Using a co-design process to develop an integrated model of care for delivering self-management intervention to multi-morbid COPD people in rural Nepal.

BACKGROUND: People with chronic obstructive pulmonary disease (COPD) in Nepal are not receiving adequate support to self-manage their chronic conditions, and primary health care can play a key role in the effective management of these. In this study, we aimed to develop a model of care, using a co-design approach, for delivering evidence-based biomedical and psycho-social care to support self-management for people with multi-morbid COPD in rural Nepal. METHODS: A co-design approach, guided by the five stages of the design thinking model, was used for this study. Layering on "empathize" and "define" phases, we ideated a model of care that was further refined in a "prototype" stage, which included a series of consultative meetings and a 1-day co-design workshop with stakeholders. This co-design process involved a wide range of stakeholders from Nepal, including people with COPD and their families, community representatives, local government representatives, primary care practitioners, community health workers, policymakers, state-level government representatives and academics. RESULTS: Through our co-design approach, a model of integrated care for delivering evidence-based biomedical and psycho-social care to support self-management for people with multi-morbid COPD was designed. The integrated model of care included: screening of the community members aged > 40 years or exhibiting symptoms for COPD and management of symptomatic patients within primary health care, establishing referral pathways for severe cases to and from secondary/tertiary-level health care and establishing a community-based support system. It involved specific roles for community health workers, patients and their caregivers and community representatives. It was built on existing services and programmes linking primary health care centres and tertiary-level health facilities. CONCLUSION: The co-design approach is different from the currently dominant approach of rolling out models of care, which were designed elsewhere with minimal community engagement. In our study, the co-design approach was found to be effective in engaging various stakeholders and in developing a model of care for rural Nepal. This grassroots approach is more likely to be acceptable, effective and sustainable in rural Nepal. Further research is required to test the effectiveness of an integrated model of care in delivering self-management support for people with multi-morbid COPD in rural Nepal.

Socio-demographic characteristics, lifestyle factors, multi-morbid conditions and depressive symptoms among Nepalese older adults.

BACKGROUND: Depressive symptoms (DS) are a well-recognized public health problem across the world. There is limited evidence with regard to DS and its associates, such as socio-demographic characteristics, lifestyle factors and chronic conditions in low-income countries like Nepal. In this study, we aimed to assess the level of DS and its relationship with socio-demographic characteristics, lifestyle factors and chronic disease conditions among community dwelling older people in Nepal. METHODS: We conducted a cross-sectional study of 794 older adults aged 60 or above residing in the rural setting of the Sunsari and Morang districts of eastern Nepal between January and April 2018. Multi-stage cluster sampling was adopted to select the study participants. Data included socio-demographics, lifestyle factors, self-reported chronic disease conditions and the Geriatric depression scale. On Geriatric depression scale, an older adult with a test score greater than five were defined as having depressive symptoms. Determinants of DS were estimated through the generalized estimating equation (GEE) approach by considering exchangeable correlation structure among clusters. RESULTS: In our study samples, nearly 55.8% of the older adults were found to be suffering from DS. We found a significant association between DS and being female (aOR: 1.25, 95% CI: 0.89-2.09), Buddhism (aOR: 1.95, 95% CI: 1.58-2.42), Dalits (aOR: 2.60, 95% CI: 1.19-5.65), unemployed, low family income (aOR: 1.77, 95% CI: 1.07-2.92), smokers (aOR: 1.49, 95% CI: 1.01-2.20) and having chronic multi-morbid conditions (aOR: 1.67, 95% CI: 1.09-2.55). CONCLUSIONS: The prevalence of DS was high among community-dwelling older adults in eastern Nepal. Our findings suggest the need for mental health prevention and management programs targeting the older population in rural Nepal.

What do consumers with chronic conditions expect from their interactions with general practitioners? A qualitative study of Australian consumer and provider perspectives.

