The impact of patient narratives on self-efficacy and self-care in Australians with type 2 diabetes: stage 1 results of a randomized trial.

UNLABELLED: A randomized-controlled trial (RCT) was conducted from September 2009 to June 2011. National Diabetes Services Scheme registrants diagnosed with type 2 diabetes and aged 30-70 years were invited to participate in a 3-week intervention programme with follow-up at 4 weeks and 6 months. Data were collected using self-report questionnaires in the participant's homes. The intervention group received diabetes factsheets and a DVD comprising patient stories (narratives) of type 2 diabetes management. The control group (CG) received factsheets only. The RCT evaluated the impact of patient narratives on the study outcomes, self-efficacy and self-care, using the Aust/English Diabetes Management Self-efficacy Scale and the Summary Diabetes Self-care Activities measure. Participants were randomly assigned to the intervention or CG using block randomization. The study was not blinded. Six hundred and seventy people enrolled into the study with 335 allocated to each group. At 4 weeks, data were available for 598 participants. t-tests were used to analyse the results. The mean difference between the groups for self-efficacy was 7.2 units (P < 0.001, 95% Confidence Interval (CI) 3.8, 10.7) favouring the intervention group. Change in self-care behaviours during the previous 7 days was also significantly greater for the intervention group: general diet (0.31 days, 95% CI 0.13, 0.48), specific diet (0.26 days, 95% CI 0.05, 0.46), exercise (0.51 days, 95% CI 0.23, 0.80), blood glucose (0.52 days, 95% CI 0.19, 0.85) and foot care (0.38 days, 95% CI 0.06, 0.71). Narrative communication shows promise as a valuable component of type 2 diabetes self-management programmes. REGISTRATION: ACTRN 12609000210279.

Individual and area factors associated with general practitioner integration in Australia: a multilevel analysis.

The further integration of primary care within the wider health system is an imperative for reform in all countries. The aim of this paper is to determine the factors associated with general practitioner (GP) integration using the GP Integration Index which has been recently developed and is demonstrating good reliability. The analysis is based on a database derived from an Australia-wide mail questionnaire survey of 1874 GPs drawn from a 20% stratified random sample of 123 Divisions of General Practice (47.8% adjusted response rate). The GP Integration Index measures the level of GPs' integration with the health care system based upon a description of their own behaviour. It consists of nine GP integration factors, and their two associated higher-order factors-Primary Care Management (PCM) and Community Health Role (CHR)-as well as five GP integration enabling factors. A multivariate multilevel analysis was undertaken. An explanatory model for both PCM and CHR was tested based on the GP integration factors as well as general practice, GP and regional characteristics. CHR and PCM were most strongly associated with GP integration enabling factors (mainly at the individual-level) and, for CHR only, with urban-rural location (mainly at the area-level). The most important single explanatory variable for both PCM and CHR was the GP integration enabling factor, "Knowledge of local resources." The important explanatory variables were those reflecting the way GPs work, rather than their broad 'classification' within individual or GP-setting groupings. Based on these results, some revision to the proposed model was necessary. We conclude that processes of care factors (as compared to structure of care factors) are more important in relation to GP integration than previously recognised. Future policy initiatives to promote GP integration should focus on programs to improve GP's knowledge of local resources.

Costing the Morbidity and Mortality Consequences of Zoonoses Using Health-Adjusted Life Years.

Governments are routinely involved in the biosecurity of agricultural and food imports and exports. This involves controlling the complex ongoing threat of the broad range of zoonoses: endemic, exotic and newly emerging. Policy-related decision-making in these areas requires accurate information and predictions concerning the effects and potential impacts of zoonotic diseases. The aim of this article was to provide information concerning the development and use of utility-based tools, specifically disability-adjusted life years (DALYs), for measuring the burden on human disease (morbidity and mortality) as a consequence of zoonotic infections. Issues and challenges to their use are also considered. Non-monetary utility approaches that are reviewed in this paper form one of a number of tools that can be used to estimate the monetary and non-monetary 'cost' of morbidity- and mortality-related consequences. Other tools derive from cost-of-illness, willingness-to-pay and multicriteria approaches. Utility-based approaches are specifically designed to capture the pain, suffering and loss of functioning associated with diseases, zoonotic and otherwise. These effects are typically complicated to define, measure and subsequently 'cost'. Utility-based measures will not be able to capture all of the effects, especially those that extend beyond the health sector. These will more normally be captured in financial terms. Along with other uncommon diseases, the quality of the relevant epidemiological data may not be adequate to support the estimation of losses in utility as a result of zoonoses. Other issues in their use have been identified. New empirical studies have shown some success in addressing these issues. Other issues await further study. It is concluded that, bearing in mind all caveats, utility-based methods are important tools in assessing the magnitude of the impacts of zoonoses in human disease. They make an important contribution to decision-making and priority setting across all sectors. In doing so, they highlight the relative importance of the burden of zoonotic disease globally.

