Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting : Greater Green Triangle (GGT) Diabetes Prevention Project

Background
Randomised controlled trials demonstrate a 60% reduction in type 2 diabetes incidence through lifestyle modification programmes. The aim of this study is to determine whether such programmes are feasible in primary health care.

Methods
An intervention study including 237 individuals 40–75 years of age with moderate or high risk of developing type 2 diabetes. A structured group programme with six 90 minute sessions delivered during an eight month period by trained nurses in Australian primary health care in 2004–2006. Main outcome measures taken at baseline, three, and 12 months included weight, height, waist circumference, fasting plasma glucose and lipids, plasma glucose two hours after oral glucose challenge, blood pressure, measures of psychological distress and general health outcomes. To test differences between baseline and follow-up, paired t-tests and Wilcoxon rank sum tests were performed.

Results
At twelve months participants' mean weight reduced by 2.52 kg (95% confidence interval 1.85 to 3.19) and waist circumference by 4.17 cm (3.48 to 4.87). Mean fasting glucose reduced by 0.14 mmol/l (0.07 to 0.20), plasma glucose two hours after oral glucose challenge by 0.58 mmol/l (0.36 to 0.79), total cholesterol by 0.29 mmol/l (0.18 to 0.40), low density lipoprotein cholesterol by 0.25 mmol/l (0.16 to 0.34), triglycerides by 0.15 mmol/l (0.05 to 0.24) and diastolic blood pressure by 2.14 mmHg (0.94 to 3.33). Significant improvements were also found in most psychological measures.

Conclusion
This study provides evidence that a type 2 diabetes prevention programme using lifestyle intervention is feasible in primary health care settings, with reductions in risk factors approaching those observed in clinical trials.

Trial Number
Current Controlled Trials ISRCTN38031372

Gender and health promotion: A multisectoral policy approach

Women and men are different as regards their biology, the roles and responsibilities that society assigns to them and their position in the family and community. These factors have a great influence on causes, consequences and management of diseases and ill-health and on the efficacy of health promotion policies and programmes. This is confirmed by evidence on male–female differences in cause-specific mortality and morbidity and exposure to risk factors. Health promoting interventions aimed at ensuring safe and supportive environments, healthy living conditions and lifestyles, community involvement and participation, access to essential facilities and to social and health services need to address these differences between women and men, boys and girls in an equitable manner in order to be effective. The aim of this paper is to (i) demonstrate that health promotion policies that take women's and men's differential biological and social vulnerability to health risks and the unequal power relationships between the sexes into account are more likely to be successful and effective compared to policies that are not concerned with such differences, and (ii) discuss what is required to build a multisectoral policy response to gender inequities in health through health promotion and disease prevention. The requirements discussed in the paper include i) the establishment of joint commitment for policy within society through setting objectives related to gender equality and equity in health as well as health promotion, ii) an assessment and analysis of gender inequalities affecting health and determinants of health, iii) the actions needed to tackle the main determinants of those inequalities and iv) documentation and dissemination of effective and gender sensitive policy interventions to promote health. In the discussion of these key policy elements, we use illustrative examples of good practices from different countries around the world.

The sustainability of health promotion interventions for different levels of social organization

In health promotion, enthusiasm for sustainability has frequently overshadowed critical reflection with regard to whether this aim is warranted, let alone feasible. Consequently, the not insubstantial body of literature on sustainability in health promotion is not particularly helpful to decision makers. In this paper we seek to provide some guidance for the development of sustainability for health promotion interventions, arguing that it is necessary to be able to differentiate between (i) levels of social organization which are the focus of change, (ii) the programmes and agencies which are the means employed to achieve change, and (iii) the outcomes or effects that are achieved. Furthermore, funding allocations need to be congruent with programme characteristics if one is serious about achieving sustainability.

Action research in health promotion

Objectives This article aims to define what is action research and where it fits in with health promotion practice, through drawing upon associated literature and personal action research experience. It also seeks to investigate the possible reasons why it is that health promotion researchers have not readily taken on the processes of action research strategies.

