A systems science leverage point analysis of climate change advocacy.

Failure of governments across the world to address climate change has fuelled social movements focused on climate-related policy and action. Research analysing these movements has focused mainly on the types of strategies employed including blockades and occupations, marches and petitions, divestment, boycotts and litigation as well as how groups are framing climate change as a problem. What has been largely missed are the ways these groups are framing the change they want to see, that is their demands to governments. Not all demands and actions have the same potential to create the changes needed to mitigate climate change. Used in public health and health promotion, the systems science Intervention Level Framework (ILF) is a tool that can help analyse to what extent different demands have the leverage to create change in a system. We use the ILF to analyse 131 demands from 35 different climate-related advocacy groups in Australia. Results show demands are more focused on lower system leverage points, such as stopping particular projects, rather than on more impactful leverage points, such as the governance structures that determine climate-related policy and decision-making mechanisms. Further, the results highlight the lack of attention on public health related topics of transport and food systems. This paper shows how a systems science framework used in health promotion, the ILF, could enable climate advocacy groups to more effectively target demands to achieve more impactful outcomes from governments, corporations and the public.

Estimating the reduction in US mortality if cigarettes were largely replaced by e-cigarettes.

BACKGROUND: Recent estimates indicated substantially replacing cigarettes by e-cigarettes would, during 2016-2100, reduce US deaths and life-years lost (millions) by 6.6 and 86.7 (Optimistic Scenario) and 1.6 and 20.8 (Pessimistic). To provide additional insight we use alternative modelling based on a shorter period (1991-2040), four main smoking-associated diseases, deaths aged 30-79 years, and a full product history. We consider variations in: assumed effective dose of e-cigarettes versus cigarettes (F); their relative quitting rate (Q); proportions smoking after 10 years (X); and initiation rate (I) of vaping, relative to smoking. METHODS: We set F = 0.05, X = 5%, Q = 1.0 and I = 1.0 (Main Scenario) and F = 0.4, X = 10%, Q = 0.5 and I = 1.5 (Pessimistic Scenario). Sensitivity Analyses varied Main Scenario parameters singly; F from 0 to 0.4, X 0.01% to 15%, and Q and I 0.5 to 1.5. To allow comparison with prior work, individuals cannot be dual users, re-initiate, or switch except from cigarettes to e-cigarettes. RESULTS: Main Scenario reductions were 2.52 and 26.23 million deaths and life-years lost; Pessimistic Scenario reductions were 0.76 and 8.31 million. These were less than previously, due to the more limited age-range and follow-up, and restriction to four diseases. Reductions in deaths (millions) varied most for X, from 3.22 (X = 0.01%) to 1.31 (X = 15%), and F, 2.74 (F = 0) to 1.35 (F = 0.4). Varying Q or I had little effect. CONCLUSIONS: Substantial reductions in deaths and life-years lost were observed even under pessimistic assumptions. Estimates varied most for X and F. These findings supplement literature indicating e-cigarettes can importantly impact health challenges from smoking.

Application of theories of the policy process in research on consumption of sustainable diets: a systematic review.

BACKGROUND: There is a significant global lack of policy action on consumption of sustainable diets. Application of political science theories such as theories of the policy process can help in understanding policy inaction. Applying these theories could provide a more in-depth understanding of how various influences on the policy process shape decision making for consumption of sustainable diet policy. METHODS: A systematic review to examine application of eight key political science theories of the policy process to research on consumption of sustainable diets was conducted. RESULTS: The review identified no papers applying a theory of the policy process although 17 papers did mention or discuss influences on the policy process that are common elements within theories of the policy process. Most notably these elements were the influence of coalitions/networks, evidence use, narratives and framing, institutional and political system factors, and the importance of value and belief systems and socio-cultural norms. However, in most papers these influences were not examined in a detailed or in-depth way and often presented as suggestions for lack of policy action without the support of empirical data or application of any theory. CONCLUSIONS: Most research discussing policy inaction on the consumption of sustainable diets fails to utilise political science theories of the policy process, although a small number of papers include mention of or discussion of influences on the policy process. Application of political science theories could provide a more in-depth understanding of how different determinants might shape decision making at various points in the policy process. This could help identify key reasons for policy inaction on the consumption of sustainable diets and suggest possible ways to increase attention and action on the issue from policy decision makers.

Organisational structures and processes for health and well-being: insights from work integration social enterprise.

