Behaviour change interventions to improve physical activity in adults: a systematic review of economic evaluations.

BACKGROUND: Behaviour change interventions can result in lasting improvements in physical activity (PA). A broad implementation of behaviour change interventions are likely to be associated with considerable additional costs, and the evidence is unclear whether they represent good value for money. The aim of this study was to investigate costs and cost-effectiveness of behaviour change interventions to increase PA in community-dwelling adults. METHODS: A search for trial-based economic evaluations investigating behaviour change interventions versus usual care or alternative intervention for adults living in the community was conducted (September 2023). Studies that reported intervention costs and incremental cost-effectiveness ratios (ICERs) for PA or quality-adjusted life years (QALYs) were included. Methodological quality was assessed using the Consensus Health Economic Criteria (CHEC-list). A Grading of Recommendations Assessment, Development and Evaluation style approach was used to assess the certainty of evidence (low, moderate or high certainty). RESULTS: Sixteen studies were included using a variety of economic perspectives. The behaviour change interventions were heterogeneous with 62% of interventions being informed by a theoretical framework. The median CHEC-list score was 15 (range 11 to 19). Median intervention cost was US$313 per person (range US$83 to US$1,298). In 75% of studies the interventions were reported as cost-effective for changes in PA (moderate certainty of evidence). For cost per QALY/gained, 45% of the interventions were found to be cost-effective (moderate certainty of evidence). No specific type of behaviour change intervention was found to be more effective. CONCLUSIONS: There is moderate certainty that behaviour change interventions are cost-effective approaches for increasing PA. The heterogeneity in economic perspectives, intervention costs and measurement should be considered when interpreting results. There is a need for increased clarity when reporting the functional components of behaviour change interventions, as well as the costs to implement them.

Performance of 21 Early Warning System scores in predicting in-hospital deterioration among undifferentiated admitted patients managed by ambulance services.

BACKGROUND: The optimal Early Warning System (EWS) scores for identifying patients at risk of clinical deterioration among those transported by ambulance services remain uncertain. This retrospective study compared the performance of 21 EWS scores to predict clinical deterioration using vital signs (VS) measured in the prehospital or emergency department (ED) setting. METHODS: Adult patients transported to a single ED by ambulances and subsequently admitted to the hospital between 1 January 2019 and 18 April 2019 were eligible for inclusion. The primary outcome was 30-day mortality; secondary outcomes included 3-day mortality, admission to intensive care or coronary care units, length of hospital stay and emergency call activations. The discriminative ability of the EWS scores was assessed using the area under the receiver operating characteristic curve (AUROC). Subanalyses compared the performance of EWS scores between surgical and medical patient types. RESULTS: Of 1414 patients, 995 (70.4%) (53.1% male, mean age 68.7±17.5 years) were included. In the ED setting, 30-day mortality was best predicted by VitalPAC EWS (AUROC 0.71, 95% CI (0.65 to 0.77)) and National Early Warning Score (0.709 (0.65 to 0.77)). All EWS scores calculated in the prehospital setting had AUROC <0.70. Rapid Emergency Medicine Score (0.83 (0.73 to 0.92)) and New Zealand EWS (0.88 (0.81 to 0.95)) best predicted 3-day mortality in the prehospital and ED settings, respectively. EWS scores calculated using either prehospital or ED VS were more effective in predicting 3-day mortality in surgical patients, whereas 30-day mortality was best predicted in medical patients. Among the EWS scores that achieved AUROC ≥0.70, no statistically significant differences were detected in their discriminatory abilities to identify patients at risk of clinical deterioration. CONCLUSIONS: EWS scores better predict 3-day as opposed to 30-day mortality and are more accurate when estimated using VS measured in the ED. The discriminatory performance of EWS scores in identifying patients at higher risk of clinical deterioration may vary by patient type.

A five year descriptive analysis of potentially preventable hospitalisations for Ear, Nose, and Throat conditions in regional Victoria, Australia, from 2015 to 2020.

BACKGROUND: Potentially preventable hospitalisations of ear, nose, and throat conditions in the Murray Primary Health Network region have been found to be higher than the state average of Victoria, Australia. This study aimed to examine the association between selected patient-level characteristics and the likelihood of residing in a Murray PHN postcode with higher than expected numbers of potentially preventable ENT hospitalisations. METHODS: Unit record hospital separation data were obtained from the Victorian Admitted Episodes Dataset. Postcodes were classified as having higher than expected numbers of potentially preventable hospitalisations across three subgroups of ENT using indirect standardisation techniques. Differences between patients from 'higher than expected' postcodes and 'other' postcodes with respect to the distribution of demographic and other patient characteristics were determined using chi-squared tests for each ENT subgroup. The results were confirmed by logistic regression analyses using resident of a postcode with higher than expected hospitalisations as the outcome variable. RESULTS: Of the 169 postcodes located in the catchment area, 15 were identified as having higher than expected numbers of upper respiratory tract infection hospitalisations, 14 were identified for acute tonsillitis, and 12 were identified for otitis media. Patients from postcodes with 'higher than expected' hospitalisations for these conditions were more likely than others to be aged between 0 and 9 years, Indigenous, or from a culturally and linguistically diverse background. CONCLUSION: Further investigation of the identified postcodes is warranted to determine access to and utilisation of primary healthcare services in the management of PPH ENT conditions in the region.