BACKGROUND: More than half of Australian adults manage one or more chronic conditions through ongoing interactions with general practitioners (GPs). Their experience of general practice interactions has important implications for their health outcomes and is thus important to explore in-depth. Consumer expectations have emerged as a key consideration in this regard. How well they met in care settings can inform consumers' satisfaction and response to the care received. However, consumer expectations in Australian general practice are not well researched. OBJECTIVE: To identify key consumer expectations in clinical interactions in Australian general practice based on consumer and GP perspectives. DESIGN: Qualitative, phenomenological approach using thematic analysis of semi-structured interviews. SETTING AND PARTICIPANTS: Thirty-one participants: 18 patients with one or more chronic (persisting > 6 months) conditions, 10 GPs and 3 GP registrars in Sydney, Australia. RESULTS: Consumer expectations were strongly related to the context of their ongoing therapeutic relationship with a regular GP. Themes relating to some of the most commonly reported consumer expectations were as follows: (a) the importance of longevity and continuity; (b) having good rapport; (c) GP's respect for consumer opinions and expertise; (d) having effective communication; and (e) addressing mental health. CONCLUSION: Australian GPs and consumers prioritize a positive, long-term clinical relationship in which they respect one another and can communicate their expectations freely. This has implications for consumer satisfaction and in turn ensuring relational continuity, which is particularly relevant to the ongoing care and management of consumers with chronic conditions.

Self-management practice, associated factors and its relationship with health literacy and patient activation among multi-morbid COPD patients from rural Nepal.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a progressive and debilitating condition that affects individuals' quality of life. COPD self-management and supports provided by carers is key to the quality of life people living with COPD. Health literacy (HL) and Patient Activation (PA) are main drivers of self-management practices (SMPs). However, their contribution remains to be fully explored. This study aimed to examine the level of self-management practices, and the relationship with socio-demographic factors, HL and PA among multi-morbid COPD patients from rural Nepal. METHODS: This is a cross-sectional study conducted between July 2018 and January 2019. Patients completed a survey, including Self-management Practices questionnaire (SMPQ), five domains of the Health Literacy Questionnaire (HLQ), and Patient Activation Measure (PAM). The relationship between HL, PAM, and SMPs was examined using univariate statistics. Multivariable analysis was conducted to identify the factors associated with SMPs. RESULTS: A total of 238 patients responded to the study. The mean score of SMPQ was 45.31(SD = 9.00). The HLQ and PAM scores were positively correlated with the total score of SMPQ. Low level of SMPs were found to be positively associated with being uneducated (ß = - 0.43, p = .001), having a low family income (ß = - 5.22, p = .002), and, negatively associated with the presence of more than one co-morbidity (ß = 3.58, p = 0.007) after controlling for other socio-demographic variables in the multivariable analysis. CONCLUSION: The overall SMPs among this sample of Nepalese with COPD were low. Our findings highlight the need to implement a self-management intervention program involving patient activation and health literacy-focused activities for COPD, creating a support system for patients from low-income families and low education.

Prevalence and determinants of frailty in the absence of disability among older population: a cross sectional study from rural communities in Nepal.

BACKGROUND: Longevity and frailty have significant implications for healthcare delivery. They increase demands for healthcare service and surge risk of hospitalization. Despite gaining global attention, determinants of frailty have remained unmeasured in the rural community settings in Nepal. This study aimed to address this gap by accessing the prevalence and determinants of frailty in the absence of disability among older population living in rural communities in eastern Nepal. METHODS: We conducted a cross-sectional analytical study of 794 older adults aged ≥60 living in the rural part of Sunsari and Morang district of eastern Nepal between January and April in 2018. Multi-stage cluster sampling was applied to recruit the study participants. Study measures included socio-demographics; Frail Non-disabled scale (FiND) measuring frailty, Barthel's Index measuring basic activities of daily living and Geriatric depression scale. Determinants of frailty in the absence of disability were identified using generalized estimating equation (GEE). RESULTS: About 65% of the participants self-reported the presence of frailty in the absence of disability. In the adjusted models, those from underprivileged ethnic groups, lack of daily physical exercise, presence of depressive symptoms and those not getting enough social support from family were found to be significantly associated with frailty among older participants. CONCLUSIONS: The prevalence of frailty in the absence of disability was high among rural community old population living in eastern Nepal. Our findings suggest that need of frailty awareness (both for clinicians and general public), so as to avoid negative consequences. To reduce the healthcare burden early screening frailty in primary care has potentials to prevent implications of frailty in Nepal.

Do general practice management and/or team care arrangements reduce avoidable hospitalisations in Central and Eastern Sydney, Australia?

