Introducing mental health and substance use screening into a community-based health service in Australia : usefulness and implications for service change

Mental health issues such as depression or anxiety and alcohol or other drug (AOD) problems often remain undiagnosed and untreated despite their prevalence in the community. This paper reports on the implementation and evaluation of an AOD and depression/anxiety screening programme within two Community Health Services (CHS) in Australia. Study 1 examined results from 5 weeks of screening (March–April 2008) using the Patient Health Questionnaire (two- and nine-item, Kroenke et al. 2001, 2003), the Conjoint Screen for Alcohol and other Drug Problems (Brown et al. 2001) and the Alcohol, Smoking and Substance Involvement Screening Test (Humeniuk & Ali 2006). Of the 55 clients screened, 33% were at risk of depression or anxiety, 22% reporting moderate-severe depression. Thirteen per cent were at risk of substance use disorders. A substantial proportion of at-risk clients were not currently accessing help for these issues from the CHS and therefore screening can facilitate identification and treatment referral. However, the majority of eligible clients were not screened, limiting screening reach. A second study evaluated the screening implementation from a process perspective via thematic analysis of focus group data from six managers and 14 intake/assessment workers (April 2008). This showed that when screening occurred, it facilitated opportunities for education and intervention with at-risk clients, although cultural mores, privacy concerns and shame/stigma could affect accuracy of screen scores at times. Importantly, the evaluation revealed that most decisions not to screen were made by workers, not by clients. Reasons for non-screening related to worker discomfort in asking sensitive questions and/or managing client distress, and a reluctance to spend long periods of time screening in time-pressured environments. The evaluation suggested that these problems could be resolved by splitting screening responsibilities, enhancing worker training and expanding follow-up screening. Findings will inform any community-based health system considering introducing screening.

A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people

Racial discrimination is increasingly recognised as a determinant of racial and ethnic health inequalities, with growing evidence of strong associations between racial discrimination and adult health outcomes. There is a growing body of literature that considers the effects of racial discrimination on child and youth health. The aim of this paper is to provide a systematic review of studies that examine relationships between reported racial discrimination and child and youth health. We describe the characteristics of 121 studies identified by a comprehensive search strategy, including definitions and measurements of racial discrimination and the nature of reported associations. Most studies were published in the last seven years, used cross-sectional designs and were conducted in the United States with young people aged 12–18 years. African American, Latino/a, and Asian populations were most frequently included in these studies. Of the 461 associations examined in these studies, mental health outcomes (e.g. depression, anxiety) were most commonly reported, with statistically significant associations with racial discrimination found in 76% of outcomes examined. Statistically significant associations were also found for over 50% of associations between racial discrimination and positive mental health (e.g. self esteem, resilience), behaviour problems, wellbeing, and pregnancy/birth outcomes. The field is currently limited by a lack of longitudinal studies, limited psychometrically validated exposure instruments and poor conceptualisation and definition of racial discrimination. There is also a need to investigate the complex and varying pathways by which reported racial discrimination affect child and youth health. Ensuring study quality in this field will allow future research to reveal the complex role that racial discrimination plays as a determinant of child and youth health.

Diabetes and risk of physical disability in adults: a systematic review and meta-analysis

Background
According to previous reports, the risk of disability as a result of diabetes varies from none to double. Disability is an important measure of health and an estimate of the risk of disability as a result of diabetes is crucial in view of the global diabetes epidemic. We did a systematic review and meta-analysis to estimate this risk.

Methods
We searched Ovid, Medline, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature up to Aug 8, 2012. We included studies of adults that compared the risk of disability—as measured by activities of daily living (ADL), instrumental activities of daily living (IADL), or mobility—in people with and without any type of diabetes. We excluded studies of subpopulations with specific illnesses or of people in nursing homes. From the studies, we recorded population characteristics, how diabetes was diagnosed (by doctor or self-reported), domain and definition of disability, and risk estimates for disability. We calculated pooled estimates by disability type and type of risk estimate (odds ratio [OR] or risk ratio [RR]).

Results
Our systematic review returned 3224 results, from which 26 studies were included in our meta-analyses. Diabetes increased the risk of mobility disability (15 studies; OR 1·71, 95% CI 1·53—1·91; RR 1·51, 95% CI 1·38—1·64), of IADL disability (ten studies; OR 1·65, 95% CI 1·55—1·74), and of ADL disability (16 studies; OR 1·82, 95% CI 1·63—2·04; RR 1·82, 95% CI 1·40—2·36).

Interpretation
Diabetes is associated with a strong increase in the risk of physical disability. Efforts to promote healthy ageing should account for this risk through prevention and management of diabetes.

Funding
Monash University, Baker IDI Bright Sparks Foundation, Australian Postgraduate Award, VicHealth, National Health and Medical Research Council, Australian Research Council, Victorian Government.