Predictors of weight stigma experienced by middle-older aged, general-practice patients with obesity in disadvantaged areas of Australia: a cross-sectional study.

BACKGROUND: Rates of obesity have increased globally and weight stigma is commonly experienced by people with obesity. Feeling stigmatised because of one's weight can be a barrier to healthy eating, physical activity and to seeking help for weight management. The aim of this study was to identify predictors of perceived weight among middle-older aged patients with obesity attending general practices in socioeconomically disadvantaged urban areas of Australia. METHODS: As part of a randomised clinical trial in Australia, telephone interviews were conducted with 120 patients from 17 general practices in socioeconomically disadvantaged of Sydney and Adelaide. Patients were aged 40-70 years with a BMI ≥ 30 kg/m2. The interviews included questions relating to socio-demographic variables (e.g. gender, language spoken at home), experiences of weight-related discrimination, and the Health Literacy Questionnaire (HLQ). Multi-level logistic regression data analysis was undertaken to examine predictors of recent experiences of weight-related discrimination ("weight stigma"). RESULTS: The multi-level model showed that weight stigma was positively associated with obesity category 2 (BMI = 35 to < 40; OR 4.47 (95% CI 1.03 to 19.40)) and obesity category 3 (BMI = ≥ 40; OR 27.06 (95% CI 4.85 to 150.95)), not being employed (OR 7.70 (95% CI 2.17 to 27.25)), non-English speaking backgrounds (OR 5.74 (95% CI 1.35 to 24.45)) and negatively associated with the HLQ domain: ability to actively engage with healthcare providers (OR 0.12 (95% CI 0.05 to 0.28)). There was no association between weight stigma and gender, age, education or the other HLQ domains examined. CONCLUSIONS: Weight stigma disproportionately affected the patients with obesity most in need of support to manage their weight: those with more severe obesity, from non-English speaking backgrounds and who were not in employment. Additionally, those who had experienced weight stigma were less able to actively engage with healthcare providers further compounding their disadvantage. This suggests the need for a more proactive approach to identify weight stigma by healthcare providers. Addressing weight stigma at the individual, system and population levels is recommended. TRIAL REGISTRATION: The trial was registered with the Australian Clinical Trials Registry ACTRN126400102162 .

An Australian general practice based strategy to improve chronic disease prevention, and its impact on patient reported outcomes: evaluation of the preventive evidence into practice cluster randomised controlled trial.

BACKGROUND: Implementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care. METHODS: PEP Intervention practices received education, clinical audit and feedback and practice facilitation. Patients (40­69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires. Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar's test and multilevel analysis was used to determine the effect of the intervention on follow-up scores. RESULTS: Five hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes. CONCLUSIONS: The lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012.

The impact of health literacy and life style risk factors on health-related quality of life of Australian patients.

BACKGROUND: Limited evidence exists regarding the relationship between health literacy and health-related quality of life (HRQoL) in Australian patients from primary care. The objective of this study was to investigate the impact of health literacy on HRQoL in a large sample of patients without known vascular disease or diabetes and to examine whether the difference in HRQoL between low and high health literacy groups was clinically significant. METHODS: This was a cross-sectional study of baseline data from a cluster randomised trial. The study included 739 patients from 30 general practices across four Australian states conducted in 2012 and 2013 using the standard Short Form Health Survey (SF-12) version 2. SF-12 physical component score (PCS-12) and mental component score (MCS-12) are derived using the standard US algorithm. Health literacy was measured using the Health Literacy Management Scale (HeLMS). Multilevel regression analysis (patients at level 1 and general practices at level 2) was applied to relate PCS-12 and MCS-12 to patient reported life style risk behaviours including health literacy and demographic factors. RESULTS: Low health literacy patients were more likely to be smokers (12 % vs 6 %, P = 0.005), do insufficient physical activity (63 % vs 47 %, P < 0.001), be overweight (68 % vs 52 %, P < 0.001), and have lower physical health and lower mental health with large clinically significant effect sizes of 0.56 (B (regression coefficient) = -5.4, P < 0.001) and 0.78(B = -6.4, P < 0.001) respectively after adjustment for confounding factors. Patients with insufficient physical activity were likely to have a lower physical health score (effect size = 0.42, B = -3.1, P < 0.001) and lower mental health (effect size = 0.37, B = -2.6, P < 0.001). Being overweight tended to be related to a lower PCS-12 (effect size = 0.41, B = -1.8, P < 0.05). Less well-educated, unemployed and smoking patients with low health literacy reported worse physical health. Health literacy accounted for 45 and 70 % of the total between patient variance explained in PCS-12 and MCS-12 respectively. CONCLUSIONS: Addressing health literacy related barriers to preventive care may help reduce some of the disparities in HRQoL. Recognising and tailoring health related communication to those with low health literacy may improve health outcomes including HRQoL in general practice.