BACKGROUND: Previous research on employee well-being for those who have experienced social and economic disadvantage and those with previous or existing mental health conditions has focused mainly on programmatic interventions. The purpose of this research was to examine how organisational structures and processes (such as policies and culture) influence well-being of employees from these types of backgrounds. METHODS: A case study ethnographic approach which included in-depth qualitative analysis of 93 semi-structured interviews of employees, staff, and managers, together with participant observation of four social enterprises employing young people. RESULTS: The data revealed that young people were provided a combination of training, varied work tasks, psychosocial support, and encouragement to cultivate relationships among peers and management staff. This was enabled through the following elements: structure and space; funding, finance and industry orientation; organisational culture; policy and process; and fostering local service networks.. The findings further illustrate how organisational structures at these workplaces promoted an inclusive workplace environment in which participants self-reported a decrease in anxiety and depression, increased self-esteem, increased self-confidence and increased physical activity. CONCLUSIONS: Replicating these types of organisational structures, processes, and culture requires consideration of complex systems perspectives on implementation fidelity which has implications for policy, practice and future research.

The health and well-being impacts of a work integration social enterprise from a systems perspective.

Recent research has drawn upon the social determinants of health (SDH) framework to attempt to systematize the relationship between social enterprise and health. In this article, we adopt a realist evaluation approach to conceptualize social enterprises, and work integration social enterprises in particular, as 'complex interventions' that necessarily produce differential health outcomes for their beneficiaries, communities and staff. Drawing upon the findings from four social enterprises involving a range of methods including 93 semi-structured interviews with employees, managers and enterprise partners, together with participant observation, we demonstrate that these health outcomes are influenced by a limitless mix of complex and dynamic interactions between systems, settings, spaces, relationships and organizational and personal factors that cannot be distilled by questions of causality and attribution found in controlled trial designs. Given the increased policy focus on the potential of social enterprises to affect the SDH, this article seeks to respond to evidence gaps about the mechanisms and contexts through which social enterprises promote or constrain health outcomes, and thereby provide greater clarity about how research evidence can be used to support the social enterprise sector and policy development more broadly.

Work integration social enterprises (WISEs) are hybrid organizations that operate as businesses with a social purpose. WISEs focus on employment of people excluded from open employment, often as a result of discriminatory attitudes and practices of employers to people from minority groups and those experiencing disability or health-related problems. There is a lack of research on the ways in which a WISE could positively impact on individual health and well-being. We interviewed employees, managers and enterprise partners, together with participant observation, across four social enterprises to understand these dynamics. Through a number of strategies including flexible workplace structures, a culture of acceptance and support, encouragement to take risks and make mistakes and creative use of space, the participants described changes to health and well-being such as decreased symptoms of anxiety and depression, increased social connections, improved physical activity and increased confidence and self-esteem. Results show a mix of strategies combined with individually tailored support; this has implications for the type of research that is appropriate to understand these impacts. We conclude with suggestions on how future research could use complex research designs to understand how WISEs can influence health and well-being.

Neuropilins guide preganglionic sympathetic axons and chromaffin cell precursors to establish the adrenal medulla.

The adrenal medulla is composed of neuroendocrine chromaffin cells that secrete adrenaline into the systemic circulation to maintain physiological homeostasis and enable the autonomic stress response. How chromaffin cell precursors colonise the adrenal medulla and how they become connected to central nervous system-derived preganglionic sympathetic neurons remain largely unknown. By combining lineage tracing, gene expression studies, genetic ablation and the analysis of mouse mutants, we demonstrate that preganglionic axons direct chromaffin cell precursors into the adrenal primordia. We further show that preganglionic axons and chromaffin cell precursors require class 3 semaphorin (SEMA3) signalling through neuropilins (NRP) to target the adrenal medulla. Thus, SEMA3 proteins serve as guidance cues to control formation of the adrenal neuroendocrine system by establishing appropriate connections between preganglionic neurons and adrenal chromaffin cells that regulate the autonomic stress response.

Changes in Interventional Pain Physician Decision-Making, Practice Patterns, and Mental Health During the Early Phase of the SARS-CoV-2 Global Pandemic.