Does Life Education's drug education programme have a public health benefit?

The Life Education organization offers a drug education programme to an estimated one million Australian primary schoolchildren. It is believed the programme delays experimentation with or initiation into smoking, alcohol use and the taking of analgesics. This study examined the short-term public health effects on 3000 11- and 12-year-old students, of whom 1700 were exposed to 5 consecutive years of the programme. The other 1300 students were not exposed to the programme. After controlling for the known predictors of social drug use there was no evidence that Life Education students, when compared with students receiving conventional school-based drug education, were less likely to have smoked, were less likely to have drunk or were less likely to have used analgesics. Indeed, the evidence suggested that Life Education-students were slightly more likely to use these substances, and that the programme had different effects on boys' and girls' drug use. Given that these findings are consistent with previous research evaluating similar drug education programmes, it is hypothesized they are most likely to do with the design of the programme itself.

Construction of a GP integration model.

There are frequent calls to improve integration of health services, within and between primary and secondary care sectors. In Australia, general medical practitioners (GPs) are central to these endeavours. This paper aims to better conceptualise GP integration and to develop a model and index based on this. A conceptualisation of integration is proposed based on integration fundamentally as an activity or process not structure. Integration process is the frequency and quality of episodes of information exchange involving the GP and another practitioner or patient and aimed at fulfilling the objectives of the health care system with regard to patient care. These are both direct responses to structural forces and emergent GP capacities and dispositions. The content of this typology was studied using Concept Mapping in 11 groups of GPs, consumers and other practitioners. Clusters of related statements within thematic domains were used as the basis for a provisional model. This was tested using confirmatory factor analysis in a data set derived from a national probability sample of 501 GPs. Some re-specification of the model was necessary, with three integration process factors needing to be subdivided. One factor congeneric model assumptions were used to identify the constituent items for these factors. The result was a model in which 50 items measured nine integration process factors and 20 items measured five enabling factors. Two distinct but correlated higher order factors, relating to individual patient care and public (or community) health--in contrast to a single higher order factor for integration--were identified. The re-specified model was tested with a new sample of 151 GPs and exhibited strong psychometric properties. Reliability and validity were acceptable to this stage of the indices' development. Further testing of the index is necessary to demonstrate factor invariance of the indices in other contexts as well as their utility in cross-structural analysis. That said, the indices have immediate uses.

Factors influencing mothers' decisions to consult a general practitioner about their children's illnesses.

BACKGROUND: In the management of childhood illness only a small proportion of symptoms result in a medical consultation. AIM: This pilot study set out to assess the influence of sociodemographic factors, social network, reason of choice of doctor and contact with allied health professionals on mothers' decisions to consult a general practitioner about their children's illnesses. METHOD: In one suburb of Melbourne, Australia all mothers with children aged 11 to 26 months were identified from the maternal and child health centre register. Mothers were invited for interview and if they attended were asked to keep a health diary for their child for four weeks. Logistic regression was used to test a multivariate model of factors predicting consultation with the general practitioner. RESULTS: A total of 150 mothers were identified. Interviews were carried out with 81% of target mothers and diary data collected for 72% of target children. Over the four-week diary period, consultation rates with the general practitioner were significantly higher if symptoms were recorded on 15 days or more, or the general practitioner had been recommended by a friend or was the mother's own doctor before the child's birth. Contact with a maternal and child health nurse was also a significant predictor of medical contact. Contact with friends and relatives, whether or not the study child was the first child in the family, mother's education, husband's occupational status or contact with a chemist were not significantly related to medical consultation rates. CONCLUSION: Choice of doctor (current doctor same as doctor before birth of child, or doctor recommended by a friend) resulted in significantly more consultations as did contact with a maternal and child health nurse. These factors would seem to require further study and inclusion in future models of consulting behaviour.