Rationale The place of action research in health promotion programmes is an important yet relatively unacknowledged and understated activity. It has proven to be very popular with other professional groups, such as in the education, management and social sciences. In terms of health service activity, it is widely established in the fields of nursing and mental health and is beginning to establish itself in medicine. While there are a few health promotion examples to draw upon, they tend to be isolated, dated and often lie outside of the mainstream literature. It is suggested that this continuing state of affairs denies many health promotion researchers a valuable resource for managing effective change in practice.

Conclusion The authors suggest that action research is both a valid and
important research method for health promotion researchers, who are advised to further consider its merits in future studies. This article draws attention to the National Health Service (NHS) South West Regional Office-commissioned Our Healthier Nation: Improving the Competence of the Workforce in Health Promotion participatory action research project, as a means of promoting and validating action research strategy. The authors were all actively involved in this project.

Family and carer smoking control programmes for reducing children's exposure to environmental tobacco smoke

Background: Exposure to other people’s cigarette smoke (environmental tobacco smoke, or ETS) is an important child health issue.
Objectives: To determine the effectiveness of interventions aiming to reduce exposure of children to ETS.
Search strategy: The Tobacco Addiction Group register of studies was searched.MEDLINE, EMBASE and four other health and psychology databases were searched electronically, bibliographies of retrieved primary studies were checked and specialists in the area consulted.
Selection criteria: Controlled trials with or without random allocation were included in this review if they addressed participants (parents and other family members, child care workers and teachers) involved with the care and education of infants and young children (aged 0-12 years). All mechanisms for reduction of children’s environmental tobacco smoke exposure, and smoking prevention, cessation, and control programmes targeting these participants are included. These include smoke free policies and legislation, health promotion, social behavioural therapies, technology, education and clinical interventions.
Data collection and analysis: Two reviewers independently assessed studies and extracted data. Due to heterogeneity of methodologies and outcomes, no summary measures were possible and results were synthesised using narrative summaries.
Main results: Nineteen studies met the inclusion criteria, one of which was subsequently excluded. Three interventions were targeted at populations or community settings, seven studies were conducted in the well child health care setting and eight in the ill child health care setting. Twelve of these studies are from North America. In 12 of the 18 studies there was reduction of ETS exposure for children in both intervention and comparison groups. In only four of the 18 studies was there a statistically significant intervention effect. Three of these successful studies employed intensive counselling interventions targeted to smoking parents. There is little difference between the well infant, child respiratory illness and other child illness settings as contexts for parental smoking cessation interventions. The fourth successful intervention was in the school setting targeting the ETS exposure of children from smoking fathers.
Authors’ conclusions: Brief counselling interventions, successful in the adult health setting when coming from physicians, cannot be extrapolated to adults in the setting of child health. There is limited support for more intensive counselling interventions. There is no clear evidence for differences between the respiratory, non-respiratory ill child, well child and peripartum settings as contexts for reduction of children’s ETS exposure.

The effects of an area-based intervention on the uptake of maternal and child health assessments in Australia : a community trial

Background
Recognition of the importance of the early years in determining health and educational attainment and promotion of the World Health Organization Health for All (HFA) principles has led to an international trend towards community-based initiatives to improve developmental outcomes among socio-economically disadvantaged children. In this study we examine whether, Best Start, an Australian area-based initiative to improve child health was effective in improving access to Maternal and Child Health (MCH) services.

Methods
The study compares access to information, parental confidence and annual 3.5 year Ages and Stages visiting rates before (2001/02) and after (2004/05) the introduction of Best Start. Access to information and parental confidence were measured in surveys of parents with 3 year old children. There were 1666 surveys in the first wave and 1838 surveys in the second wave. The analysis of visiting rates for the 3.5 year Ages and Stages visit included all eligible Victorian children. Best Start sites included 1,739 eligible children in 2001/02 and 1437 eligible children in 2004/05. The comparable figures in the rest of the state were and 45, 497 and 45, 953 respectively.