Implementing guidelines to routinely prevent chronic vascular disease in primary care: the Preventive Evidence into Practice cluster randomised controlled trial.

OBJECTIVE: To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease. SETTING: 32 urban general practices in 4 Australian states. RANDOMISATION: Stratified randomisation of practices. PARTICIPANTS: 122 general practitioners (GPs) and practice nurses (PNs) were recruited at baseline and 97 continued to 12 months. 21,848 patient records were audited for those aged 40-69 years who attended the practice in the previous 12 months without heart disease, stroke, diabetes, chronic renal disease, cognitive impairment or severe mental illness. INTERVENTION: The practice level intervention over 6 months included small group training of practice staff, feedback on audited performance, practice facilitation visits and provision of patient education and referral information. OUTCOME MEASURES: Primary: 1. Change in proportion of patients aged 40-69 years with smoking status, alcohol intake, body mass index (BMI), waist circumference (WC), blood pressure (BP) recorded and for those aged 45-69 years with lipids, fasting blood glucose and cardiovascular risk in the medical record. 2. Change in the level of risk for each factor. SECONDARY: change in self-reported frequency and confidence of GPs and PNs in assessment. RESULTS: Risk recording improved in the intervention but not the control group for WC (OR 2.52 (95% CI 1.30 to 4.91)), alcohol consumption (OR 2.19 (CI 1.04 to 4.64)), smoking status (OR 2.24 (1.17 to 4.29)) and cardiovascular risk (OR 1.50 (1.04 to 2.18)). There was no change in recording of BP, lipids, glucose or BMI and no significant change in the level of risk factors based on audit data. The confidence but not reported practices of GPs and PNs in the intervention group improved in the assessment of some risk factors. CONCLUSIONS: This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000578808, results.

Prognostic value of the lymph node ratio for lymph-node-positive breast cancer- is it just a denominator problem?

PURPOSE: To examine the prognostic value of lymph node ratio (LNR) for patients with node-positive breast cancer with varying numbers of minimum nodes removed (>5, > 10 and > 15 total node count). METHODS: This study examined the original histopathological reports of 332 node-positive patients treated in the state of New South Wales (NSW), Australia between 1 April 1995 and 30 September 1995. The LNR was defined as the number of positive lymph nodes (LNs) over the total number of LNs removed. The LNR cutoffs were defined as low-risk, 0.01-0.20; intermediate-risk, 0.21- 0.65; and high-risk, LNR >0.65. RESULTS: The median follow-up was 10.3 years. In multivariate analysis, LNR was an independent predictor of 10-year breast cancer specific survival when > 5 nodes were removed. However, LNR was not an independent predictor when > 15 nodes were removed. In a multivariate analysis the relative risk of death (RR) decreased from 2.20 to 1.05 for intermediate-risk LNR and from 3.07 to 2.64 for high-risk while P values increased from 0.027 to 0.957 for intermediate-risk LNR and 0.018 to 0.322 for high-risk with the number of nodes removed increasing from > 5 to > 15. CONCLUSIONS: Although LNR is important for patients with low node denominators, for patients with macroscopic nodal metastases in several nodes following an axillary dissection who have more than 15 nodes dissected, the oncologist can be satisfied that prognosis, selection of adjuvant chemotherapy and radiotherapy fields can be based on the numerator of the positive nodes.