Tobacco retailer density and smoking behaviour: how are exposure and outcome measures classified? A systematic review.

INTRODUCTION: To date only a limited number of reviews have focused on how exposure and outcome measures are defined in the existing literature on associations between tobacco retailer density ('density') and smoking behaviour ('smoking'). Therefore this systematic review classified and summarised how both density and smoking variables are operationalised in the existing literature, and provides several methodological recommendations for future density and smoking research. METHODS: Two literature searches between March and April 2018 and April 2022 were conducted across 10 databases. Inclusion and exclusion criteria were developed and keyword database searches were undertaken. Studies were imported into Covidence. Cross-sectional studies that met the inclusion criteria were extracted and a quality assessment was undertaken. Studies were categorised according to the density measure used, and smoking was re-categorised using a modified classification tool. RESULTS: Large heterogeneity was found in the operationalisation of both measures in the 47 studies included for analysis. Density was most commonly measured directly from geocoded locations using circular buffers at various distances (n = 14). After smoking was reclassified using a smoking classification tool, past-month smoking was the most common smoking type reported (n = 26). CONCLUSIONS: It is recommended that density is measured through length-distance and travel time using the street network and weighted (e.g. by the size of an area), or by using Kernel Density Estimates as these methods provide a more accurate measure of geographical to tobacco and e-cigarette retailer density. The consistent application of a smoking measures classification tool, such as the one developed for this systematic review, would enable better comparisons between studies. Future research should measure exposure and outcome measures in a way that makes them comparable with other studies. IMPLICATIONS: This systematic review provides a strong case for improving data collection and analysis methodologies in studies assessing tobacco retailer density and smoking behaviour to ensure that both exposure and outcome measures are clearly defined and captured. As large heterogeneity was found in the operationalisation of both density and smoking behaviour measures in the studies included for analysis, there is a need for future studies to capture, measure and classify exposure measures accurately, and to define outcome measures in a manner that makes them comparable with other studies.

Identifying tobacco retailers in the absence of a licensing system: lessons from Australia.

OBJECTIVES: To estimate the proportion of retailers that sell tobacco in the absence of appropriate local government oversight, and to describe the characteristics by which they differ from those that can expect to receive such oversight. METHODS: A database of listed tobacco retailers was obtained from a regional Victorian local government. Potential unlisted tobacco retailers were added using online searches, and attempts to visit all retailers were undertaken. GPS coordinates and sales type information of retailers that sold tobacco were recorded and attached to neighbourhood-level data on socioeconomic disadvantage and smoking prevalence using ArcMap. Logistic regression analyses, χ2 tests and t-tests were undertaken to explore differences in numbers of listed and unlisted retailers by business and neighbourhood-level characteristics. RESULTS: Of 125 confirmed tobacco retailers, 43.2% were trading potentially without government oversight. Significant differences were found between listed and unlisted retailers by primary business type (p<0.001), and sales type (p<0.001) but not by the other characteristics. CONCLUSIONS: The database of tobacco retailers was inaccurate in two ways: (1) a number of listed retailers no longer operated or sold tobacco, and (2) 43.2% of businesses confirmed as selling tobacco were missing. As no form of licensing system exists in Victoria, it is difficult to identify the number of retailers operating, or to determine how many receive formal regulatory oversight. A positive licensing system is recommended to regulate the sale of tobacco and to generate a comprehensive database of retailers, similar to that which exists for food registration, gaming and liquor-licensed premises.

Exploring the ability of self-report measures to identify risk of high treatment burden in chronic disease patients: a cross-sectional study.