Recruitment of women by GPs for pap tests: a meta-analysis.

General practitioners (GPs) have a pivotal role to play in recruiting women for Pap tests. In recent times, considerable attention has been paid to the role of reminder systems in encouraging women to have regular Pap tests. Although a number of studies have investigated the effectiveness of reminder systems, there has been no comprehensive review. This paper aims to determine the effectiveness of patient and GP reminders in increasing the proportion of women screened for cervical cancer. Two electronic databases were searched for English-language randomized controlled trials conducted in a general practice or family medicine setting, and examining the effectiveness of GP and patient reminders in increasing the proportion of women screened for cervical cancer. Ten trials were identified, and meta-analytic techniques were employed to analyse the data from these trials. The women whose GPs had been prompted to remind them to have a Pap test were significantly more likely to do so than were control women (typical risk difference (TRD) = 6.6%, 95% CI = 5.2%-8.0%). The typical risk difference for the patient reminder studies was 4.9% (95% CI = 2.6%-7.2%). In both cases, sensitivity analysis revealed that one study stood out as an exceptional result. The omission of this study induced homogeneity among the remaining studies. Once this study was removed, the TRDs for the GP reminder and patient reminder studies were 7.9% (95% CI = 6.5%-9.4%) and 10.8% (95% CI = 8.1%-13.6%), respectively. The results strongly suggest that GPs should make use of GP and patient reminder systems.

Self-reported needs for care among persons who have suicidal ideation or who have attempted suicide.

This study examined the self-reported needs of suicidal users of mental health services and the extent to which needs were met. Data on 10,641 adults were available from the Australian National Survey of Mental Health and Wellbeing. In the year before the survey, 245 persons with suicidal ideation used services, 37 of whom had attempted suicide. Suicidal persons reported a range of needs, especially for counseling, medication, and information. More than half of those with suicidal ideation and those who had attempted suicide who reported any needs felt that their needs had not been fully met. Suicidal persons were significantly more likely to perceive that they had needs.

Nursing outside hospitals: the working experience of community nurses: job characteristics.

The Community Nursing Project reports the results of a mailed questionnaire survey of the working and educational experience of 689 nurses employed outside hospitals and nursing homes in Victoria in 1985. This paper reports that part of the study relevant to their practice settings, job titles, job content and working conditions. Confusion about titles for community nurses was evident given that subjects offered 281 separate job titles. A title with the general form 'Community Nurse--specialist designation' was acceptable to 88% of nurses. Eighteen (of 57) job activities were identified that were performed at least weekly by four of the six principal practice areas. Therefore while the concept of the generic community nurse is a meaningful one, it is only so when the differences in job content across practice areas are acknowledged. Medical clinic nurses however do not conform to this general pattern. Seventy-nine per cent of the nurses currently had a job description. However, only 45% had a statement of job conditions, 26% had a formal job orientation, 24% worked overtime unrewarded by payment or time in lieu and only 59% could reschedule their work times. These figures varied greatly between practice areas. It is suggested that the concept of the community nurse--specialist designation be promoted. Specifically this could be done by the adoption of this title and the development of appropriate post-basic educational courses. While these conclusions have most relevance for Australia, they will also be of interest to nurses of other countries where an increasing emphasis on primary health care has resulted in an expansion of community nursing practice.

Suicidal ideation and suicide attempts among Australian adults.

Too little is known about suicidal thoughts and behaviors at a population level to recommend appropriate preventive strategies. Using data from the Australian National Survey of Mental Health and Wellbeing (NSMHWB), this study examined rates of, and risk factors for, suicidal ideation and suicide attempts. For 10,641 respondents, the 12-month and lifetime cumulative incidence rates of suicidal ideation were 3.4% and 16.0%, respectively; the 12-month and lifetime cumulative incidence rates of suicide attempts were 0.4% and 3.6%, respectively. 12-month ideation was associated with anxiety disorders (relative risk ratio [RRR] = 3.51; population attributable risk percent [PAR%] = 19.6%), affective disorders (RRR = 11.94; PAR% = 38.8%) and substance abuse disorders (RRR = 1.85; PAR% = 6.1%). Attempts in the past 12 months were also associated with anxiety disorders (RRR = 7.06; PAR% = 37.0%), affective disorders (RRR = 12.24; PAR% = 39.5%), and substance abuse disorders (RRR = 2.09; PAR% = 7.7%). Age, marital status, and disability were associated with ideation; marital status and employment status with attempts. Approximately 12% of ideators in the sample progressed to making an attempt; employment status was the only significant predictor. Reducing suicidal ideation and attempts requires a multi-faceted approach that targets those with mental illness but also adopts population-based strategies that address other factors, such as unemployment.