Quit in general practice: a cluster randomized trial of enhanced in-practice support for smoking cessation.

OBJECTIVES: To evaluate the uptake and effectiveness of tailored smoking cessation support, provided primarily by the practice nurse (PN), and compare this to other forms of cessation support. METHODS: Three arm cluster randomized controlled trial conducted in 101 general practices in Sydney and Melbourne involving 2390 smokers. The Quit with PN intervention was compared to Quitline referral and a usual care control group. Smoking cessation pharmacotherapy was recommended to all groups. Outcomes were assessed by self-report at 3- and 12-month follow-up. Uptake of the interventions is also reported. RESULTS: The three groups were similar at baseline. Follow-up at 12 months was 82%. The sustained and point prevalence abstinence rates, respectively, at 3 months by group were: PN intervention 13.1% and 16.3%; Quitline referral 10.8% and 14.2%; Usual GP care 11.4% and 15.0%. At 12 months, the rates were: PN intervention 5.4% and 17.1%; Quitline referral 4.4% and 18.8%; Usual GP care 2.9% and 16.4%. Only 43% of patients in the PN intervention group attended to see the nurse. Multilevel regression analysis showed no effect of the intervention overall, but patients who received partial or complete PN support were more likely to report sustained abstinence [partial support odds ratio (OR) 2.27; complete support OR 5.34]. CONCLUSION: The results show no difference by group on intention to treat analysis. Those patients who received more intensive PN intervention were more likely to quit. This may have been related to patient motivation or an effect of PN led cessation support.

Health worker performance in rural health organizations in low- and middle-income countries: do organizational factors predict non-task performance?

Health worker (HW) performance is a critical issue facing many low- and middle-income countries (LMICs). The aim of this study was to test the effects of factors in the work environment, such as organizational culture and climate, on HW non-task performance in rural health work settings in a LMIC. The data for the study is from a sample of 963 HWs from rural health centres (HCs) in 16 of the 20 provinces in Papua New Guinea. The reliability and validity of measures for organizational citizenship behaviour (OCB), counterproductive work behaviour (CWB) and work climate (WC) were tested. Multilevel linear regression models were used to test the relationship of individual and HC level factors with non-task performance. The survey found that 62 per cent of HCs practised OCB "often to always" and 5 percent practised CWB "often to always". Multilevel analysis revealed that WC had a positive effect on organizational citizenship behaviour (OCB) and a negative effect on CWB. The mediation analyses provided evidence that the relationship between WC and OCB was mediated through CWB. Human resource policies that improve WC in rural health settings would increase positive non-task behaviour and improve the motivation and performance of HWs in rural settings in LMICs.

Changing community health service delivery in economically less-developed rural areas in China: impact on service use and satisfaction.

OBJECTIVE: To evaluate the impact of a model of rural community health service (CHS) on the use and acceptability of primary healthcare services. DESIGN: Quasi-experimental. SETTING: Two adjacent rural counties in China. PARTICIPANTS: 5842 residents in 2009 and 3807 in 2010 from 980 households in 7 intervention townships and 49 villages; 2232 residents in 2009 and 2315 in 2010 from 628 households in 3 comparison townships and 9 villages. All residents were approached to participate, with no significant differences in age or sex between groups. INTERVENTION: Multilevel intervention in 2009 including training rural practitioners, encouraging clinic improvements, providing clinical guidelines, standards and subsidies. DATA COLLECTION: Surveys of community members from randomly sampled households in 2009 and 2010. PRIMARY OUTCOME MEASURES: Satisfaction with and utilisation of outpatient and public health services. ANALYSIS: Factor analysis confirmed two components of satisfaction. Univariate and multilevel analysis was used. RESULTS: Satisfaction scores for intervention county respondents increased from 21.4 (95% CI 21.1 to 21.7) to 22.1 (95% CI 21.7 to 22.4) with no change in comparison area. In multilevel analysis, satisfaction with patient-centred care was associated with chronic disease, shorter waiting times and county. Satisfaction with clinic environment and cost was associated with female gender, shorter waiting times but not county. The proportion of children receiving immunisation in intervention village clinics increased from 42.5% (95% CI 27.9% to 47.1%) to 59.2% (95% CI 53.8% to 64.6%) whereas this decreased in comparison villages (16.5%; 95% CI 10.3% to 22.7% to 6.0%; 95% CI 1.3% to 10.7%). Antenatal visits increased in intervention villages (from 69.0%, 95% CI 65.8% to 73.1% to 75.8%, 95% CI 72.2% to 79.4%) with no change in comparison villages. CONCLUSIONS: Introduction of a CHS model adapted to economically less-developed rural areas was associated with some improvements in satisfaction with care and use of some village-based public health services. Further research is needed to determine its public health impact and application to other areas.

