Out of pocket costs to stroke patients during the first year after stroke - results from the North East Melbourne stroke incidence study

Non-reimbursed ‘out of pocket’ costs to stroke patients have not been included in existing cost of illness studies. We aimed to determine the nature and magnitude of ‘out of pocket’ costs to stroke patients during the first year after stroke. ‘Out of pocket’ costs during the first year after stroke were documented for 165 persons registered in a community-based stroke incidence study during 1996/1997. Virtually all cases reported some ‘out of pocket’ costs. The average cost over 12 months was A$1110. The highest cost items were home modifications, aids and equipment. The most commonly incurred expense was for prescription medications. Total ‘out of pocket’ costs incurred by first-ever stroke patients in Australia in 1997 were estimated to be A$29 million or 5% of the total cost of stroke. The majority of ‘out of pocket’ costs relate to post-acute care aimed at minimising disability and handicap rather than to ‘acute’ healthcare.

Beyond the power of one : redesigning the work of school principals

There is mounting international research evidence that the work of school principals is increasingly difficult, time consuming and more unattractive to prospective applicants. We suggest that the solution to this situation lies in redesigning the work that principals do. Using the New London Group’s (1996) definition of design as both process and product and as a hybrid of existing resources, we offer five cases of redesign: distributed pedagogical leadership, co-principalship, shared principalship, multi-campus principalship, and community-based principalship. We argue that these examples show that redesigns that focus on the school, rather than on the work of the principal, have more far-reaching effects, but are also much more vulnerable to context. We propose three emerging principles for redesign viz. developing a strong warrant for redesign, attending to infrastructure and building organic relations between school and community.

Social, cultural and environmental influences on child activity and eating in Australian migrant communities

Aim: This study set out to examine the socio-cultural, familial and environmental factors influencing health, eating habits and patterns of physical activity contributing to child and adolescent overweight and obesity. Methods: Semi-structured, community-based interviews were conducted with contrasting key informant three-generation families; and generation by generation focus groups of grandparents, parents and children from four cultural communities in the state of Victoria, Australia. Purposive sampling occurred from Turkish, Greek, Indian and Chinese communities that have migrated to Australia within the last three generations (n = 160, eight families, 47 children aged 5–15 years, 29 parents, 42 grandparents). Results: Evidence of two-way influences on eating and physical activity across three generations was evident, with children reporting the greatest cross-cultural diversity. A range of dietary restrictions was reported across all cultural groups. Efforts to foster healthy eating and lifestyle patterns within communities were evident. Parents, as a generation in particular, felt the need for more access to education and support regarding healthy limits for pre-puberty and puberty stages. Conclusion: There is a dynamic influence of culture on many aspects of family lifestyle across three generations. To achieve successful intervention design, childhood obesity researchers need to collaborate with diverse groups and communities. Considering the role and influence of extended family, a multigenerational, whole-of-community approach beyond that of parent and child populations ought to be considered.

A review of stock enhancement practices in the inland water fisheries of Asia

Inland fisheries contribute only about ten percent to global fish production. Asia is the leading producer of inland fish, accounting for over 80 percent of the total production. Until recently, the inland fisheries sector had taken back stage in fisheries development plans, particularly so, given the emphasis being placed on aquaculture development throughout the world, including Asia. This report evaluates the inland fishery practices in a number of Asian countries according to habitat type, role in overall foodfish supplies and development trends. Special emphasis is laid on stock enhancement in inland fisheries in Asia, and only those fisheries in which some form of stock enhancement is practised are considered in this report.

In Asia, inland fisheries are mostly rural, artisanal activities catering to rural populations and providing an affordable source of animal protein, employment and household income. Stock enhancement is an integral component of many inland fisheries. With recent developments in
artificial propagation techniques for fast-growing and desirable fish species and the consequent increased availability of seed stock, such activities are beginning to affect inland fishery production in most Asian countries. Indeed, new avenues of production such as culture-based fisheries are increasingly adopted and seen as a way forward in most countries. Inland fishery activities also have a distinct advantage in that their development is usually less resource intensive than is aquaculture.

The economic viability of stock enhancement of large lacustrine waterbodies and rivers has not been demonstrated in any of the Asian countries, the fisheries of such waterbodies being dependent on naturally recruited stocks. The most successful stock enhancements in Asia are in floodplain beels and oxbow lakes in Bangladesh where the use of small waterbodies that are not capable of supporting natural fisheries has led to culture-based fisheries having stock and recapture rates that are very high. Culture-based fisheries are not resource intensive and are community-based activities. However, their success requires major institutional changes, and these are affected by national and local governments. In general, they can be considered to have the greatest potential for further development.

