Osteo-cise : Strong bones for life': protocol for a community-based randomised controlled trial of a multi-modal exercise and osteoporosis education program for older adults at risk of falls and fractures

Background : Osteoporosis affects over 220 million people worldwide, and currently there is no 'cure' for the disease. Thus, there is a need to develop evidence-based, safe and acceptable prevention strategies at the population level that target multiple risk factors for fragility fractures to reduce the health and economic burden of the condition.

Methods : The 'Osteo-cise: Strong Bones for Life' study will investigate the effectiveness and feasibility of a multi-component targeted exercise, osteoporosis education/awareness and behavioural change program for improving bone health and muscle function, and reducing falls risk in community-dwelling older adults at an increased risk of fracture. Men and women aged 60 years or above will participate in an 18-month randomised controlled trial comprising a 12-month structured and supervised community-based program and a 6-month 'research to practise' translational phase. Participants will be randomly assigned to either the 'Osteo-cise' intervention or a self-management control group. The intervention will comprise a multi-modal exercise program incorporating high velocity progressive resistance training, moderate impact weight-bearing exercise and high challenging balance exercises performed three times weekly at local community-based fitness centres. A behavioural change program will be used to enhance exercise adoption and adherence to the program. Community-based osteoporosis education seminars will be conducted to improve participant knowledge and understanding of the risk factors and preventative measures for osteoporosis, falls and fractures. The primary outcomes measures, to be collected at baseline, 6, 12, and 18 months, will include DXA-derived hip and spine bone mineral density measurements and functional muscle power (timed stair-climb test). Secondary outcomes measures include: MRI-assessed distal femur and proximal tibia trabecular bone micro-architecture, lower limb and back maximal muscle strength, balance and function (four square step test, functional reach test, timed up-and-go test and 30-second sit-to-stand), falls incidence and health-related quality of life. Cost-effectiveness will also be assessed.

Discussion : The findings from the Osteo-cise: Strong Bones for Life study will provide new information on the efficacy of a targeted multi-modal community-based exercise program incorporating high velocity resistance training, together with an osteoporosis education and behavioural change program for improving multiple risk factors for falls and fracture in older adults at risk of fragility fracture. Trial Registration: Australian New Zealand Clinical Trials Registry reference ACTRN12609000100291

Getting research into policy : lots of ideas but how do we make it happen? Insights from the policy experience

Evidence and health policy discussions to date have largely focused on the relationship between those generating research evidence and policy decision-makers and how improving this relationship will increase research use in policy development. All too often policy makers are perceived as the problem, not understanding or seeing the importance of research evidence. Policy makers do have a responsibility to source and use available evidence, as do researchers to the sharp and meaningful production and syntheses of policy relevant research evidence. This takes more than improved communication mechanisms between individual researcher and policy makers. Evidence-informed policy making is a science in its own right requiring the development and application of methods that conceptualise, synthesise and exchange research evidence. Policy organisations need to develop as receptor sites for research and its application to day-to-day decision-making, this is a significant program of work if it is to be done well and affect the evidence culture of organisations.

Best practice for prevention and treatment of cardiovascular disease through an equity lens : a review

Background Despite declining rates of cardiovascular disease (CVD) mortality in developed countries, lower socioeconomic groups continue to experience a greater burden of the disease. There are now many evidence-based treatments and prevention strategies for the management of CVD and it is essential that their impact on the more disadvantaged group is understood if socioeconomic inequalities in CVD are to be reduced.

Aims To determine whether key interventions for CVD prevention and treatment are effective among lower socioeconomic groups, to describe barriers to their effectiveness and the potential or actual impact of these interventions on the socioeconomic gradient in CVD.

Methods Interventions were selected from four stages of the CVD continuum. These included smoking reduction strategies, absolute risk assessment, cardiac rehabilitation, secondary prevention medications, and heart failure self-management programmes. Electronic searches were conducted using terms for each intervention combined with terms for socioeconomic status (SES).

Results Only limited evidence was found for the effectiveness of the selected interventions among lower SES groups and there was little exploration of socioeconomic-related barriers to their uptake. Some broad themes and key messages were identified. In the majority of findings examined, it was clear that the underlying material, social and environmental factors associated with disadvantage are a significant barrier to the effectiveness of interventions.

Conclusion Opportunities to reduce socioeconomic inequalities occur at all stages of the CVD continuum. Despite this, current treatment and prevention strategies may be contributing to the widening socioeconomic-CVD gradient. Further research into the impact of best-practice interventions for CVD upon lower SES groups is required.