BACKGROUND: Effective self-management of chronic health conditions is key to avoiding disease escalation and poor health outcomes, but self-management abilities vary. Adequate patient capacity, in terms of abilities and resources, is needed to effectively manage the treatment burden associated with chronic health conditions. The ability to measure different elements of capacity, as well as treatment burden, may assist to identify those at risk of poor self-management. Our aims were to: 1. Investigate correlations between established self-report tools measuring aspects of patient capacity, and treatment burden; and 2. Explore whether individual questions from the self-report tools will correlate to perceived treatment burden without loss of explanation. This may assist in the development of a clinical screening tool to identify people at risk of high treatment burden. METHODS: A cross-sectional survey in both a postal and online format. Patients reporting one or more chronic diseases completed validated self-report scales assessing social, financial, physical and emotional capacity; quality of life; and perceived treatment burden. Logistic regression analysis was used to explore relationships between different capacity variables, and perceived high treatment burden. RESULTS: Respondents (n = 183) were mostly female (78%) with a mean age of 60 years. Most participants were multimorbid (94%), with 45% reporting more than five conditions. 51% reported a high treatment burden. Following logistic regression analyses, high perceived treatment burden was correlated with younger age, material deprivation, low self-efficacy and usual activity limitation. These factors accounted for 50.7% of the variance in high perceived treatment burden. Neither disease burden nor specific diagnosis was correlated with treatment burden. CONCLUSIONS: This study supports previous observations that psychosocial factors may be more influential than specific diagnoses for multimorbid patients in managing their treatment workload. A simple capacity measure may be useful to identify those who are likely to struggle with healthcare demands.

Benchmarking gambling screens to health-state utility: the PGSI and the SGHS estimate similar levels of population gambling-harm.

BACKGROUND: Both the Problem Gambling Severity Index (PGSI) and the Short Gambling Harms Screen (SGHS) purport to identify individuals harmed by gambling. However, there is dispute as to how much individuals are harmed, conditional on their scores from these instruments. We used an experienced utility framework to estimate the magnitude of implied impacts on health and wellbeing. METHODS: We measured health utility using the Short Form Six-Dimension (SF-6D), and used this as a benchmark. All 2603 cases were propensity score weighted, to balance the affected group (i.e., SGHS 1+ or PGSI 1+ vs 0) with a reference group of gamblers with respect to risk factors for gambling harm. Weighted regression models estimated decrements to health utility scores attributable to gambling, whilst controlling for key comorbidities. RESULTS: We found significant attributable decrements to health utility for all non-zero SGHS scores, as well as moderate-risk and problem gamblers, but not for PGSI low-risk gamblers. Applying these coefficients to population data, we find a similar total burden for both instruments, although the SGHS more specifically identified the subpopulation of harmed individuals. For both screens, outcomes on the SF-6D implies that about two-thirds of the 'burden of harm' is attributable to gamblers outside of the most severe categories. CONCLUSIONS: Gambling screens have hitherto provided nominal category membership, it has been unclear whether moderate or 'at-risk' scores imply meaningful impact, and accordingly, population surveys have typically focused on problem gambling prevalence. These results quantify the health utility decrement for each category, allowing for tracking of the aggregate population impact based on all affected gamblers.

Stressful Life Events Precede Gambling Problems, and Continued Gambling Problems Exacerbate Stressful Life Events; A Life Course Calendar Study.

Do stressful life events cause gambling problems, or do gambling problems cause stressful life events? This study used a retrospective design to examine the temporal order of these associations. Specifically, the study employed a life course calendar in a self-directed online survey to minimise memory biases common in retrospective designs. A total of 1564 US respondents who had gambled at any point in their life (51.0% female, median age 46) were asked whether, for each year of their adult life, they had experienced each of eight stressful life events, and whether they had engaged in casual or heavy gambling, drinking or drug use, with heavy gambling defined in line with a problem gambling definition. We found that five stressful life events were associated with the onset of heavy gambling: work issues, financial issues, legal issues, relationship issues and the death of a loved one. The same five stressful life events predict the cessation of an episode of heavy gambling, indicating a possible tendency for gambling problems to self-resolve in the presence of stress. Insights are also gained into comorbidities with alcohol and drug use, and the course of stressful life events and gambling and substance use throughout the life course, albeit with a non-representative sample. The methodology allows tentative conclusions in terms of possible causation pathways, indicating that stressful life events may play a role both in the onset and the maintenance (or cessation) of gambling problems.

The effect of behaviour change interventions on changes in physical activity and anthropometrics in ambulatory hospital settings: a systematic review and meta-analysis.