A major concern related to stock enhancements in inland waters is their possible effects on biodiversity. This is for two reasons: firstly, most countries depend wholly or partially on exotic species for stock enhancement and secondly, freshwater fishes are known to be among the most threatened of vertebrates. Major studies should be undertaken to evaluate the current situation so that remedial steps can be taken, if needed, without causing serious harm to some of the stock enhancement practices that are gaining momentum.

Flora Fit street : a qualitative evaluation

This report summaries a qualitative evauation of the Flora Fit Street community based health living initiative.

Teacher or trainer? The shaping of teacher identity in adult education contexts

In response to changing government funding priorities there has been a shift away from the provision of needs based language and personal development courses for adults in community based contexts towards the delivery of vocational education. Much vocational education is characterized by competency-based curriculum and outcomes influenced by the needs of the current labour market as well as economic driven initiatives such as competitive tendering for short-term course funding. These trends have resulted in changes to the nature of curriculum, assessment, and the purpose and nature of the delivery of courses to adult learners. In turn, these changes affect the ways in which teachers see themselves and carry out their roles as professionals. This paper explores the ways in which the current discourses of vocational education shape teacher identities across a variety of vocational education contexts and the ways in which teacher identities are played out through training and teaching practices.

'Research as dialogue' and cross cultural consultations : confronting relations of power

The 'rescuing' of Indigenous children (from their communities) through education, and the notions of assimilation associated with that, is an aspect of colonialism that has persisted into the so-called 'post-colonial' era. Recent national policy statements (eg. MCEETYA, 2000; NBEET, 1995) argue the importance of education/research that keeps the locus of control within the Aboriginal community as a means to further the goal of self determination and improve educational outcomes. In this paper, we report on the initial stage of a small empirical research project, Engaging Aboriginal Students In Education Through Community Empowerment.

'Research as dialogue' was a guiding principal and a primary aim was to listen actively to all key stake holders in the remote community setting, particularly to Indigenous parents, teachers and service providers, in order to identify current

strengths and concerns regarding the provision of culturally inclusive schooling; and then, to develop, on the basis of these consultations and in collaboration, community-based education projects that engage non-attending Aboriginal students.

In this paper, we critically analyse the difficulties as well as potential strengths of trying to form collaborative partnerships as researchers, across cultural differences and with diverse community groups. For example, what does 'acknowledging' very different cultural perspectives actually mean to/in this kind of research process? The ways in which relations of power amongst all parties are played out in/through such an approach is also opened up for scrutiny and further discussion.

Investigation of the factors responsible for the superior performance of male students in standardised testing at one primary school

The project set out to investigate one primary school where, for four years or more, boys have outperformed girls in standardized Year 3 and 5 Basic Skills Tests in literacy and numeracy, which contradicts general findings on male and female performance in standardized literacy and numeracy testing. The school placed a heavy emphasis on literacy programs, which appear to be making a difference to the boys. Over time, there has been a slight improvement in boys’ literacy performance but the greatest area of growth is generally boys’ numeracy, rather than boys’ literacy.

Further aims of the study were to isolate school-based factors, which are potentially responsible for this phenomenon, from community-based factors and to explore the possibility that, rather than boys being advantaged, girls were actually being disadvantaged by practices at the school. The approach adopted by the research team employed intensive case-study methods and ethnographic approaches, including interviews, document analysis, and structured and unstructured observation of a range of school activities.

This paper describes how the school has transformed itself, the effects that this has had upon the teaching and learning environment and the results that have been achieved in the key areas of numeracy and literacy.

Heterogeneity in service delivery and inequity in access are common characteristics of chronic heart failure management programs

Background: The prevalence of heart failure in Australia is similar to that of Europe. In Australia, chronic heart failure management programs (CHF-MPs) have become part of standard care for patients with Chronic Heart Failure (CHF). However, heterogeneity among programs is common which can result in variable patient outcomes.

Method: A national survey was undertaken of 59 post-discharge CHF-MPs identified from within the Australian health care system. Two had ceased operating and one centre declined to participate in the study. A 33-item investigator-developed questionnaire, examining the characteristics and interventions used within each CHF-MP, was sent to the remaining 56 CHF-MPs. A response rate of 100% was achieved.