Knowledge exchange in the Pacific : The TROPIC (translational research into obesity prevention policies for communities) project

Background
Policies targeting obesogenic environments and behaviours are critical to counter rising obesity rates and lifestyle-related non-communicable diseases (NCDs). Policies are likely to be most effective and enduring when they are based on the best available evidence. Evidence-informed policy making is especially challenging in countries with limited resources. The Pacific TROPIC (Translational Research for Obesity Prevention in Communities) project aims to implement and evaluate a tailored knowledge-brokering approach to evidence-informed policy making to address obesity in Fiji, a Pacific nation challenged by increasingly high rates of obesity and concomitant NCDs.
Methods
The TROPIC project draws on the concept of ‘knowledge exchange’ between policy developers (individuals; organisations) and researchers to deliver a knowledge broking programme that maps policy environments, conducts workshops on evidence-informed policy making, supports the development of evidence-informed policy briefs, and embeds evidence-informed policy making into organisational culture. Recruitment of government and nongovernment organisational representatives will be based on potential to: develop policies relevant to obesity, reach broad audiences, and commit to resourcing staff and building a culture that supports evidence-informed policy development. Workshops will increase awareness of both obesity and policy cycles, as well as develop participants’ skills in accessing, assessing and applying relevant evidence to policy briefs. The knowledge-broking team will then support participants to: 1) develop evidence-informed policy briefs that are both commensurate with national and organisational plans and also informed by evidence from the Pacific Obesity Prevention in Communities project and elsewhere; and 2) collaborate with participating organisations to embed evidence-informed policy making structures and processes. This knowledge broking initiative will be evaluated via data from semi-structured interviews, a validated self-assessment tool, process diaries and outputs.
Discussion
Public health interventions have rarely targeted evidence-informed policy making structures and processes to reduce obesity and NCDs. This study will empirically advance understanding of knowledge broking processes to extend evidence-informed policy making skills and develop a suite of national obesity-related policies that can potentially improve population health outcomes.

Managing patient deterioration : a protocol for enhancing undergraduate nursing students’ competence through web-based simulation and feedback techniques

Aims: To describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients.
Background: There are international concerns regarding the management of deteriorating patients with issues around the ‘failure to rescue’. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders.
Design/Methods: A mixed methods triangulated convergent design. In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase.
Conclusion: This project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program.

Keeping connected: the design and overview of the research

The special issue Keeping Connected: Identity, Social Connection and Education for Young People opens with a paper that discusses the research design and overview of a three-year project by a Melbourne (Australia)-based multi-disciplinary team. Over 2007–2009, the Keeping Connected team of 10 researchers investigated the lives of adolescents with ongoing health conditions. The project centrally is developed by the young people's perspectives, their identity and wellbeing, relationships with others and engagement within changing contexts and their altered opportunities in the world. The research design includes image production underpinned by visual methods and a narrative-informed approach to interview and interpretation of images. The study, which crosses the health and education interface, set out to highlight differences of perspectives adopted by 31 young people, their families and the professional groups, such as teachers and health professionals. The special issue discusses key project findings and contributes a body of scholarship that expands our knowledge of evidence-based research across the education and health interface. The longitudinal study highlighted two themes of importance for education, and poorly catered for in current policies and guidelines: that the situation of these young people needs to be addressed by schools as a process over time (including prospectively); and that the young people's identity is strongly marked by a desire to be seen and treated as ‘normal’ combined with an awareness of being vulnerable.

Institutional environment, innovation capacity and firm performance in Russia

Purpose – Following the demise of the Soviet Union in 1992, Russia undertook major institutional and market-oriented reforms to enhance the competitive advantage of domestic enterprises. Although Russia has experienced rapid growth over the last two decades, the extent to which institutions in Russia impact on firm innovation and performance remains poorly understood due to a lack of research on the subject. This paper seeks to contribute to the literature on the competitiveness of Russian firms by focussing specifically on the extent to which the state of the regulatory quality, rule of law, and corruption affect the innovation capacity and performance of firms in Russia.

Design/methodology/approach – The study uses structural equation modelling and data from a large-scale firm level survey (n=787) of firms in Russia undertaken by the World Bank in 2009. It investigates the direct and indirect perceptions of respondents of the effects the current institutional environment has on the innovation capacity and performance of their respective organisations.

Findings – The results show that regulatory quality, rule of law and corruption have strong direct and negative impacts on both the innovation capacity and performance of firms, and that innovation capacity strongly mediates the effects of institutions on firm performance. The results suggest that the current state of the regulatory quality, rule of law and corruption in Russia inhibit firm innovation and their resulting performance.

Research limitations/implications – The findings should be interpreted with caution to the extent that the study is limited to only three elements of the formal institutional environment and does not take into consideration the role of informal institutions. These two limitations present avenues for future research.