BACKGROUND: The aim of this systematic review and meta-analysis was to investigate whether behaviour change interventions promote changes in physical activity and anthropometrics (body mass, body mass index and waist circumference) in ambulatory hospital populations. METHODS: Randomised controlled trials were collected from five bibliographic databases (MEDLINE, Embase, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL) and PsycINFO). Meta-analyses were conducted using change scores from baseline to determine mean differences (MD), standardised mean differences (SMD) and 95% confidence intervals (95% CI). The Grades of Recommendation, Assessment, Development and Evaluation approach was used to evaluate the quality of the evidence. RESULTS: A total of 29 studies met the eligibility criteria and 21 were included in meta-analyses. Behaviour change interventions significantly increased physical activity (SMD: 1.30; 95% CI: 0.53 to 2.07, p < 0.01), and resulted in significant reductions in body mass (MD: -2.74; 95% CI: - 4.42 to - 1.07, p < 0.01), body mass index (MD: -0.99; 95% CI: - 1.48 to - 0.50, p < 0.01) and waist circumference (MD: -2.21; 95% CI: - 4.01 to - 0.42, p = 0.02). The GRADE assessment indicated that the evidence is very uncertain about the effect of behaviour change interventions on changes in physical activity and anthropometrics in ambulatory hospital patients. CONCLUSIONS: Behaviour change interventions initiated in the ambulatory hospital setting significantly increased physical activity and significantly reduced body mass, body mass index and waist circumference. Increased clarity in interventions definitions and assessments of treatment fidelity are factors that need attention in future research. PROSPERO registration number: CRD42020172140.

Healthcare professionals' perspective on treatment burden and patient capacity in low-income rural populations: challenges and opportunities.

BACKGROUND: The challenges of chronic disease self-management in multimorbidity are well-known. Shippee's Cumulative Complexity Model provides useful insights on burden and capacity factors affecting healthcare engagement and outcomes. This model reflects patient experience, but healthcare providers are reported to have a limited understanding of these concepts. Understanding burden and capacity is important for clinicians, since they can influence these factors both positively and negatively. This study aimed to explore the perspectives of healthcare providers using burden and capacity frameworks previously used only in patient studies. METHODS: Participants were twelve nursing and allied health providers providing chronic disease self-management support in low-income primary care settings. We used written vignettes, constructed from interviews with multimorbid patients at the same health centres, to explore how clinicians understood burden and capacity. Interviews were recorded and transcribed verbatim. Analysis was by the framework method, using Normalisation Process Theory to explore burden and the Theory of Patient Capacity to explore capacity. RESULTS: The framework analysis categories fitted the data well. All participants clearly understood capacity and were highly conscious of social (e.g. income, family demands), and psychological (e.g. cognitive, mental health) factors, in influencing engagement with healthcare. Not all clinicians recognised the term 'treatment burden', but the concept that it represented was familiar, with participants relating it both to specific treatment demands and to healthcare system deficiencies. Financial resources, health literacy and mental health were considered to have the biggest impact on capacity. Interaction between these factors and health system barriers (leading to increased burden) was a common and challenging occurrence that clinicians struggled to deal with. CONCLUSIONS: The ability of health professionals to recognise burden and capacity has been questioned, but participants in this study displayed a level of understanding comparable to the patient literature. Many of the challenges identified were related to health system issues, which participants felt powerless to address. Despite their awareness of burden and capacity, health providers continued to operate within a single-disease model, likely to increase burden. These findings have implications for health system organisation, particularly the need for alternative models of care in multimorbidity.

Audiologists' perspective on the treatment of ear-related ear, nose, and throat conditions in rural Victoria.

OBJECTIVES: To understand the experience of audiologists in managing and treating ear-related ear, nose and throat conditions in rural areas, and to identify the compounding factors that influence patient outcomes and potential targets for intervention. DESIGN: A focus group was conducted using a qualitative descriptive approach. Responses were audio-recorded, transcribed and thematically analysed. SETTING: The focus group was conducted in the rural town of Mildura in the state of Victoria, Australia. PARTICIPANTS: A sample of 19 audiologists from Victoria participated, of which 14 were rurally based and 5 were metropolitan-based. The length of participants' professional experience ranged from 1 to 43 years. RESULTS: Long wait lists, and a lack of locally based ear, nose and throat surgeons were identified as barriers to the treatment of ear-related ear, nose and throat conditions. Open communication between health services and efficient care for time-sensitive conditions were seen as outcomes of good practice. Hand hygiene, nose-blowing, reducing tobacco smoke exposure and promoting the use of noise protective equipment were the 4 community health campaigns mentioned to support ear care for those residing in rural areas. Additional themes of ear conditions, treatment, management and primary health care were identified. CONCLUSION: Improving referral pathways for the treatment of ear-related ear, nose and throat conditions, and providing education about ear, nose and throat assessment and treatment in primary health care settings could increase appropriate referrals, improve patient outcomes and reduce wait periods for treatment.

A physical activity coaching intervention can improve and maintain physical activity and health-related outcomes in adult ambulatory hospital patients: the Healthy4U-2 randomised controlled trial.