Coronary risk factors, knowledge and beliefs in 'blue collar' men attending general practice.

OBJECTIVE: To describe risk factors, dietary knowledge and beliefs in Australian-born males of low socio-economic status (SES) in relation to coronary heart disease. METHODOLOGY: Cross-sectional prevalence survey of 180 (99.7% of 185) selected attenders at a community health centre with a high proportion of low SES residents in Melbourne. RESULTS: Mean BMI and prevalence of obesity and smoking were higher than in national sample; age-weighted serum cholesterol somewhat lower. A majority believed that their diets were unhealthy and would continue to be so despite high perceived susceptibility to CHD. Seventy-two per cent wanted more dietary information and GPs were the most commonly nominated preferred source for this information. CONCLUSION: GPs have an important role in targeting this 'at risk' group in order to address the knowledge gaps and misconceptions identified in the study and to encourage appropriate behaviour and risk factor modification.

Immunisation initiatives in general practice. Important lessons from division projects.

AIM: To examine immunisation projects undertaken by divisions of general practice through the Divisions and Project Grants Program in the period from 1993 to mid 1997. METHOD: A simple descriptive frequency analysis was conducted of information from the National Information Service Divisions Project database and evaluation reports of the project characteristics and methodology such as: year commenced; duration; location; funding; target groups; intervention; needs assessment; aim(s); study design; measurement (assessment) and outcome(s). RESULTS: Forty-four funded immunisation projects were identified and of these, 12 projects with completed evaluation reports were analysed. Most projects were of 12-14 months duration, and were funded for a mean of $56,349 and median of $46,348 for the 44 funded projects and a mean $44,348 and median $40,318 for the 12 with evaluation reports. Most projects included a needs assessment. The main target groups were general practitioners, the general community, and children. Of the wide spectrum of interventions used, education and/or promotion and register and/or reminder systems were the most common. Study designs, the quality of measurement and outcomes were variable. CONCLUSION: In the future with the move to outcome based block funding, it will be important for projects to adopt broader target groups, refine and develop interventions and develop greater sustainability through responding to local needs, improving design and evaluation and ongoing funding.

A study of emergency ambulance utilisation.

An analysis of 373 emergency ambulance calls within the Broadmeadows municipality of Melbourne showed that eighty-seven per cent were handled by standard road car (RC) ambulance, and 13 per cent by mobile intensive care ambulance (MICA). Calls most commonly were associated with cardiorespiratory episodes, loss of consciousness and trauma. Twenty-three per cent of calls did not result in a patient being transferred to hospital mainly because of patient refusal or the absence of a medical need. Forty-two per cent of calls were categorised "not urgent" or eventually the ambulance was not required. This review highlights important topics for further study of ambulance services.

General practice integration in Australia. Primary health services provider and consumer perceptions of barriers and solutions.

OBJECTIVE: To identify practical examples of barriers and possible solutions to improve general practice integration with other health service providers. METHOD: Twelve focus groups, including one conducted by teleconference, were held across Australia with GPs and non GP primary health service providers between May and September, 1996. Focus groups were embedded within concept mapping sessions, which were used to conceptually explore the meaning of integration in general practice. Data coding, organising and analysis were based on the techniques documented by Huberman and Miles. RESULTS: Barriers to integration were perceived to be principally due to the role and territory disputes between the different levels of government and their services, the manner in which the GP's role is currently defined, and the system of GP remuneration. Suggestions on ways to improve integration involved two types of strategies. The first involves initiatives implemented 'top down' through major government reform to service structures, including the expansion of the role of divisions of general practice, and structural changes to the GP remuneration systems. The second type of strategy suggested involves initiatives implemented from the 'bottom up' involving services such as hospitals (e.g. additional GP liaison positions) and the use of information technology to link services and share appropriate patient data. CONCLUSION: The findings support the need for further research and evaluation of initiatives aimed at achieving general practice integration at a systems level. There is little evidence to suggest which types of initiatives improve integration. However, general practice has been placed in the centre of the health care debate and is likely to remain central to the success of such initiatives. Clarification of the future role and authority of general practice will therefore be required if such integrative strategies are to be successful at a wider health system level.