The prognostic value of Ki67 in systemically untreated patients with node-negative breast cancer.

AIM: To evaluate the utility of Ki67 as a prognostic marker in a series of patients with node-negative breast cancer untreated with adjuvant systemic therapy. METHODS: The cohort consisted of 203 cases treated with breast conserving surgery and radiation only; median follow-up was 183 months (range 156-277 months). An immunohistochemical panel of oestrogen receptor (ER), progesterone receptor (PR), cytokeratin (CK)5/6 and Ki67 and human epidermal growth factor 2 in situ hybridization (HER2-ISH) was performed on the tumour samples. Ki67 scores were evaluable in 193/203 patients (95.1%). The primary outcome was breast cancer specific survival (BCSS). RESULTS: Of the cohort, 29 (14.2%) died of breast cancer. A cut off of 10% separated tumours into a 'Ki67-low' (n=70) or 'Ki67-high' group (n=123). The breast cancer specific survival was 97.1% and 77.6% for Ki67-low and Ki67-high groups, respectively. Univariate analysis showed that in this lymph node-negative cohort, the predictors for BCSS were tumour size, Ki67, LVI, age and histological grade 3. Multivariable analysis showed that Ki67 index and lymphovascular space invasion were independent predictors of breast cancer death. To examine the utility of Ki67 in assignment of immunohistochemically molecular subtypes, cases were assigned into Luminal A (ER-positive, HER2-negative, Ki67 ≤14%), Luminal B (ER-positive, HER2-negative, Ki67 >14%) and triple negative (ER/PR-negative and HER2-negative, any Ki67). The 15-year breast cancer specific survival was 91.7%, 79.4% and 75.8%, respectively. CONCLUSIONS: A statistically significant difference in breast cancer specific survival is seen in groups defined using Ki67 and receptor status, whereas histological grading was not a significant predictor of survival. Ki67 immunostaining provides prognostic information beyond traditionally assessed clinicopathological variables.

Influence of cardiovascular absolute risk assessment on prescribing of antihypertensive and lipid-lowering medications: a cluster randomized controlled trial.

BACKGROUND: Guidelines for management of hypertension and lipids recommend using cardiovascular absolute risk (CVAR) to manage patients. This randomized controlled trial investigated the impact of CVAR assessment in family practice on management of cardiovascular risk, including prescription of antihypertensive and lipid-lowering medication. METHODS: A cluster randomized controlled trial was conducted from 2008 to 2010 in Sydney, Australia. Family practices were randomized, and patients aged 45 to 69 years were invited to participate. Intervention family physicians (FP) were trained in use of CVAR, provided with an electronic CVAR calculator, and assessed their patients' absolute risk in a dedicated consultation. Control practice patients received a general health check. Primary outcome analyzed was the proportion of patients in each group on antihypertensive and/or lipid-lowering medication at 12 months. Multilevel logistic regression was performed to explore variables influencing changes in pharmacologic therapy. RESULTS: The study recruited 36 FPs from 34 practices and 1,074 patients, of which 906 (84.4%) completed 12-month follow-up. At 12 months, there was no significant difference between the intervention and control groups in proportion of patients on antihypertensives (31.2% vs 34.3%, P = .31), but control group patients were more likely to be on lipid-lowering medications (30.2% vs 22.7%, P = .01). After multilevel analysis, this difference was not present. Intensification or reduction of pharmacologic therapy was associated with meeting treatment targets for blood pressure and lipids but not with the CVAR or intervention group. CONCLUSIONS: Single-risk factor management remains a strong influence on FP prescribing practices. Shifting to an approach based on CVAR will require more intensive intervention.