Results
There was a significant increase in attendance at the 3.5 year Ages and Stages visit in 2004/05 compared to 2001/02 in all areas. However the increase in attendance was significantly greater at Best Start sites than the rest of the state. Access to information and parental confidence improved over the course of the intervention in Best Start sites with MCH projects compared to other Best Start sites.

Conclusion
These results suggest that community-based initiatives in disadvantaged areas may improve parents' access to child health information, improve their confidence and increase MCH service use. These outcomes suggest such programmes could potentially contribute to strategies to reduce child health inequalities.

Drop-out from parenting training programmes : a retrospective study

Objective: Parent training programmes are a well-established treatment approach for children and adolescents with disruptive behaviour disorders. However, dropout from treatment is a common problem that confounds research on the efficacy of this approach, and wastes important mental health resources. This study sought to further our understanding of the reasons why parents drop out of parent training programmes.

Method: Nine parents of children with disruptive behaviour disorders who had dropped out of a parent training programme were interviewed to investigate why they discontinued the programme.

Results: Parents who dropped out of treatment believed that their children were more difficult than other children with the same disorder and may have been better suited to a child-focused intervention. The parents themselves had very stressful lives, with the majority being single mothers with little support. Dropout parents also had difficulty with the group context and putting strategies into place. Practical concerns included parking, timing of session and the length and number of sessions.

Conclusions: The findings are discussed in terms of what modifications can be made to these programmes to increase retention.

Addressing the contradiction between discourse and practice in health promotion

The main theme of this thesis is the contradiction between discourse and practice in health promotion. Many health promoters continue to exert power-over the community through top-down programming whilst at the same time using an emancipatory discourse. The thesis has addressed this contradiction in three parts. The first part determines how the emancipatroty discourse has evolved and eplores the role of social movements in the development of contemporary health discourses and their influence on the legitimisation of empowerment. Central to this discourse is the empowerment of communities. To understand the role of this concept the thesis provides an interpretation of the different meanings of power and community, and the different levels of analysis of empowerment in the context of health promotion programming. The second part identifies the nature of health programming and the dominance of top-down, and to a much lesser extent, bottom-up approaches. The thesis argues that these two approaches are not, and do not have to be, mutually exclusive. To address this issue the thesis presents a new methodology is situated within a framework developed for the accomodation of empowerment goals within health promotion programmes. The study also identifies the organisational areas of influence on the processs of community empowerment and it is these which are used for the assessment of this concept. Both the framework and the methodology address the contradiction in health promotion by making community empowerment operational within a programme context. The third part of the thesis supports the rationale for the design of the methodology with field work in rural Fijian communities. The findings are presented as a composite case study to highlight the experiences of implementing the methodolgy and the main themes that emerged during the field work. the final chapter of the thesis brings together the central themes of the study and draws from these and 'emergent agenda' as a way forward for health promotion research and practice.

Family functioning, parental psychological distress and child behaviours : evidence from the Victorian child health and wellbeing study

We examined, using data from the 2006 Victorian Child Health and Wellbeing Study (VCHWS), whether family functioning is associated with parental psychological distress and children’s behavioural difficulties. The VCHWS was a statewide cross-sectional telephone survey to 5,000 randomly selected primary caregivers of 0- to 12-year-old children between October 2005 and March 2006. Only parents or guardians of children aged 4–12 years (n = 3,370) were included in this study. After adjusting for sociodemographic variables and ethnicity, parents or guardians scoring higher on the family functioning scale (i.e., from poorly functioning households) were at greater risk of psychological distress and had children with lower levels of prosocial behaviour and higher levels of behavioural difficulties relative to those from healthily functioning households. Mental health prevention programmes addressing child mental and conduct problems should consider the family environment and target those families functioning poorly.