Results: Our survey revealed a disproportional distribution of CHF-MPs across the Australian continent: the State of Victoria had 3.6 CHF-MPs/million population, New South Wales had 3.7 CHF-MPs/million population, Queensland had 1 program/million population, South Australia had 0.3 CHF-MPs/million population and Western Australia had 1 program/million population.Overall, 8000 postdischarge CHF pts (median: 126; IQR: 26-260) were managed via CHF-MPs. Approximately 40,000 CHF pts are discharged from metropolitan institutions nationally, this represents only 22% of the potential caseload for these cost-effective CHF-MPs. Only 8% of these programs were located within rural regions. The majority of CHF-MPs were located within an acute metropolitan hospital (52%) and 36% were community based (all associated with a hospital). Heterogeneity of CHF-MPs in applied models of care was evident with 75% of CHF-MPs offering CHF outpatient clinics and 77% conducting home visits. Of the programs offering home visits 78% were funded by regional government (p<0.048). There were no nurse-led CHF outpatient clinics. A hybrid approach to CHF-MPs was common with many CHF-MPs comprising an outpatient clinic, home visits and inpatient visits. Various medications were titrated by nurses in 43% of CHF-MPs. In the programs that allowed nurses to titrate medications 79% were located in an acute hospital (p<0.011).

Conclusion: Variability of service availability is of concern within the context of universal coverage. In addition, heterogeneity between programs and the diversity in models of care delivery highlights the inconsistency and questions the quality of health related outcomes. We are currently analysing health outcome data from the 1015 patients managed in these CHF-MPs to describe the relationship between quality of care and health outcomes.

COSMOS: COmparing standard maternity care with one-to-one midwifery support: a randomised controlled trial

Background: In Australia and internationally, there is concern about the growing proportion of women giving birth by caesarean section. There is evidence of increased risk of placenta accreta and percreta in subsequent pregnancies as well as decreased fertility; and significant resource implications. Randomised controlled trials (RCTs) of continuity of midwifery care have reported reduced caesareans and other interventions in labour, as well as increased maternal satisfaction, with no statistically significant differences in perinatal morbidity or mortality. RCTs conducted in the UK and in Australia have largely measured the effect of teams of care providers (commonly 6–12 midwives) with very few testing caseload (one-to-one) midwifery care. This study aims to determine whether caseload (one-to-one) midwifery care for women at low risk of medical complications decreases the proportion of women delivering by caesarean section compared with women receiving 'standard' care. This paper presents the trial protocol in detail.

Methods/design: A two-arm RCT design will be used. Women who are identified at low medical risk will be recruited from the antenatal booking clinics of a tertiary women's hospital in Melbourne, Australia. Baseline data will be collected, then women randomised to caseload midwifery or standard low risk care. Women allocated to the caseload intervention will receive antenatal, intrapartum and postpartum care from a designated primary midwife with one or two antenatal visits conducted by a 'back-up' midwife. The midwives will collaborate with obstetricians and other health professionals as necessary. If the woman has an extended labour, or if the primary midwife is unavailable, care will be provided by the back-up midwife. For women allocated to standard care, options include midwifery-led care with varying levels of continuity, junior obstetric care and community based general medical practitioner care. Data will be collected at recruitment (self administered survey) and at 2 and 6 months postpartum by postal survey. Medical/obstetric outcomes will be abstracted from the medical record. The sample size of 2008 was calculated to identify a decrease in caesarean birth from 19 to 14% and detect a range of other significant clinical differences. Comprehensive process and economic evaluations will be conducted.

Trial registration: Australian New Zealand Clinical Trials Registry ACTRN012607000073404.

The politics of resistance to workplace cultural diversity education for health service providers : an Australian study

This qualitative study has as its focus an exploration of health service providers' perceptions and experiences of the processes and implications of delivering workplace cultural diversity education for staff. Data were obtained from conducting in-depth individual and focus group interviews with a purposeful sample of 137 healthcare professionals, recruited from over 17 different organizational sites. Participants included cultural diversity educators, ethnic liaison officers, health service managers, nurses, health interpreters, allied health professionals, and community-based ethnic welfare organization personnel working in or with select metropolitan health services in Victoria, Australia. Analysis of the data revealed that workplace cultural diversity education in healthcare is a significant site of resistance and struggle. 'Resistance' was expressed in several forms including: the problematization of resources and staff availability to attend cultural diversity education forums; indifferent failure to recognize cultural imperatives in healthcare; deliberate refusal to recognize cultural imperatives in healthcare; selective recognition of cultural imperatives in healthcare ('facts sheets' only); and the angry rejection of cultural imperatives in healthcare. 'Struggle', in turn, largely involved cultural diversity educators having to constantly 'cajole and convince' (and even manipulate) staff to attend cultural diversity education forums and using a 'velvet glove and iron fist' approach to teaching staff who remained resolute in their resistance when participating in educational forums. An important implication of this study is that the politics of workplace cultural diversity education - and the 'politics of resistance' to such programs - need to be better recognized and understood if the status quo is to be successfully challenged and changed. The need for critical debate and further comparative research on the subject are also highlighted.