Does health literacy affect patients' receipt of preventative primary care? A multilevel analysis.

BACKGROUND: People with limited health literacy are more likely to be socioeconomically disadvantaged and have risk factors for preventable chronic diseases. General practice is the ideal setting to address these inequalities however these patients engage less in preventive activities and experience difficulties navigating health services. This study aimed to compare primary care patients with and without sufficient health literacy in terms of their lifestyle risk factors, and explore factors associated with receiving advice and referral for these risk factors from their GPs. METHODS: A mailed survey of 739 patients from 30 general practices across four Australian states was conducted in 2012. Health literacy was measured using the Health Literacy Management Scale. Patients with a mean score of <4 within any domain were defined as having insufficient health literacy. Multilevel logistic regression was used to adjust for clustering of patients within practices. RESULTS: Patients with insufficient health literacy (n = 351; 48%) were more likely to report being overweight or obese, and less likely to exercise adequately. Having insufficient health literacy increased a patient's chance of receiving advice on diet, physical activity or weight management, and referral to and attendance at lifestyle modification programs. Not speaking English at home; being overweight or obese; and attending a small sized practice also increased patients' chances of receiving advice on these lifestyle risks. Few (5%, n = 37) of all patients reported being referred to lifestyle modification program and of those around three-quarters had insufficient health literacy. Overweight or obese patients were more likely to be referred to lifestyle modification programs and patients not in paid employment were more likely to be referred to and attend lifestyle programs. CONCLUSION: Patients with insufficient health literacy were more likely to report receiving advice and being referred by GPs to attend lifestyle modification. Although the number of patients referred from this sample was very low, these findings are positive in that they indicate that GPs are identifying patients with low health literacy and appropriately referring them for assistance with lifestyle modification. Future research should measure the effectiveness of these lifestyle programs for patients with low health literacy.

Relevance of the American College of Surgeons Oncology Group Z0011 Trial to breast cancer in the Australian setting.

BACKGROUND: Conventional wisdom suggests that a patient with a positive sentinel node requires a completion axillary clearance to obtain full staging and durable regional control. However, this dictum has been challenged by the recent American College of Surgeons Oncology Group Z0011 Trial demonstrating that women with node-positive breast cancer who underwent sentinel node biopsy only, and were treated with breast conserving surgery and radiation, had equivalent locoregional recurrence and survival rates to those who had a completion axillary clearance. The aim of our study was to determine what the clinical impact of the Z0011 findings might be if patients were managed according to the Z0011 criteria in an Australian teaching hospital setting. METHODS: We performed a retrospective review, using prospectively collected data, of all female patients with breast cancer assessed at the Westmead Breast Cancer Institute in 2010 and identified the subgroup who would potentially have fulfilled all Z0011 criteria. The characteristics and management of this group were compared with node-positive and to mastectomy patient subgroups. RESULTS: A total of 280 patients with invasive breast cancer were identified. Twenty-six patients satisfied all Z0011 criteria, representing 9.3% of all patients and 21.5% of node-positive patients. Twenty-two (84.6%) patients had a subsequent axillary clearance, with six (27.3%) having additional positive nodes. CONCLUSIONS: The Z0011 study is relevant to 9.3% of all breast cancer patients and 21.5% of node-positive breast cancer patients treated in a major Australian teaching hospital.

Analysis of the psychological impact of a vascular risk factor intervention: results from a cluster randomized controlled trial in Australian general practice.