BACKGROUND: The Healthy 4 U-2 study sought to evaluate the effect of a twelve-week, physical activity (PA) coaching intervention for changes and maintenance in PA, anthropometrics and health-related outcomes in adults presenting to an ambulatory hospital clinic. METHODS: One hundred and twenty insufficiently active adults were recruited from an ambulatory hospital clinic and randomised to an intervention group that received an education session and five 20-min telephone sessions of PA coaching, or to a control group that received the education session only. ActiGraph GT3X accelerometers were used to measure moderate-to-vigorous physical activity (MVPA) at baseline, post-intervention (3-months) and follow-up (9-months). Secondary outcome measures (anthropometrics, PA self-efficacy, and health-related quality of life) were also assessed at the three time points. RESULTS: At baseline, the mean age and body mass index of participants were 53 ± 8 years and 31 ± 4 kg/m2, respectively. Relative to control, the intervention group increased objectively measured MVPA at post-intervention (p < 0.001) and 9 months follow-up (p < 0.001). At the 9-month follow-up the intervention group completed 22 min/day of MVPA (95% CI: 20 to 25 min/day), which is sufficient to meet the recommended PA guidelines. The intervention group exhibited beneficial changes in body mass (p < 0.001), waist circumference (p < 0.001), body mass index (p < 0.001), PA self-efficacy (p < 0.001), and health-related quality of life (p < 0.001) at the 9-month follow-up. CONCLUSIONS: This study demonstrates that a low contact PA coaching intervention results in beneficial changes in PA, anthropometrics and health-related outcomes in insufficiently active adults presenting to an ambulatory care clinic. The significant beneficial changes were measured at post-intervention and the 9-month follow-up, demonstrating a maintenance effect of the intervention. TRIAL REGISTRATION: Prospectively registered on the Australian and New Zealand Clinical Trials Registry (ANZCTR, Trial registration number: ACTRN12619000036112 .

Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates.

BACKGROUND: Workplace aggression is becoming increasingly prevalent in health care, with serious consequences for both individuals and organisations. Research and development of organisational interventions to prevent and minimise workplace aggression has also increased. However, it is not known if interventions prevent or reduce occupational violence directed towards healthcare workers. OBJECTIVES: To assess the effectiveness of organisational interventions that aim to prevent and minimise workplace aggression directed towards healthcare workers by patients and patient advocates. SEARCH METHODS: We searched the following electronic databases from inception to 25 May 2019: Cochrane Central Register of Controlled Trials (CENTRAL) (Wiley Online Library); MEDLINE (PubMed); CINAHL (EBSCO); Embase (embase.com); PsycINFO (ProQuest); NIOSHTIC (OSH-UPDATE); NIOSHTIC-2 (OSH-UPDATE); HSELINE (OSH-UPDATE); and CISDOC (OSH-UPDATE). We also searched the ClinicalTrials.gov (www.ClinicalTrials.gov) and the World Health Organization (WHO) trials portals (www.who.int/ictrp/en). SELECTION CRITERIA: We included randomised controlled trials (RCTs) or controlled before-and-after studies (CBAs) of any organisational intervention to prevent and minimise verbal or physical aggression directed towards healthcare workers and their peers in their workplace by patients or their advocates. The primary outcome measure was episodes of aggression resulting in no harm, psychological, or physical harm. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods for data collection and analysis. This included independent data extraction and 'Risk of bias' assessment by at least two review authors per included study. We used the Haddon Matrix to categorise interventions aimed at the victim, the vector or the environment of the aggression and whether the intervention was applied before, during or after the event of aggression. We used the random-effects model for the meta-analysis and GRADE to assess the quality of the evidence. MAIN RESULTS: We included seven studies. Four studies were conducted in nursing home settings, two studies were conducted in psychiatric wards and one study was conducted in an emergency department. Interventions in two studies focused on prevention of aggression by the vector in the pre-event phase, being 398 nursing home residents and 597 psychiatric patients. The humour therapy in one study in a nursing home setting did not have clear evidence of a reduction of overall aggression (mean difference (MD) 0.17, 95% confidence interval (CI) 0.00 to 0.34; very low-quality evidence). A short-term risk assessment in the other study showed a decreased incidence of aggression (risk ratio (RR) 0.36, 95% CI 0.16 to 0.78; very low-quality evidence) compared to practice as usual. Two studies compared interventions to minimise aggression by the vector in the event phase to practice as usual. In both studies the event was aggression during bathing of nursing home patients. In one study, involving 18 residents, music was played during the bathing period and in the other study, involving 69 residents, either a personalised shower or a towel bath was used. The studies provided low-quality evidence that the interventions may result in a medium-sized reduction of overall aggression (standardised mean difference (SMD -0.49, 95% CI -0.93 to -0.05; 2 studies), and physical aggression (SMD -0.85, 95% CI -1.46 to -0.24; 1 study; very low-quality evidence), but not in verbal aggression (SMD -0.31, 95% CI; -0.89 to 0.27; 1 study; very low-quality evidence). One intervention focused on the vector, the pre-event phase and the event phase. The study compared a two-year culture change programme in a nursing home to practice as usual and involved 101 residents. This study provided very low-quality evidence that the intervention may result in a medium-sized reduction of physical aggression (MD 0.51, 95% CI 0.11 to 0.91), but there was no clear evidence that it reduced verbal aggression (MD 0.76, 95% CI -0.02 to 1.54). Two studies evaluated a multicomponent intervention that focused on the vector (psychiatry patients and emergency department patients), the victim (nursing staff), and the environment during the pre-event and the event phase. The studies included 564 psychiatric staff and 209 emergency department staff. Both studies involved a comprehensive package of actions aimed at preventing violence, managing violence and environmental changes. There was no clear evidence that the psychiatry intervention may result in a reduction of overall aggression (odds ratio (OR) 0.85, 95% CI 0.63 to 1.15; low-quality evidence), compared to the control condition. The emergency department study did not result in a reduction of aggression (MD = 0) but provided insufficient data to test this. AUTHORS' CONCLUSIONS: We found very low to low-quality evidence that interventions focused on the vector during the pre-event phase, the event phase or both, may result in a reduction of overall aggression, compared to practice as usual, and we found inconsistent low-quality evidence for multi-component interventions. None of the interventions included the post-event stage. To improve the evidence base, we need more RCT studies, that include the workers as participants and that collect information on the impact of violence on the worker in a range of healthcare settings, but especially in emergency care settings. Consensus on standardised outcomes is urgently needed.

