in some form. The model developed involves the pairing of two students with one supervisor with students changing peer partners and supervisors every three weeks during the nine-week placement to diversify exposure to working and learning styles. The model integrates four customised approaches: incremental exposure to tasks; use of a clinical reasoning framework to help structure student understanding of the methods and judgements involved in patient care; structured enquiry in group discussions; and peer observation and feedback.

Conclusions: The model has potential to achieve efficiencies in supervisors' involvement by coordinating the skill development activities of students as a group and promoting peer-assisted learning.

Learning 'through' or learning 'about'? The ridiculous and extravagant medium of opera : Gardner's multiple intelligences in pre-service teacher education

In recent years, pre-service teacher education has attempted to incorporate into programs an understanding of Gardner’s theory of multiple intelligences as it applies to schools. In this paper the tension between ‘learning about’ multiple intelligences and ‘learning through’ multiple intelligences supports Gardner’s (1993) distinction between ‘understanding’ and ‘coverage’. This paper examines the use of the performing arts in the professional studies component of our teacher education program. During 2002 at The University of Melbourne, a group of education students were offered the opportunity to develop an opera in order to learn about assessment and curriculum. Thirty-seven of the students volunteered to be involved and over a period of six months met this challenge. Our action research study asked two critical questions. To what extent is the understanding of multiple intelligences by pre-service teachers improved by ‘learning through’? Can pre-service teachers address fundamental issues in curriculum and assessment through the development of a performance? This experience would be of value to other teacher educators.

Constructing globalisation in international higher education

The discourse of internationalization is well established but it appears that globalisation has crept ‘by stealth’ (Currie, 1998) into our international programs resulting in an apparent domination by a neoliberal economic discourse. Clyne, Marginson and Woock (2001), drawing on research regarding globalisation and internationalization in Australian universities, suggest that this domination is so pervasive that the term is “irretrievably lost” to cultural usages of globalisation. This paper arises from a case study of the understandings of globalisation within an international higher education program. Understandings of globalisation were sought from both Australian  and Thai policymakers and participants in an international higher education program. It is argued that domination by the neoliberal discourse is evident and predominant but that, in the use of metaphors of globalisation by these  educators, a repositioned understanding from lived experience exists alongside the economically dominated experience of international higher  education. It is here that divergent understandings of globalisation are  constructed. These findings are of value to those involved in the  internationalization of higher education.

Learning 'through' or learning 'about'? The ridiculous and extravagant medium of opera: Gardner's multiple intelligences in pre-service teacher education

In recent years, pre-service teacher education has attempted to incorporate into programs an understanding of Gardner's theory of multiple intelligences as it applies to schools. In this paper the tension between 'learning about' multiple intelligences and 'learning through' multiple intelligences supports Gardner's (1993) distinction between 'understanding' and 'coverage'. This paper examines the use of the performing arts in the professional studies component of our teacher education program. During 2002 at The University of Melbourne, a group of primary and secondary students were offered the opportunity to develop an opera in order to learn about assessment and curriculum. Thirty-seven of the students volunteered to be involved and over a period of six months met this challenge. Our action research study asked two critical questions. To what extent is the understanding of multiple intelligences by pre-service teachers improved by 'learning through'? Can pre-service teachers address fundamental issues in curriculum and assessment through the development of a performance? This experience would be of value to other teacher educators.

Barriers to learners' successful completion of VET flexible delivery programs

In the early 1990s, Australian policymakers began explicitly promoting increased use of flexible delivery in vocational education and training (VET). Some researchers argued that many students lack the learning skills required to deal with the unique demands of flexible delivery. Concerns were also raised about the VET sector's capacity to help students develop needed cognitive and metacognitive skills. A review of the literature revealed wide agreement that students' success in flexible delivery and open and distance education in Australia and elsewhere is generally determined by a complex interplay of factors, including the following: readiness for self-directed learning; ability to balance the time demands of study with other commitments such as family and work; level of literacy; ability to understand and deal with assessment requirements; level of motivation; and previous educational experiences. Two case studies based on the actual experiences of two of six students interviewed about their experiences in flexible VET delivery were reviewed. Both students decided to withdraw from their VET course because of several interconnected factors that built up over time. Both cases illustrated that some problems that can be addressed quickly in face-to-face learning environments are much more difficult to resolve when students are off campus.