Originality/value – The study is one of the first to provide empirical evidence based on a large-scale survey of the extent to which formal institutions inhibit innovation and firm performance in Russia, and provides valuable guidance to business policy-makers in Russia on possible avenues for enhancing the overall competitiveness of Russian firms.

Food fortification : the evidence, ethics and politics of adding nutrients to food

This research book presents a critical analysis of mandatory food fortification as a technology for protecting and promoting public health. Increasing numbers of foods fortified with novel amounts and combinations of nutrients are being introduced into the food supplies of countries around the world to raise populations’ nutrient intakes. Three topical food fortification case studies representing the different public health rationales for adding nutrients to food were assessed for their public health benefits, risks and ethical considerations: Universal salt iodisation (USI) to help prevent iodine deficiency disorders; mandatory flour fortification with folic acid (MFFFA) to help prevent neural tube defects; and mandatory milk fortification with vitamin D (MMFVD) to help prevent vitamin D deficiency. These assessments found that whereas USI performs strongly as a public health intervention, MFFFA and MMFVD are associated with more risks and less ethical justification than an alternative policy option. Food fortification can be a blunt policy response to complex policy problems. The findings highlight that the primary predictor of a mandatory food fortification policy’s benefits, risks and ethics is its ability to address the underlying cause of the policy problem. The analysis of the policy-making processes for each case study found that certain powerful actors use their influence to determine what counts as evidence in policy processes to privilege food fortification activities over alternative policy options. Policy-making frequently was notable for the low prominence it afforded ethical considerations and its lack of public engagement. Priority activities to help strengthen policy processes and outcomes are suggested.

Primary prevention of gestational diabetes for women who are overweight and obese : a randomised controlled trial

Background: Gestational Diabetes Mellitus (GDM) has well recognised adverse health implications for the  mother and her newborn that are both short and long term. Obesity is a significant risk factor for developing GDM and the prevalence of obesity is increasing globally. It is a matter of public health importance that clinicians have evidence based strategies to inform practice and currently there is insufficient evidence regarding the impact of dietary and lifestyle interventions on improving maternal and newborn outcomes. The primary aim of this study is to measure the impact of a telephone based intervention that promotes positive lifestyle modifications on the incidence of GDM. Secondary aims include: the impact on gestational weight gain; large for gestational age babies; differences in blood glucose levels taken at the Oral Glucose Tolerance Test (OGTT) and selected factors relating to self-efficacy and psychological wellbeing. 

An argument for uniform Australian sentencing law

Sentencing law and practice impacts on fundamental individual interests, both from the perspective of offenders and victims. It also affects community safety and security The scope of sentencing law and its principal objectives are broadly similar throughout Australia. However, there are many important differences, especially in relation to sentencing practice, with some jurisdictions appearing to impose considerably heavier penalties for certain offence types. This article argues that uniform sentencing law should be implemented throughout Australia. The likely benefits would extend beyond achieving greater consistency in sentencing outcomes. A move toward uniform national sentencing laws would provide the catalyst for an objective, evidence-based review of sentencing policy and practice, thereby providing a vehicle for harmonising the law with a wealth of empirical data regarding the objectives that can be achieved through a system of state-imposed sanctions. It would also present a meaningful opportunity for a normative assessment of the justifiable operation of sentencing law. The main impediment to uniform sentencing laws is likely to come from state and territory governments seeking to maintain control over this often socially controversial area as a means of securing and maintaining community support. However, this obstacle is not necessarily insurmountable. It is not clear whether sentencing policy is, in fact, a main driver of voter preferences. Some politicians may prefer to have ·national uniformity' as a buffer to counteract reflexive calls for tougher sentencing that often occur following particularly serious crimes or seemingly light sentences handed down by courts.

Inclusion in participatory research: what were the whitefellas doing in an Aboriginal health project?

Health research in indigenous communities, like many interactions between such communities and white-dominated institutions, has a chequered history leading to a three-fold decrement: suspicion and resistance to research that is seen as coming from outside of the community; a shortage of research generators and leaders within the community; and cumulative gaps in the research evidence base, both in terms of coverage of topics and in terms of meeting the priorities of the community.

Additionally, these decrements have been mistakenly located as problems being caused from within the community, rather than recognising that these are outcomes of wider contextual, historical and institutional factors and failings. Good research, as culturally appropriate, inclusive of community voices and meeting the needs and priorities of the community, is necessary in an increasingly evidence-based-practice culture within policy and health settings. Culturally safe research with and for indigenous communities has the potential to be empowering, and to bring community voices, views and experiences into the influential realm of'evidence.