Is sleep duration associated with overweight/obesity in Indigenous Australian adults?

BACKGROUND: Associations between high BMI and sleep duration and chronic illness are recognised. Short sleep is an accepted predictor of high BMI for children, including Indigenous Australian children. Short sleep has also been associated with high BMI in Australian adults, although not specifically in Indigenous Australian adults. This study aims to determine whether the relationship between sleep duration and BMI observed in non-Indigenous adults holds for Indigenous adults. METHODS: Data collected from 5204 non-Indigenous and 646 Indigenous participants aged over 18 years in a nationally representative Australian Health Survey 2011-2013 were analysed. Sleep duration was self-reported as the time between going to bed and time waking up; BMI was derived from measurement and categorised into normal weight (BMI = 18.5-24.9) and overweight/obese (BMI ≥ 25). Logistic regression was performed for the non-Indigenous and Indigenous groups separately to examine the association between sleep duration and BMI in each group. RESULTS: Proportionally more Indigenous people were classified as overweight/obese than non-Indigenous (χ2 = 21.81, p < 0.001). Short sleep was reported by similar proportions in both groups (Indigenous 15% vs non-Indigenous 17%) whereas long sleep of > 9 h was reported by proportionally more Indigenous than non-Indigenous people (41% vs 26%). Without accounting for possible confounders, the association between sleep duration and BMI for the Indigenous group was not significant but a possible dose-response relationship was evident, with the odds of overweight/obesity being greatest for those who typically slept < 7 h (OR = 1.77, 95% CI 0.38-3.94) and < 6 h (OR = 1.55, 95%CI = 0.58-4.14). The same model for the non-Indigenous group was significant, with the odds of overweight/obesity being greatest for those who typically slept < 6 h (OR = 1.67, 95%CI 1.25-2.25). The risk of overweight/obesity diminished for both groups with sleep > 7 h. Accounting for a range of socioeconomic and personal confounders attenuated the strength of these relationships marginally. CONCLUSION: Adding to reports relating sleep duration and BMI for Australian adults, this study provides evidence for an inverse relationship in non-Indigenous adults and suggests a similar trend for Indigenous adults. This trend was non-significant but is consistent with previous results for Indigenous children.

A framework for indirect elicitation of the public health impact of gambling problems.