Designing collaborative e-learning for the net generation

The designer of higher education programs is on the cusp of some very exciting resource development particularly in the area of postgraduate coursework. Part of this is because of the new learner, a millennial or net generation learner who is time-poor, a networker with strong inclinations towards social or community knowledge pooling and a multiple media literacy which is comfortable in virtual worlds and with visual emphasis. The other element is the perceived changing role of the university or higher education in the transfer of knowledge, moving from a transmission or narrative model to learner-centred and performative approaches. This has been highlighted by greater emphasis on experiential learning methodologies, and the development of action learning practices. The nexus of these two influences, the new learner and the higher education response to delivering learning, may be elaborated further from learning theory which seems to be moving beyond social constructivist approaches, or certainly encompassing what is referred to as connectivism.

This may be a new theoretical approach, or it could simply be an organic growth in meeting the needs of large numbers of higher education student participants who perceive a degree as a skills-based workplace preparation. Whatever the theoretical underpinning may be, the large numbers of learners moving to postgraduate coursework or more workplace oriented programs and subjects has thrown out the challenge to instructional designers to provide just-in-time, relevant and socially transferred learning with strong creative and imaginative engagement.

The case studies incorporated in this paper provide two separate approaches to these challenges - one is a workplace oriented postgraduate team project in a Masters in Communication, the other provides a virtual simulation for developing creative and professional writing skills at postgraduate levels. They both provide perspectives on the net generation learner and collaborative and connected learning models.

'Girls talking about girls' issues' : the importance of girls-only health and physical education in promoting well-being

Recognition of the important role schools play in the promotion of student well-being can be seen in the growing number of policies and programs being implemented in schools across Australia. This paper reports on some initial data from focus group interviews with Year 9 and 10 girls involved in the pilot of a health and physical activity intervention designed to connect them to their local community and reconnect them with their school and their peers. The aim of the program was to build connectedness and resilience by engaging young women in non-traditional physical activities whilst providing them with a sound understanding of health issues relevant to adolescent girls. Situated in a relatively isolated rural community 200 kilometres south-east of Melbourne the program was overwhelmingly delivered by regional and local agencies in conjunction with the local secondary school. The intervention was built on a partnerships model designed with the purpose of increasing participation and access for young women whilst building a sustainable program run in partnership between the school and local agencies and services. The initial data from this pilot indicates the program is having a positive impact on the young women's sense of self and their bodies, their relationships with their peers and in reducing bullying behaviour amongst the girls. However, the data raises some important questions around the adequacy of school-based health education, and the sustainability of approaches designed to be delivered by outside agencies rather than classroom teachers.

Scanners, brokers and providers : partners in developing learning programs

This paper reports some of the findings from a project that aimed to identify effective processes for ensuring that the content of learning activities is relevant to the changing needs of clients, and evolves so as to always incorporate the best available knowledge and science. This paper focuses on findings relating to the drivers for the development of new or substantially revised learning programs. The project, ‘Providing client-focussed education and training’, was funded by the FarmBis section of the Department of Agriculture, Fisheries and Forestry. The project also produced a self-assessment checklist for training providers to identify ways of improving the development and delivery of training. The key issues include continuous monitoring of client’s needs, and actively seeking opportunities to meet and work with industry organisations, other training providers and funding bodies.

There appear to be two drivers for the development of learning programs. One is problems or opportunities identified by people and organisations that could be termed ‘scanners’ and who tend not to be potential participants, the other is learning needs expressed by individuals or enterprises who want to participate in learning activities.

Scanners are typically industry organisations, government agencies and researchers, but may include providers and participants. Scanners identify learning needs that are not yet being expressed by potential participants, with the occasional exception of leading primary producers. Expressed participant needs drive the development of other programs. Providers become aware of the need for a new or substantially revised program, for example as a result of feedback from an existing program, because of legislative change or from delivering a similar program in other industries or contexts (for example computer training). Brokers (such as industry organisations who work to connect providers and participants) and ‘champions’ of training help participants identify and articulate their learning needs.

Integrating farm production and natural resource management in Tasmania, Australia

This paper reports on the social learning from a project aimed to increase the knowledge and capacity of a group of farmers in Tasmania, Australia, to reduce the impacts of intensive agriculture on soil health and waterways, and to optimise the efficient use of on-farm inputs. The plan-do-check-review cycle adopted in this project required the farmers to assess current management practices, identify where to make changes, implement changes and monitor for improvements. The success of the project was due to careful attention to social processes as well as technical input. The combination of group activities with individual mentoring and one-to-one advice was key to the success of this project in enabling farmers to undertake on-farm action.

There is value in social learning that included developing relationships, using one-to-one contact and group workshops together with expert input when working with farmers to tackle some difficult and complex interrelated natural resource management and production issues. Sufficient time must be allowed for the process of facilitating good practice in natural resource management, particularly when addressing systemic environmental impacts. Practical operational recommendations are presented on communication, feedback, focus of activities and meeting content, as these will be useful to other project officers and facilitators working with farmer groups.