The concept mapping method. An alternative to focus group inquiry in general practice.

BACKGROUND: The concept mapping rationale and process are explained step by step. The concept mapping method produces a two dimensional conceptual map of ideas produced by the group which can be analysed at the level of individual statements, clusters of statements, and groups of similar clusters. An example of concept mapping conducted with four general practitioner (GP) groups from different practice types and demographic locations is provided. A total of 51 participating GPs were asked to complete an 'evaluation questionnaire' at the end of each group session. The majority of GP participants (68%) rated the method as highly useful. OBJECTIVE: To describe the concept mapping method and its interpretation for use in general practice research. To report on its perceived usefulness and acceptability by general practitioners. DISCUSSION: Concept mapping is a very useful method combining benefits from qualitative and quantitative approaches for exploring the breadth of a topic in its entirety, especially for abstract concepts. GPs found the concept mapping method to be efficient for group inquiry, rating it high on utility. There is scope to refine the method, reducing time spent in some stages of the session, and substituting more time on final analysis.

Differences in patient throughput between community health centre and private general practitioners.

This study sought to compare the rate of patient throughput by community health centre general practitioners (GPs) and their private practice fee-for-service counterparts. The study group comprised 44 community health centre GPs (out of an identified 51) in 16 community health centres; the control group comprised 268 GPs. Community health centre GPs were found to have significantly fewer consultants and significantly smaller rebates than their private practice counterparts. The difference of means for consultation numbers and rebates was 30.3 per cent. The pattern was reversed in the case of rural community health centre GPs (who retain fee-for-service arrangements). Figures are uncorrected for patient status, and data relate to Medicare billing practices rather than observed activity or outcome. However, at face value they would indicate that if Australian general practice moved to a community health centre model, with predominantly salaried GPs, then patient throughput in general practice could be expected to drop. Whether these reflect the impact of incentives on throughput and, if so, whether this indicates a difference in the quality or accessibility of the service provided to patients is not certain.

Delivery of traditional hospital services to patients at home.

The high cost of traditional inpatient care, advances in the delivery of depot antibiotics and narcotics, and the demands of patients for realistic alternatives to frequent hospitalisation have led to programs for the provision of acute hospital care in the home. We review the progress of overseas hospital-in-the-home programs and the issues that such service delivery has raised for clinicians and administrators. The potential application in Australia is examined and priorities for preparative research are suggested. It seems inevitable that for a select number of conditions in a select group of patients, home hospital services will become a reality in this country.

Clinical and host differences between infections with the two varieties of Cryptococcus neoformans.

A population-based register of cases of cryptococcosis in patients treated in Victoria, Australia, over a 10-year period was established for studying the epidemiologic and clinical features of infection with Cryptococcus neoformans and its two varieties, gattii and neoformans. One hundred thirty-three cases of cryptococcosis were entered on the register; the incidence was 3.0 cases per 1 million population per year, a rate that increased to 5.0 cases per 1 million population per year over the decade as a result of the AIDS epidemic. There was a distinct association between immune status and C. neoformans variety: all C. neoformans variety gattii infections occurred in healthy hosts and 90% of C. neoformans variety neoformans infections occurred in immunosuppressed hosts. Meningitis was the commonest manifestation, with focal CNS and pulmonary lesions occurring primarily in healthy hosts with C. neoformans variety gattii infection; isolation of C. neoformans from blood and urine was associated with immunosuppression and C. neoformans variety neoformans infection. The mortality among patients with C. neoformans variety neoformans infection was high, while none of those patients with C. neoformans variety gattii died but often had neurological sequelae that required surgery and prolonged therapy. These findings appear to be related to variety-specific interactions between host and parasite and warrant further epidemiologic and immunologic study.