Gambling problems are increasingly understood as a health-related condition, with harms from excessive time and money expenditure contributing to significant population morbidity. In many countries, the prevalence of gambling problems is known with some precision. However, the true severity of gambling problems in terms of their impact on health and wellbeing is the subject of ongoing debate. We firstly review recent research that has attempted to estimate harm from gambling, including studies that estimate disability weights using direct elicitation. Limitations of prior approaches are discussed, most notably potential inflation due to non-independent comorbidity with other substance use and mental health conditions, and potential biases in the subjective attribution of morbidity to gambling. An alternative indirect elicitation approach is outlined, and a conceptual framework for its application to gambling is provided. Significant risk factors for propensity to develop gambling problems are enumerated, and relative risks for comorbidities are calculated from recent meta-analyses and reviews. Indirect elicitation provides a promising alternative framework for assessing the causal link between gambling problems and morbidity. This approach requires implementation of propensity score matching to estimate the counterfactual, and demands high quality information of risk factors and comorbid conditions, in order to estimate the unique contribution of gambling problems. Gambling harm is best understood as a decrement to health utility. However, achieving consensus on the severity of gambling problems requires triangulation of results from multiple methodologies. Indirect elicitation with propensity score matching and accounting for comorbidities would provide an important step towards full integration of gambling within a public health paradigm.

Levels of support for the licensing of tobacco retailers in Australia: findings from the National Drug Strategy Household Survey 2004-2016.

BACKGROUND: Assessing public opinion towards tobacco policies is important, particularly when determining the possible direction of future public health policies. The aim of this study was to describe the implementation of tobacco retailer licensing systems by state and territory governments in Australia, and to use the National Drug Strategy Household Survey (NDSHS) to assess levels of public support for a retailer licensing system in each jurisdiction over time and by a range of socio-demographic and behavioural attributes. METHODS: National and state/territory estimates of public support for a tobacco retailer licensing system were derived as proportions using NDSHS data from 2004 to 2016. The effect of one's jurisdiction of residence on the likelihood of supporting such an initiative in 2016 was assessed using logistic regression while controlling for various socio-demographic and behavioural characteristics. RESULTS: Public support for a tobacco retailer licensing system ranged from a high of 67.2% (95% CI 66.5-67.9%) nationally in 2007 and declined to 59.5% (95% CI 58.9-60.2%) in 2016. In 2016, support was greatest amongst those from Tasmania, those aged 50 years and older, females, those from the least disadvantaged areas, those living in major cities, never-smokers and never-drinkers. After adjusting for the socio-demographic and behavioural attributes of respondents, those from Queensland were significantly less likely to support a licensing system (adjusted OR = 0.85, 95% CI 0.77-0.94) compared to those from other jurisdictions, while those from Tasmania were significantly more likely to support a licensing system compared to those from other jurisdictions (adjusted OR = 1.29, 95% CI 1.09-1.52). CONCLUSIONS: A clear majority of the public support a tobacco retailer licensing system, regardless of whether or not such a system is already in place in their jurisdiction of residence. Tobacco control initiatives other than a retailer licensing system may explain some of the residual variations in support observed between jurisdictions.

What impact do chronic disease self-management support interventions have on health inequity gaps related to socioeconomic status: a systematic review.

BACKGROUND: The social gradient in chronic disease (CD) is well-documented, and the ability to effectively self-manage is crucial to reducing morbidity and mortality from CD. This systematic review aimed to assess the moderating effect of socioeconomic status on self-management support (SMS) interventions in relation to participation, retention and post-intervention outcomes. METHODS: Six databases were searched for studies of any design published until December 2018. Eligible studies reported on outcomes from SMS interventions for adults with chronic disease, where socioeconomic status was recorded and a between-groups comparison on SES was made. Possible outcomes were participation rates, retention rates and clinical or behavioural post-intervention results. RESULTS: Nineteen studies were retrieved, including five studies on participation, five on attrition and nine studies reporting on outcomes following SMS intervention. All participation studies reported reduced engagement in low SES cohorts. Studies assessing retention and post-intervention outcomes had variable results, related to the diversity of interventions. A reduction in health disparity was seen in longer interventions that were individually tailored. Most studies did not provide a theoretical justification for the intervention being investigated, although four studies referred to Bandura's concept of self-efficacy. CONCLUSIONS: The limited research suggests that socioeconomic status does moderate the efficacy of SMS interventions, such that without careful tailoring and direct targeting of barriers to self-management, SMS may exacerbate the social gradient in chronic disease outcomes. Screening for patient disadvantage or workload, rather than simply recording SES, may increase the chances of tailored interventions being directed to those most likely to benefit from them. Future interventions for low SES populations should consider focussing more on treatment burden and patient capacity. TRIAL REGISTRATION: PROSPERO registration CRD42019124760. Registration date 17/4/19.

The mediating role of sleep in the relationship between Indigenous status and body mass index in Australian school-aged children.