BACKGROUND: Screening for vascular disease, risk assessment and management are encouraged in general practice however there is limited evidence about the emotional impact on patients. The Health Improvement and Prevention Study evaluated the impact of a general practice-based vascular risk factor intervention on behavioural and physiological risk factors in 30 Australian practices. The primary aim of this analysis is to investigate the psychological impact of participating in the intervention arm of the trial. The secondary aim is to identify the mediating effects of changes in behavioural risk factors or BMI. METHODS: This study is an analysis of a secondary outcome from a cluster randomized controlled trial. Patients, aged 40-65 years, were randomly selected from practice records. Those with pre-existing cardiovascular disease were excluded. Socio-demographic details, behavioural risk factors and psychological distress were measured at baseline and 12 months. The Kessler Psychological Distress Score (K10) was the outcome measure for multi-level, multivariable analysis and a product-of-coefficient test to assess the mediating effects of behaviour change. RESULTS: Baseline data were available 384 participants in the intervention group and 315 in the control group. Twelve month data were available for 355 in the intervention group and 300 in the control group. The K10 score of patients in the intervention group (14.78, SD 5.74) was lower at 12 months compared to the control group (15.97, SD 6.30). K10 at 12 months was significantly associated with the score at baseline and being unable to work but not with age, gender, change in behavioural risk factors or change in BMI. CONCLUSIONS: The reduction of K10 in the intervention group demonstrates that a general practice based intervention to identify and manage vascular risk factors did not adversely impact on the psychological distress of the participants. The impact of the intervention on distress was not mediated by a change in the behavioural risk factors or BMI, suggesting that there must be other mediators that might explain the positive impact of the intervention on emotional wellbeing. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12607000423415.

Referral pathways in colorectal cancer: an audit of surgeons's records.

PURPOSE: To explore the referral pathways of patients with newly diagnosed colorectal cancer to surgeons. METHOD: Australian surgeons from three states completed a questionnaire and their records were audited. RESULTS: Thirty-three surgeons provided data on 530 patients seen in the preceding 12 months. The median time between colonoscopy and first surgical consult was 10 days, with 19% of patients waiting more than 28 days. After adjustment for clustering, no surgeon factors were associated with the number of days between colonoscopy and surgery. A report back to the general practitioner (GP) was found in 78% of patients' records. This feedback varied between surgeons but none of the specific surgeon characteristics examined could explain this. CONCLUSION: Surgeons usually communicated with GP regardless of whether they were the referral source. However, communication with GP varied considerably among surgeons, with no evidence of a report to the GP in one-fifth of cases.

Factors influencing participation in a vascular disease prevention lifestyle program among participants in a cluster randomized trial.

BACKGROUND: Previous research suggests that lifestyle intervention for the prevention of diabetes and cardiovascular disease (CVD) are effective, however little is known about factors affecting participation in such programs. This study aims to explore factors influencing levels of participation in a lifestyle modification program conducted as part of a cluster randomized controlled trial of CVD prevention in primary care. METHODS: This concurrent mixed methods study used data from the intervention arm of a cluster RCT which recruited 30 practices through two rural and three urban primary care organizations. Practices were randomly allocated to intervention (n = 16) and control (n = 14) groups. In each practice up to 160 eligible patients aged between 40 and 64 years old, were invited to participate. Intervention practice staff were trained in lifestyle assessment and counseling and referred high risk patients to a lifestyle modification program (LMP) consisting of two individual and six group sessions over a nine month period. Data included a patient survey, clinical audit, practice survey on capacity for preventive care, referral and attendance records at the LMP and qualitative interviews with Intervention Officers facilitating the LMP. Multi-level logistic regression modelling was used to examine independent predictors of attendance at the LMP, supplemented with qualitative data from interviews with Intervention Officers facilitating the program. RESULTS: A total of 197 individuals were referred to the LMP (63% of those eligible). Over a third of patients (36.5%) referred to the LMP did not attend any sessions, with 59.4% attending at least half of the planned sessions. The only independent predictors of attendance at the program were employment status - not working (OR: 2.39 95% CI 1.15-4.94) and having high psychological distress (OR: 2.17 95% CI: 1.10-4.30). Qualitative data revealed that physical access to the program was a barrier, while GP/practice endorsement of the program and flexibility in program delivery facilitated attendance. CONCLUSION: Barriers to attendance at a LMP for CVD prevention related mainly to external factors including work commitments and poor physical access to the programs rather than an individuals' health risk profile or readiness to change. Improving physical access and offering flexibility in program delivery may enhance future attendance. Finally, associations between psychological distress and attendance rates warrant further investigation. TRIAL REGISTRATION: ACTRN12607000423415.