Factors limiting participation in arthritis self-management programmes : an exploration of barriers and patient preferences within a randomized controlled trial

Objective. To improve understanding of barriers to participation in community-based arthritis self-management programmes and patient preferences for self-management education.

Methods. Individuals with hip or knee OA referred to orthopaedic surgeons or rheumatologists at six public and private hospitals in Victoria, Australia, were recruited for a randomized controlled trial (RCT) of the Stanford Arthritis Self-Management Programme (ASMP). As part of the study design, potential participants were asked during the screening and recruitment process about reasons for being unable to attend the course, reasons for not participating in the study and individual preferences for course scheduling.

Results. Of 1125 individuals assessed, 216 (19%) were unable to attend six ASMP sessions. This was commonly due to physical limitations, including illness, restricted mobility and pain (22%), difficulty getting to or from courses (22%), work commitments (22%), the time commitment required (17%) and family roles (12%). Among those who did not want to participate in the study (n = 258), the overwhelming reason was disinterest (74%). Specific preferences for course scheduling were frequent, confirming the practical challenges faced in organizing courses for the RCT.

Conclusion. Incorporating patients from public and private settings, this study has elicited new insights into barriers to ASMP participation. Many people with hip or knee OA have limited capacity and motivation to attend community-based group programmes. Future self-management programmes and research should include more accessible options for those who cannot attend group-based programmes.

Complexity of management and health outcomes in a prospective cohort study of 573 heart failure patients in Australia : does more equal less?

Aims and objectives : To compare the efficacy of chronic heart failure management programmes (CHF-MPs) according to a scoring algorithm used to quantify the level of applied interventions–the Heart Failure Intervention Score (HF-IS).

Background : The overall efficacy of heart failure programmes has been proven in several meta-analyses. However, the debate continues as to which components are essential in a heart failure programme to improve patient outcomes.

Design : Prospective cohort study of patients participating in heart failure programmes.

Method : Forty-eight of 62 (77%) programmes in Australia participating in a national register of CHF-MPs were evaluated using the HF-IS: derived from a summed and weighted score of each intervention applied by the CHF-MP (27 interventions overall). The CHF-MPs were prospectively categorised as relatively low (HF-IS < 190 – n = 39 programmes & 407 patients) or high (HF-IS ≥ 190 – n = 9 programmes & 166 patients) in complexity. Six-month morbidity and mortality rates in 573 consecutively recruited patients with systolic dysfunction and in New York Heart Association Class II–IV were prospectively examined.

Results : Patients exposed to CHF-MPs with a high HF-IS had a lower rate of unplanned, all-cause hospitalisation (n = 24, 14% vs. n = 102, 25%) compared with CHF-MPs with a low HF-IS within six months. On an adjusted basis, CHF-MPs with a high HF-IS were associated with a reduced risk of unplanned hospitalisation and/or death within six months and remained event-free longer.

Conclusion : High complexity CHF-MPs applying more evidence-based interventions are associated with a higher event-free survival over six months.

Relevance to clinical practice : The HF-IS is an easy-to-use evidence-based tool to assist programme coordinators to improve the quality of their heart failure programme which may also improve patient outcomes.

Diet and physical activity in the self-management of type 2 diabetes: barriers and facilitators identified by patients and health professionals

Aim: 

Just call me dad: health and social benefits to fathers and their children

In the past 20 years, social change and expectations for both maternal and paternal responsibilities have highlighted the need for services for families to better understand the role of a father in family relationships. In Australia, as well as internationally, there have been many contested understandings about what constitutes ‘good fathering’ in research, social media and in the political sphere. More specifically, there has also been an emerging trend to understand the challenging task of recruiting and maintaining men's involvement in child and family services programmes, particularly those fathers who are deemed a risk to children and mothers, violent or have been separated from their children. That many child and family/welfare services have exercised dedicated effort to work with fathers is still a relatively recent phenomenon, and has only emerged following criticism that services have been too geared towards working only with mothers. Despite this increasing interest, there is still ongoing need for more research to be undertaken in Australia. An important area of focus is the views of professionals about their perception and engagement of fathers, particularly the views of fathers who are described as being absent from family-based services. The purpose of this article is to report briefly on a study undertaken to examine how child and family welfare workers engage fathers in their work. First, this paper will describe some of the social and health benefits to fathers and their children, focusing on the key role of attachment through play. Research into effective service delivery involving fathers will then be presented, concluding with key practice factors necessary for fathers to be involved in family life.