AIM: Associations between sleep duration and obesity and between obesity and chronic illness are established. Current rates of obesity for all Australian people are rising. Recent reports indicate that high body mass index (BMI) is a leading contributor to overall burden of disease for Indigenous Australians. Understanding the factors that contribute to higher rates of obesity in Indigenous people is critical to developing effective interventions for reducing morbidity and premature mortality in this population. To explore the effect of sleep duration on the relationship between Indigenous status and BMI in Australian children. METHODS: 716 non-Indigenous and 186 Indigenous children aged 5-12 years in the Australian Health Survey 2011-2013. Primary carers were interviewed regarding children's sleep times; BMI was derived from measurement. RESULTS: Analysis of covariance revealed that regardless of a number of demographic and socio-economic status markers, sleep duration and Indigenous status were independent predictors of BMI. However when both predictors were considered together, only sleep duration remained predictive of BMI. CONCLUSIONS: Sleep duration plays an important mediating role in the relationship between Indigenous status and BMI in this Australian sample. Modification of sleep duration for Indigenous children may lead to longer-term positive health outcomes.

Surgeons and preventive health: a mixed methods study of current practice, beliefs and attitudes influencing health promotion activities amongst public hospital surgeons.

BACKGROUND: Little is known about the participation of surgeons in preventative health activities in the non-admitted hospital care setting. The aim of this study was to identify which preventive health activities surgeons practice and to explore their attitudes towards preventive health. METHODS: A mixed methods study was conducted using a sequential explanatory design. Quantitative results were obtained from a self-reported clinician survey (n = 16) and a Generalized Estimating Equation was used to assess the relationship between dependent (preventive health practice) and independent (confidence and knowledge in preventive health practice, years of practice, and attitudinal factors) variables. Using a building approach to integration, results from the quantitative analyses informed design of the interview guide. Surgeons' beliefs and attitudes were explored using in-depth, semi structured interviews with a purposeful sample of surgeons (n = 14). Responses were collected, independently coded and analysed using a qualitative descriptive approach. RESULTS: In accordance with a contiguous narrative approach to integration, the quantitative and qualitative findings are reported separately. The clinician survey found that the surgeons carried out preventive health activities at low levels. Preventive health advice was predominantly verbal in nature, and few surgeons provided written material or referred patients to additional services. The GEE analyses indicated that the following factors best predicted the tendency to undertake preventive health activities: years of clinical practice (p = 0.041), and the perceived work priority placed on preventive health (p = 0.008). Interviews generated four themes that influenced the tendency of surgeons to undertake preventive health activities: perceptions of their role in preventive health, perceived motivation of patients, hospital structure, and facilitating factors. In regards to enabling factors that are likely to increase preventive health practice, surgeons unanimously advocated for referral pathways into specialist behaviour change programs that they could facilitate within their relatively brief consulting time. CONCLUSIONS: The findings suggests that the majority of public hospital surgeons engage in routine preventive health advice at a low level. The high volume of non-admitted surgical consultations undertaken annually, coupled with medium to high self-reported knowledge and confidence in addressing behavioural risk factors, support an increased involvement of surgeons in preventive health practice.

Integrated motivational interviewing and cognitive behaviour therapy for lifestyle mediators of overweight and obesity in community-dwelling adults: a systematic review and meta-analyses.

BACKGROUND: The aim of this study was to investigate whether integrated motivational interviewing and cognitive behaviour therapy leads to changes in lifestyle mediators of overweight and obesity in community-dwelling adults. METHOD: Six electronic databases were systematically searched up to 04 October, 2017. Analyses were restricted to randomised controlled trials that examined the effect of integrated motivational interviewing and cognitive behaviour therapy on lifestyle mediators of overweight and obesity (physical activity, diet, body composition) in community-dwelling adults. Meta-analyses were conducted using change scores from baseline in outcome measures specific to the lifestyle mediators of overweight and obesity to determine standardized mean differences (SMD) and 95% confidence intervals (95% CI). The Grades of Recommendation, Assessment, Development and Evaluation approach was used to evaluate the quality of the evidence. RESULTS: Ten randomised controlled trials involving 1949 participants were included. Results revealed moderate quality evidence that integrated motivational interviewing and cognitive behaviour therapy had a significant effect in increasing physical activity levels in community-dwelling adults (SMD: 0.18, 95% CI: 0.06 to 0.31, p < 0.05). The combined intervention resulted in a small, non-significant effect in body composition changes (SMD: -0.12, 95% CI: -0.24 to 0.01, p = 0.07). Insufficient evidence existed for outcome measures relating to dietary change. DISCUSSION: The addition of integrated motivational interviewing and cognitive behaviour therapy to usual care can lead to modest improvements in physical activity and body composition for community-dwelling adults. The available evidence demonstrates that it is feasible to integrate MI with CBT and that this combined intervention has the potential to improve health-related outcomes. CONCLUSION: This review details recommendations for future research including the adoption of uniform objective outcome measures and well-defined interventions with sufficient follow-up durations and assessments of treatment fidelity.