BACKGROUND: The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management program was introduced to Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The program supports General Practitioners (GP)s claiming for up to one general practice management plan (GPMP) and one team care arrangement (TCA) every year and the patient claiming for up to five private allied health visits. We describe the profile of participants who claimed for GPMPs and/or TCAs in Central and Eastern Sydney (CES) and explore if GPMPs and/or TCAs are associated with fewer emergency hospitalisations (EH)s or potentially preventable hospitalisations (PPH)s over the following 5 years. METHODS: This research used the CES Primary and Community Health Cohort/Linkage Resource (CES-P&CH) based on the 45 and Up Study to identify a community-dwelling population in the CES region. There were 30,645 participants recruited within the CES area at baseline. The CES-P&CH includes 45 and Up Study questionnaire data linked to MBS data for the period 2006-2014. It also includes data from the Admitted Patient Data Collection, Emergency Department Data Collection and Deaths Registry linked by the NSW Centre for Health Record Linkage. RESULTS: Within a two-year health service utilisation baseline period 22% (5771) of CES participants had at least one claim for a GPMP and/or TCA. Having at least one claim for a GPMP and/or TCA was closely related to the socio-demographic and health needs of participants with higher EHs and PPHs in the 5 years that followed. However, after controlling for confounding factors such as socio-demographic need, health risk, health status and health care utilization no significant difference was found between having claimed for a GPMP and/or TCA during the two-year health service utilisation baseline period and EHs or PPHs in the subsequent 5 years. CONCLUSIONS: The use of GPMPs and/or TCAs in the CES area appears well-targeted towards those with chronic and complex care needs. There was no evidence to suggest that the use of GPMPs and /or TCAs has prevented hospitalisations in the CES region.

What matters to people with chronic conditions when accessing care in Australian general practice? A qualitative study of patient, carer, and provider perspectives.

BACKGROUND: Research underpinning the patient experience of people with chronic conditions in Australian general practice is not well developed. We aimed to ascertain the perspectives of key stakeholders on aspects of patient experience, more specifically with regards to accessing general practice in Australia. METHODS: Using a qualitative design, semi-structured interviews were conducted by telephone and face-to-face with people living with one or more chronic conditions, informal carers, and primary care providers between October 2016 and October 2017. Participants were recruited and selected from three demographically representative primary health networks across Sydney, Australia. Interview transcripts and researcher's reflective fieldnotes were coded and analyzed for key themes of access. Analysis and interpretation of data were guided by Levesque's model of access, a conceptual framework to evaluate access broadly and from corresponding patient- and provider-side dimensions. RESULTS: A total of 40 interviews were included in the analysis. Most participants had attended their general practices for 10 years or more and had regular primary care providers. People with chronic conditions reported access barriers predominantly in their ability to reach services, which were related to illness-related disabilities (limited mobility, chronic pain, fatigue, frailty) and limitations in the availability and accommodation of health services to address patient preferences (unavailability of after-hours services, lack of alternative modes of service delivery). While cost was not a major barrier, we found a lack of clarity in the factors that determined providers' decisions to waive or reduce costs for some patients and not others. CONCLUSIONS: People managing chronic conditions with a long-term primary care provider experienced access barriers in general practice, particularly in their ability to physically reach care and to do so on a timely basis. This study has important policy and practice implications, as it highlights patients' experiences of accessing care and possible areas for improvement to appropriately respond to these experiences. Themes identified may be useful in the design of a patient experience survey tool specific to this population. While it incorporates perspectives from patients, carers and providers, this study could be further strengthened by including perspectives from culturally and linguistically underrepresented patient groups and more carers.

How health literacy and patient activation play their own unique role in self-management of chronic obstructive pulmonary disease (COPD)?

Current evidence indicates that although they are correlated, health literacy (HL) and patient activation (PA) are distinct. This article describes how HL, PA and their determinants intersect and diverge and how these concepts might inform the development of self-management interventions. The concepts of HL and PA contribute to self-management interventions in different ways. HL includes the skills and confidence required for self-management while PA focuses more on motivation and ability to take action. In this light, communication of concepts on HL and PA needs to be more widely understood by academics, researchers and policy experts as each of them plays a unique role in promoting self-management for long-term conditions such as chronic obstructive pulmonary disease.

Content analysis of nutritional information in paediatric oral health education leaflets.