Effects of a multi-component exercise program and calcium–vitamin-D3-fortified milk on bone mineral density in older men : a randomised controlled trial

Summary We examined the independent and combined effects of a multi-component exercise program and calcium–vitamin-D3-fortified milk on bone mineral density (BMD) in older men. Exercise resulted in a 1.8% net gain in femoral neck BMD, but additional calcium–vitamin D3 did not enhance the response in this group of older well-nourished men.

Introduction This 12-month randomised controlled trial assessed whether calcium–vitamin-D3-fortified milk could enhance the effects of a multi-component exercise program on BMD in older men.

Methods Men (n  = 180) aged 50–79 years were randomised into: (1) exercise + fortified milk; (2) exercise; (3) fortified milk; or (4) controls. Exercise consisted of high intensity progressive resistance training with weight-bearing impact exercise. Men assigned to fortified milk consumed 400 mL/day of low fat milk providing an additional 1,000 mg/day calcium and 800 IU/day vitamin D3. Femoral neck (FN), total hip, lumbar spine and trochanter BMD and body composition (DXA), muscle strength 25-hydroxyvitamin D and parathyroid hormone (PTH) were assessed.

Results There were no exercise-by-fortified milk interactions at any skeletal site. Exercise resulted in a 1.8% net gain in FN BMD relative to no-exercise (p < 0.001); lean mass (0.6 kg, p < 0.05) and muscle strength (20–52%, p < 0.001) also increased in response to exercise. For lumbar spine BMD, there was a net 1.4–1.5% increase in all treatment groups relative to controls (all p < 0.01). There were no main effects of fortified milk at any skeletal site.

Conclusion A multi-component community-based exercise program was effective for increasing FN BMD in older men, but additional calcium–vitamin D3 did not enhance the osteogenic response.

Depression in people with intellectual disability : an evaluation of a staff-administered treatment program

The prevalence of co-morbid depression in people with intellectual disability (ID) provides a strong rationale for the early identification and treatment of individuals at risk. The aim of this study was to evaluate a staff-administered group CBT program for the treatment of depression in people with mild ID. A sample of 13 staff employed at two community-based disability agencies were trained to deliver the program to 47 individuals with mild ID and symptoms of depression. A wait list control group comprised of 27 individuals subsequently completed the program. Compared to the control group, individuals who had participated in the treatment program showed lower depression scores, and fewer automatic negative thoughts. Furthermore, these changes were maintained at a 3-month follow-up. The results indicate that staff can be trained to deliver a CBT program within community settings that is effective in the reduction of depression symptomatology in people with mild ID.

Femoral sulcus angle and increased patella facet cartilage volume in an osteoarthritic population

Objective
The patellofemoral joint is an example of an incongruent articulation commonly affected by osteoarthritis (OA). The relationship between femoral sulcus angle and the development and progression of patellofemoral OA is unclear. The aim of this study was to examine the relationship between the femoral sulcus angle at baseline and patella cartilage volume at baseline and at 2-year follow-up among community based adults with established knee OA.

Methods
One hundred subjects had magnetic resonance imaging of their symptomatic knee at baseline and at 2-year follow-up. From these images, patella cartilage volume was determined. Radiographic skyline views of the patellofemoral joint were taken at baseline to measure the femoral sulcus angle.

Results
For every 1° increase in the femoral sulcus angle (i.e., as the sulcus angle became more shallow) there was an associated 9.1 mm3 (95% CI 3.1, 15.0) increase in medial patella cartilage volume at baseline (P = 0.003). There was a similar trend that approached statistical significance between the femoral sulcus angle and the lateral patella facet cartilage volume at baseline (P = 0.09). There was no association between the femoral sulcus angle at baseline and the change in patella cartilage volume over 2 years in either patellofemoral compartment.

Conclusion
These results infer that the femoral sulcus angle is a cross-sectional determinant of the amount of patella cartilage, but is not a major determinant of the annual change of patella cartilage volume among people with knee OA. These data suggest that a shallower sulcus in the context of established OA may be an advantageous anatomical variant. Further longitudinal studies are required to determine the role of the femoral sulcus angle in OA.