Gender differences in health-related quality of life of Australian chronically-ill adults: patient and physician characteristics do matter.

BACKGROUND: The aims of this study were to explore the health-related quality of life (HRQoL) in a large sample of Australian chronically-ill patients (type 2 diabetes and/or hypertension/ischaemic heart disease), to investigate the impact of characteristics of patients and their general practitioners on their HRQoL and to examine clinically significant differences in HRQoL among males and females. METHODS: This was a cross-sectional study with 193 general practitioners and 2181 of their chronically-ill patients aged 18 years or more using the standard Short Form Health Survey (SF-12) version 2. SF-12 physical component score (PCS-12) and mental component score (MCS-12) were derived using the standard US algorithm. Multilevel regression analysis (patients at level 1 and general practitioners at level 2) was applied to relate PCS-12 and MCS-12 to patient and general practitioner (GP) characteristics. RESULTS: Employment was likely to have a clinically significant larger positive effect on HRQoL of males (regression coefficient (B) (PCS-12) = 7.29, P < 0.001, effect size = 1.23 and B (MCS-12) = 3.40, P < 0.01, effect size = 0.55) than that of females (B(PCS-12) = 4.05, P < 0.001, effect size = 0.78 and B (MCS-12) = 1.16, P > 0.05, effect size = 0.16). There was a clinically significant difference in HRQoL among age groups. Younger men (< 39 years) were likely to have better physical health than older men (> 59 years, B = -5.82, P < 0.05, effect size = 0.66); older women tended to have better mental health (B = 5.62, P < 0.001, effect size = 0.77) than younger women. Chronically-ill women smokers reported clinically significant (B = -3.99, P < 0.001, effect size = 0.66) poorer mental health than women who were non-smokers. Female GPs were more likely to examine female patients than male patients (33% vs. 15%, P < 0.001) and female patients attending female GPs reported better physical health (B = 1.59, P < 0.05, effect size = 0.30). CONCLUSIONS: Some of the associations between patient characteristics and SF-12 physical and/or mental component scores were different for men and women. This finding underlines the importance of considering these factors in the management of chronically-ill patients in general practice. The results suggest that chronically ill women attempting to quit smoking may need more psychological support. More quantitative studies are needed to determine the association between GP gender and patient gender in relation to HRQoL.

The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial).

BACKGROUND: The risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge. METHODS: The study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an 'early intervention' and two to a 'late intervention' group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30-80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques. RESULTS: 804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months. CONCLUSION: The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses. TRIAL REGISTRATION: ACTRN12609001081202.

Effectiveness of Moving On: an Australian designed generic self-management program for people with a chronic illness.