BACKGROUND: The aim of this study was to determine if paediatric oral health education leaflets with a food and nutritional focus provide messages that are clear and consistent with the current Australian Dietary Guidelines and the Infant Feeding Guidelines. METHODS: Forty-three leaflets aimed at parents were sourced from Australian state and territory Health Departments, oral health industry partners and commercial organisations, and a content analysis was performed. Recommendations on food and drink type, consumption frequency and general diet and nutrition advice were considered and cross-referenced with the Australian Dietary Guidelines and the Infant Feeding Guidelines to identify areas of consistency and discrepancy. RESULTS: Twenty leaflets recommended reducing the consumption of sugary and/or acidic food, while 23 leaflets recommended reducing the consumption of sugary and/or acidic drinks. The majority of the leaflets advised water (n = 35) and milk (n = 23) to drink. Although 33 leaflets encouraged a healthy diet, seven of these did not specify what a healthy diet was. Twenty-eight leaflets provided early childhood-related (0-2 years) feeding advice. Confusing messages were found in nine leaflets, with ambiguous recommendations that were open to individual interpretation. CONCLUSIONS: There were some inconsistencies between the leaflets and the dietary and infant feeding guidelines in Australia; and across the leaflets, as not all important messages were included in any one leaflet. Government Health Departments and other relevant agencies should ensure that advisory messages regarding diet, particularly those with dental implications, are clear, complete and consistent across all dental educational leaflets.

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.

An explorative qualitative study on acceptability of physical activity assessment instruments among primary care professionals in southern Sydney.

BACKGROUND: There are a substantial number of instruments for primary-care clinicians to assess physical-activity (PA). However, there are few studies that have explored the views of clinicians regarding comparative acceptability and ease of use. A better understanding of how clinicians perceive instruments could help overcome barriers, and inform future interventions. This study explored the acceptability of five PA-assessment instruments amongst a sample of Australian primary-care clinicians, including family-physicians (FP) and practice-nurses (PN). METHODS: A purposive sample of FPs (N = 9) and PNs (N = 10) from eight family-practices in southern Sydney consented to participate. Stage-1 involved semi-structured interviews with participants to select preferred instruments. An analysis of the two preferred instruments was conducted as Stage-2, to identify differences in instrument purpose and content. Stage-3 involved participants using the two instruments, selected from Stage-1, for 12-weeks. At the end of this period, semi-structured interviews were repeated to explore clinician experience. RESULTS: Clinicians indicated preferences for the GP-Physical-Activity-Questionnaire and 3-Questionnaire Physical-Activity-Questionnaire. These instruments demonstrated distinct variations in content, theoretical orientation, and outcome measures. Reasons for preference included; variations in individual clinician PA levels, knowledge in PA-assessment and instrument features. CONCLUSION: Findings demonstrated two instruments as preferred. Reasons for preference related to internal characteristics of clinicians such as variations in the level of individual PA and external circumstances, such as instrument features.

Impact of diabetes on hospital admission and length of stay among a general population aged 45 year or more: a record linkage study.

BACKGROUND: The increased prevalence of diabetes and its significant impact on use of health care services, particularly hospitals, is a concern for health planners. This paper explores the risk factors for all-cause hospitalisation and the excess risk due to diabetes in a large sample of older Australians. METHODS: The study population was 263,482 participants in the 45 and Up Study. The data assessed were linked records of hospital admissions in the 12 months following completion of a baseline questionnaire. All cause and ambulatory care sensitive admission rates and length of stay were examined. The associations between demographic characteristics, socioeconomic status, lifestyle factors, and health and wellbeing and risk of hospitalisation were explored using zero inflated Poisson (ZIP) regression models adjusting for age and gender. The ratios of adjusted relative rates and 95% confidence intervals were calculated to determine the excess risk due to diabetes. RESULTS: Prevalence of diabetes was 9.0% (n = 23,779). Age adjusted admission rates for all-cause hospitalisation were 631.3 and 454.8 per 1,000 participant years and the mean length of stay was 8.2 and 7.1 days respectively for participants with and without diabetes. In people with and without diabetes, the risk of hospitalisation was associated with age, gender, household income, smoking, BMI, physical activity, and health and wellbeing. However, the increased risk of hospitalisation was attenuated for participants with diabetes who were older, obese, or had hypertension or hyperlipidaemia and enhanced for those participants with diabetes who were male, on low income, current smokers or who had anxiety or depression. CONCLUSIONS: This study is one of the few studies published to explore the impact of diabetes on hospitalisation in a large non-clinical population, the 45 and Up Study. The attenuation of risk associated with some factors is likely to be due to correlation between diabetes and factors such as age and obesity. The increased risk in association with other factors such as gender and low income in participants with diabetes is likely to be due to their synergistic influence on health status and the way services are accessed.