This process of developing safe, appropriate and inclusive research is not straightforward: the decrements are recursive, with a shortage of connections between the community, its priorities and research. However, as the Healing Stories project that we discuss here has shown, it is possible to develop culturally safe participatory research by working with Elders from within the community and with leaders from within white institutions, in a spirit of reconciliation. The methods and findings of Healing Stories have been reported elsewhere, with an emphasis on the voices from the community; this chapter explores some of the 'behind the scenes' processes, from the perspective of the white researchers working from within white- dominated institutions.

After briefly describing the Healing Stories project, this chapter reflects on three parts of the participatory research process: getting started, leading together, and working together. The first of these considers laying the foundations for participatory research, working with Elders and leaders, and planning for inclusion, examining participatory research as a recognisable research design, with potential for rigour, cultural safety and inclusion. The second explores developing participatory methods, working with communities, and opportunities and choices for inclusion. The third examines the process of being participatory, working together and engaging in inclusion across the long-term commitment to the project.

Comparative evaluation of PBL and traditional lecturebased teaching in undergraduate engineering courses : evidence from controlled learning environment

Project and problem-based learning (PBL) has been widely recognised as an active, collaborative, cumulative and integrative learning approach that engages learners, motivates team creativity and centres on practical education. On the other hand, traditional lecture-tutorial teaching is often criticised for being a passive, surface learning and exam-focused approach. In spite of these evidence-based observations and claims over the years, the traditional lecture-tutorial teaching approach still dominates as the preferred teaching approach at Australian universities. This study sets up a control environment to compare these two teaching and learning approaches by analysing data from students' actual performance, course evaluation and expectation in two large undergraduate engineering courses in 2009 and 2010. The evidence reported in this study is broadly interesting in that both courses were taught by the same teaching staff using two entirely different learning and teaching approaches to the same cohort of students in the same semester within the same degree program. The analysis shows that there are significant differences between the students' actual performance, course evaluation and their expectation. Such conflicting differences may be some of the reasons that may negatively impact teaching staff deterring them from switching to PBL from traditional lecture-tutorial teaching.

Integrating psychologists into the Canadian health care system : the example of Australia

Canada and Australia share many similarities in terms of demographics and the structure of their health systems; however, there has been a divergence in policy approaches to public funding of psychological care. Recent policy reforms in Australia have substantially increased community access to psychologists for evidence-based treatment for high prevalence disorders. In Canada, access remains limited with the vast majority of consultations occurring in the private sector, which is beyond the reach of many individuals due to cost considerations. With the recent launch of the Mental Health Commission of Canada, it is timely to reflect on the context of the current Canadian and Australian systems of psychological care. We argue that integrating psychologists into the publicly-funded primary care system in Canada would be feasible, beneficial for consumers, and cost-effective.

Programs to improve interpersonal safety in Indigenous communities: evidence and issues

There is now a substantial amount of published literature describing the range of programs and interventions that have been implemented in an attempt to improve aspects of community safety. Only a small body of this work, however, has examined the outcomes of those programs delivered to Indigenous Australians or, indeed, the communities in which they live. This Issues paper provides an overview of those programs that were identified in a systematic search of relevant research databases. 

Thai emergency nurses’ management of patients with severe traumatic brain injury: comparison of knowledge and clinical management with best available evidence

Background:
In Thailand, the rate of TBI-related hospitalisation is increasing, however, little is known about the evidence-based management of severe TBI in the developing world. The aim of this study was to explore Thai emergency nurses’ management of patients with severe TBI.

Methods:
An exploratory descriptive mixed method design was used to conduct this two stage study: survey methods were used to examine emergency nurses’ knowledge regarding management of patients with severe TBI (Stage 1) and observational methods were used to examine emergency nurses’ clinical management of patients with severe TBI (Stage 2). The study setting was the emergency department (ED) at a regional hospital in Southern Thailand.

Results:
34 nurses participated in Stage 1 (response rate 91.9%) and the number of correct responses ranged from 33.3% to 95.2%. In Stage 2, a total of 160 points of measurement were observed in 20 patients with severe TBI over 40 h. In this study there were five major areas identified for the improvement of care of patients with severe TBI: (i) end-tidal carbon dioxide (ETCO2) monitoring and targets; (ii) use of analgesia and sedation; (iii) patient positioning; (iv) frequency of nursing assessment; and (v) dose of Mannitol diuretic.

Conclusions:
There is variation in Thai nurses’ knowledge and care practices for patients with severe TBI. To increase consistency of evidence-based TBI care in the Thai context, a knowledge translation intervention that is ecologically valid, appropriate to the Thai healthcare context and acceptable to the multidisciplinary care team is needed.