BACKGROUND: This paper presents the evaluation of "Moving On", a generic self-management program for people with a chronic illness developed by Arthritis NSW. The program aims to help participants identify their need for behaviour change and acquire the knowledge and skills to implement changes that promote their health and quality of life. METHOD: A prospective pragmatic randomised controlled trial involving two group programs in community settings: the intervention program (Moving On) and a control program (light physical activity). Participants were recruited by primary health care providers across the north-west region of metropolitan Sydney, Australia between June 2009 and October 2010. Patient outcomes were self-reported via pre- and post-program surveys completed at the time of enrolment and sixteen weeks after program commencement. Primary outcomes were change in self-efficacy (Self-efficacy for Managing Chronic Disease 6-Item Scale), self-management knowledge and behaviour and perceived health status (Self-Rated Health Scale and the Health Distress Scale). RESULTS: A total of 388 patient referrals were received, of whom 250 (64.4%) enrolled in the study. Three patients withdrew prior to allocation. 25 block randomisations were performed by a statistician external to the research team: 123 patients were allocated to the intervention program and 124 were allocated to the control program. 97 (78.9%) of the intervention participants commenced their program. The overall attrition rate of 40.5% included withdrawals from the study and both programs. 24.4% of participants withdrew from the intervention program but not the study and 22.6% withdrew from the control program but not the study. A total of 62 patients completed the intervention program and follow-up evaluation survey and 77 patients completed the control program and follow-up evaluation survey. At 16 weeks follow-up there was no significant difference between intervention and control groups in self-efficacy; however, there was an increase in self-efficacy from baseline to follow-up for the intervention participants (t=-1.948, p=0.028). There were no significant differences in self-rated health or health distress scores between groups at follow-up, with both groups reporting a significant decrease in health distress scores. There was no significant difference between or within groups in self-management knowledge and stage of change of behaviours at follow-up. Intervention group attenders had significantly higher physical activity (t=-4.053, p=0.000) and nutrition scores (t=2.315, p= 0.01) at follow-up; however, these did not remain significant after adjustment for covariates. At follow-up, significantly more participants in the control group (20.8%) indicated that they did not have a self-management plan compared to those in the intervention group (8.8%) (X²=4.671, p=0.031). There were no significant changes in other self-management knowledge areas and behaviours after adjusting for covariates at follow-up. CONCLUSIONS: The study produced mixed findings. Differences between groups as allocated were diluted by the high proportion of patients not completing the program. Further monitoring and evaluation are needed of the impact and cost effectiveness of the program. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12609000298213.

The impact of a team-based intervention on the lifestyle risk factor management practices of community nurses: outcomes of the community nursing SNAP trial.

BACKGROUND: Lifestyle risk factors like smoking, nutrition, alcohol consumption, and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care is an appropriate setting to address these risk factors in individuals. Generalist community health nurses (GCHNs) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time. The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practices of GCHNs. METHODS: The trial used a quasi-experimental design involving four generalist community nursing services in NSW, Australia. The services were randomly allocated to either an intervention group or control group. Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessments and interventions. The control group provided usual care. A sample of 129 GCHNs completed surveys at baseline, 6 and 12 months to examine changes in their practices and levels of confidence related to the management of SNAP risk factors. Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice. RESULTS: Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers. Nurses in the intervention group reported assessing physical activity, weight and nutrition more frequently, as well as providing more brief interventions for physical activity, weight management and smoking cessation. There was little change in referral rates except for an improvement in weight management related referrals. Nurses' perception of the importance of 'client and system-related' barriers to risk factor management diminished over time. CONCLUSIONS: This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practices of GCHNs. Barriers to referral remained. The service model needs to be adapted to sustain these changes and enhance referral. TRIAL REGISTRATION: ACTRN12609001081202.

Preventive evidence into practice (PEP) study: implementation of guidelines to prevent primary vascular disease in general practice protocol for a cluster randomised controlled trial.

BACKGROUND: There are significant gaps in the implementation and uptake of evidence-based guideline recommendations for cardiovascular disease (CVD) and diabetes in Australian general practice. This study protocol describes the methodology for a cluster randomised trial to evaluate the effectiveness of a model that aims to improve the implementation of these guidelines in Australian general practice developed by a collaboration between researchers, non-government organisations, and the profession. METHODS: We hypothesise that the intervention will alter the behaviour of clinicians and patients resulting in improvements of recording of lifestyle and physiological risk factors (by 20%) and increased adherence to guideline recommendations for: the management of CVD and diabetes risk factors (by 20%); and lifestyle and physiological risk factors of patients at risk (by 5%). Thirty-two general practices will be randomised in a 1:1 allocation to receive either the intervention or continue with usual care, after stratification by state. The intervention will be delivered through: small group education; audit of patient records to determine preventive care; and practice facilitation visits adapted to the needs of the practices. Outcome data will be extracted from electronic medical records and patient questionnaires, and qualitative evaluation from provider and patient interviews. DISCUSSION: We plan to disseminate study findings widely and directly inform implementation strategies by governments, professional bodies, and non-government organisations including the partner organisations.