Feasibility, acceptability and potential effectiveness of a mobile health (mHealth) weight management programme for New Zealand adults

Background
Mobile health (mHealth) behaviour change programmes use mobile phones and the internet to deliver health information and behaviour change support to participants. Such programmes offer a potentially cost-effective way to reach many individuals who do not currently access weight loss services. We developed a mHealth weight management programme using proven face-to-face behaviour change techniques and incorporating target population input. Our aim was to evaluate the feasibility, acceptability and potential effectiveness of this programme for ethnically diverse adults with a view to informing a larger trial.

Results
Fifty three adults who had a BMI of ≥25 kg/m2 and wanted to lose weight (81% female, mean age 42 years, mean BMI 35.7 kg/m2, 26% Maori, 34% Pacific) received the eight-week mHealth weight loss programme. Anthropometric measures were taken at two face-to-face assessments at baseline and 12-weeks (i.e. four weeks after cessation of intervention).

Twelve-week follow-up measurements were available for 36/53 participants (68%). Non-completers were younger and more likely to be male and of Pacific ethnicity. Thirty five participants (66%) reported reading ‘all or most’ text messages sent and 96% responded to at least one text data collection question over the eight-week active intervention period. Eighty one per cent of participants logged in to the study website at least once during the eight-week study period. In the intention-to-treat analysis, mean weight change was -1.0 kg (SD 3.1) at 12 weeks (p = 0.024) and change in BMI was -0.34 kg/m2 (SD 1.1) (p = 0.026). In the completers only analysis (n = 36), mean weight change was -1.4 kg (SD 3.6) (p = 0.023) and change in BMI was -0.50 kg/m2 (SD 1.3) (p = 0.025).

Conclusions
A mHealth weight management programme is feasible to deliver to an ethnically diverse population. Changes in body weight and BMI at 12 weeks indicate that the programme could be effective in supporting people with weight loss. However, the high dropout rate indicates a need for further improvements to the programme.

Assessing and intervening on OSH programmes : effectiveness evaluation of the Wellworks-2 intervention in 15 manufacturing worksites

To develop a transparent and broadly applicable method for assessing occupational safety and health (OSH) programmes or management systems; (2) to assess OSH programmes in a sample of manufacturing worksites; and (3) to determine whether a management focused occupational health intervention results in greater improvement in OSH programmes compared to minimal intervention controls. OSH programmes were assessed using an adaptation of the US Occupational Safety & Health Administration's 1995 Program Evaluation Profile. Scores were generated from 91 binary indicator variables grouped under four "Essential Elements". Essential Element scores were weighted to contribute to an overall programme score on a 100 point scale. Seventeen large manufacturing worksites were assessed at baseline; 15 sites completed the 16 month intervention and follow up assessments. There was considerable variation in Essential Element scores across sites at baseline as judged by our instrument, particularly in "management commitment and employee participation" and "workplace analysis". Most sites scored highly on "hazard prevention and control" and "training and education". For overall OSH programme scores, most sites scored in the 60-80% range at baseline, with four sites scoring below 60%, suggesting weak programmes. Intervention sites showed greater improvements than controls in the four programme elements and in overall programme scores, with significantly greater improvements in "management commitment and employee participation". The OSH programme assessment method used is broadly applicable to manufacturing work settings, and baseline profiles suggest needs for improvement in OSH programmes in most such worksites. Despite a small sample size, results showed that sustained management focused intervention can result in improvement in these OSH programme measures.