Development and feasibility of a child obesity prevention intervention in general practice: the Healthy 4 Life pilot study.

AIM: Approximately 20% of Australian pre-school children are overweight. Primary care providers have a crucial role in identifying children at risk of unhealthy weight gain and to offer advice and suggestions to parents. The Healthy 4 Life pilot study aimed to develop and test the feasibility of a practice nurse (PN)-led brief intervention into a healthy kid's check in general practice. METHODS: A PN intervention was developed based on a needs assessment and existing literature. A workshop was conducted, and resources were provided to enable four PNs to deliver a brief obesity prevention intervention to parents. Nurses then incorporated the Healthy 4 Life components into the healthy kid's checks they conducted on the next 10 children. Medical records were reviewed and nurses interviewed to establish the feasibility of the intervention. RESULTS: All of the nurses incorporated some Healthy 4 Life components into their healthy kid's checks. Body mass index was calculated and plotted for all children, and advice around healthy eating was offered in 60% of consultations; however, advice about limiting screen time provided in only 2% of consultations. Nurses reported that the intervention fitted well with their current practice, although time constraints were a concern for some nurses and some parents. CONCLUSION: The provision of a brief training workshop and resources can equip nurses in general practice to offer an obesity prevention intervention to parents of young children. Further research is required to examine the impact of such an intervention on parent and child behaviours and the sustainability of such practices for PNs.

How readable are Australian paediatric oral health education materials?

BACKGROUND: The objective of this study was to analyse the readability of paediatric oral health education leaflets available in Australia. METHODS: Forty paediatric oral health education materials were analysed for general readability according to the following parameters: Thoroughness; Textual framework; Terminology; and Readability (Flesch-Kincaid grade level (FKGL), Gunning Fog index (Fog) and Simplified Measure of Gobbledygook (SMOG)). RESULTS: Leaflets produced by the industry were among the hardest to read with an average readability at the 8th grade (8.4 ± 0.1). The readability of leaflets produced by the commercial sector was at the 7th grade (7.1 ± 1.7) and the government at the 6th grade (6.3 ± 1.9). The FKGL consistently yielded readabilities 2 grades below the Fog and SMOG indexes. In the content analyses, 14 essential paediatric oral health topics were noted and Early Childhood Caries (ECC) was identified as the most commonly used jargon term. CONCLUSION: Paediatric oral health education materials are readily available, yet their quality and readability vary widely and may be difficult to read for disadvantaged populations in Australia. A redesign of these leaflets while taking literacy into consideration is suggested.

Exploring organisational readiness to implement a preventive intervention in Australian general practice for overweight and obese patients: key learnings from the HeLP-GP trial.

BACKGROUND: The HeLP-GP trial aimed to increase the capacity of practice nurses to deliver weight management to overweight and obese patients through an intervention comprising a health check, a lifestyle app and/or telephone coaching. This paper describes implementation through the lens of organisational readiness with emphasis on the role of the practice nurse. METHODS: Routinely collected mixed method research data including practice surveys, field notes, and diaries and process data were mapped against the domains: motivation to implement, general capacity and intervention-specific capacity. RESULTS: Organisational readiness varied considerably, particularly the domain of intervention-specific capacity. Practice nurse turnover negatively impacted the implementation, affecting half of the practices. We observed a general lack of practice-based support for intervention delivery, and varying levels of interest, skill and confidence in delivering the intervention. Nurses struggled to complete the research and intervention tasks in a timely way. Conducting risk assessments and referring to coaching were generally not problematic; however, we noted lower confidence levels with the lifestyle app and instructing patients to use it. CONCLUSIONS: We found a lack of general 'readiness' inherent in the nursing role, particularly related to their capacity to complete intervention tasks and practice-level support to implement the intervention. For nurses in general practice to fulfil their potential in supporting patients to reduce risk and adopt healthier life choices, our study indicates that more could be done to improve their workforce positioning and remuneration, which may, in turn, improve continuity of care, retention and individual motivation.

Validating self-report of diabetes use by participants in the 45 and Up Study: a record linkage study.

BACKGROUND: Prevalence studies usually depend on self-report of disease status in survey data or administrative data collections and may over- or under-estimate disease prevalence. The establishment of a linked data collection provided an opportunity to explore the accuracy and completeness of capture of information about diabetes in survey and administrative data collections. METHODS: Baseline questionnaire data at recruitment to the 45 and Up Study was obtained for 266,848 adults aged 45 years and over sampled from New South Wales, Australia in 2006-2009, and linked to administrative data about hospitalisation from the Admitted Patient Data Collection (APDC) for 2000-2009, claims for medical services (MBS) and pharmaceuticals (PBS) from Medicare Australia data for 2004-2009. Diabetes status was determined from response to a question 'Has a doctor EVER told you that you have diabetes' (n = 23,981) and augmented by examination of free text fields about diagnosis (n = 119) or use of insulin (n = 58). These data were used to identify the sub-group with type 1 diabetes. We explored the agreement between self-report of diabetes, identification of diabetes diagnostic codes in APDC data, claims for glycosylated haemoglobin (HbA1c) in MBS data, and claims for dispensed medication (oral hyperglycaemic agents and insulin) in PBS data. RESULTS: Most participants with diabetes were identified in APDC data if admitted to hospital (79.3%), in MBS data with at least one claim for HbA1c testing (84.7%; 73.4% if 2 tests claimed) or in PBS data through claim for diabetes medication (71.4%). Using these alternate data collections as an imperfect 'gold standard' we calculated sensitivities of 83.7% for APDC, 63.9% (80.5% for two tests) for MBS, and 96.6% for PBS data and specificities of 97.7%, 98.4% and 97.1% respectively. The lower sensitivity for HbA1c may reflect the use of this test to screen for diabetes suggesting that it is less useful in identifying people with diabetes without additional information. Kappa values were 0.80, 0.70 and 0.80 for APDC, MBS and PBS respectively reflecting the large population sample under consideration. Compared to APDC, there was poor agreement about identifying type 1 diabetes status. CONCLUSIONS: Self-report of diagnosis augmented with free text data indicating diabetes as a chronic condition and/or use of insulin among medications used was able to identify participants with diabetes with high sensitivity and specificity compared to available administrative data collections.

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.

The burden of non-disabled frailty and its associated factors among older adults in Bangladesh.

OBJECTIVE: The present study aims to measure the prevalence of non-disabled frailty and its associated factors among Bangladeshi older adults. METHODS: This cross-sectional study was conducted during September and October 2021 among 1,045 Bangladeshi older adults (≥60 years). Telephone interviews, using a semi-structured questionnaire, were undertaken to collect data on participants' characteristics and level of frailty. The non-disabled frailty was measured using the 'Frail Non-Disabled (FiND)' questionnaire. A multinomial logistic regression model assessed the factors associated with frailty among the participants. RESULTS: Around a quarter of the participants (24.8%) were frail. The multinomial regression analysis showed that older participants aged ≥80 years (RRR = 3.23, 95% CI: 1.41-7.37) were more likely to be frail compared to participants aged 60-69 years. Likewise, the participants living in a large family with ≥4 members (RRR = 1.39, 95% CI: 1.01-1.92) were more likely to be frail compared to those living in smaller families. Also, participants having memory or concentration problems (RRR = 1.56, 95% CI: 1.12-2.17) were more likely to be frail compared to those who were not suffering from these problems. Moreover, participants whose family members were non-responsive to their day-to-day assistance (RRR = 1.47, 95% CI: 1.06-2.03) were more likely to be frail compared to those whose family members were responsive. Furthermore, participants who were feeling lonely (RRR = 1.45, 95% CI: 1.07-1.98) were more likely to be frail than their counterparts who were not feeling lonely. CONCLUSIONS: The findings of the present study suggest developing tailored interventions to address the burden of frailty among the older populations in Bangladesh. In particular, providing long-term care and health promotion activities can be of value in preventing frailty and reducing adverse health outcomes among this vulnerable population group.

Access to preventive care by immigrant populations.

Many immigrant populations lack access to primary health care. A recently published study on cholesterol screening among immigrant populations in the US found disparities in cholesterol screening in those originating from Mexico, largely due to limited access to healthcare. This inverse care affects immigrants in many destination countries despite their greater health need.Please see related article: http://www.equityhealthj.com/content/11/1/22.