BACKGROUND AND OBJECTIVES: The novel coronavirus outbreak (SARS-CoV-2) began in late 2019 and dramatically impacted health care systems. This study aimed to describe the impact of the early phase of the pandemic on physician decision-making, practice patterns, and mental health. METHODS: An anonymous survey was distributed to physician members of the Spine Intervention Society (SIS) on March 24 and April 7, 2020. Respondents provided information regarding changes in clinical volume, treatment, and mental health (Patient Health Questionnaire [PHQ-4]) before April 10, 2020. RESULTS: Of the 1,430 individuals who opened the survey, 260 completed it (18.2%). Overall clinical and procedural volume decreased to 69.6% and 13.0% of prepandemic volume, respectively. Mean in-person clinic visits were reduced to 17.7% of total prepandemic clinic volume. Ongoing clinical visits were predominantly completed via telemedicine (video) or telephone (74.5%), rather than in-person (25.5%). Telemedicine and telephone visits represented 24.6% and 27.3% of prepandemic clinical volume, respectively. Respondents decreased in-person visits of select groups of high-risk patients by 85.8-94.6%. Significantly more providers reported increasing rather than decreasing prescriptions of the following medications: opioids (28.8% vs 6.2% of providers, P < 0.001), muscle relaxants (22.3% vs 5.4%, P < 0.001), neuropathic pain medications (29.6% vs 3.8%, P < 0.001), and acetaminophen (26.2% vs 4.2%, P < 0.001). Respondents' mean PHQ-4 score was 3.1, with 19% reporting moderate or severe psychological distress. Several demographic factors were significantly associated with practice changes. CONCLUSIONS: The novel coronavirus pandemic dramatically altered the practice and prescribing patterns of interventional pain physicians.

Independent Validation in a Large Privately Insured Population of the Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose.

OBJECTIVE: To assess the generalizability of the overdose or serious opioid-induced respiratory depression risk index (VHA-RIOSORD), created by Zedler et al., using claims data from a large private insurer. DESIGN: A retrospective nested case-control analysis of health care claims data. SUBJECTS: Commercially insured individuals with a claim for an opioid prescription between October 1, 2014, and September 30, 2016 (N = 1,431,737). METHODS: An overdose or serious opioid-induced respiratory depression (OSORD) occurred in 1,097 patients. Ten controls were selected per case (N = 10,970). Items and the assignment of point values to predictors were consistent with those determined by Zedler et al. Modeling of risk index scores produced predicted probabilities of OSORD; risk classes were defined by the predicted probability distribution. RESULTS: All 15 items of the VHA-RIOSORD were used to determine a member's risk of OSORD. The average predicted probability of experiencing OSORD ranged from 3% in the lowest risk decile to 90% in the highest, with excellent agreement between predicted and observed incidence across risk classes. The model's C-statistic was 0.88. CONCLUSIONS: Consistent with the findings of its developers, the VHA-RIOSORD performed well in identifying members of a large private insurance company who were medical users of prescription opioids at elevated risk of overdose or life-threatening respiratory depression, those most likely to benefit from preventive interventions.

The presence and severity of nonalcoholic steatohepatitis is associated with specific changes in circulating bile acids.

The histologic spectrum of nonalcoholic fatty liver disease (NAFLD) includes fatty liver (NAFL) and steatohepatitis (NASH), which can progress to cirrhosis in up to 20% of NASH patients. Bile acids (BA) are linked to the pathogenesis and therapy of NASH. We (1) characterized the plasma BA profile in biopsy-proven NAFL and NASH and compared to controls and (2) related the plasma BA profile to liver histologic features, disease activity, and fibrosis. Liquid chromatography/mass spectrometry quantified BAs. Descriptive statistics, paired and multiple group comparisons, and regression analyses were performed. Of 86 patients (24 controls, 25 NAFL, and 37 NASH; mean age 51.8 years and body mass index 31.9 kg/m2 ), 66% were women. Increased total primary BAs and decreased secondary BAs (both P < 0.05) characterized NASH. Total conjugated primary BAs were significantly higher in NASH versus NAFL (P = 0.047) and versus controls (P < 0.0001). NASH had higher conjugated to unconjugated chenodeoxycholate (P = 0.04), cholate (P = 0.0004), and total primary BAs (P < 0.0001). The total cholate to chenodeoxycholate ratio was significantly higher in NAFLD without (P = 0.005) and with (P = 0.02) diabetes. Increased key BAs were associated with higher grades of steatosis (taurocholate), lobular (glycocholate) and portal inflammation (taurolithocholate), and hepatocyte ballooning (taurocholate). Conjugated cholate and taurocholate directly and secondary to primary BA ratio inversely correlated to NAFLD activity score. A higher ratio of total secondary to primary BA decreased (odds ratio, 0.57; P = 0.004) and higher conjugated cholate increased the likelihood of significant fibrosis (F≥2) (P = 0.007). Conclusion: NAFLD is associated with significantly altered circulating BA composition, likely unaffected by type 2 diabetes, and correlated with histological features of NASH; these observations provide the foundation for future hypothesis-driven studies of specific effects of BAs on specific aspects of NASH. (Hepatology 2018;67:534-548).

Validation of an administrative claims coding algorithm for serious opioid overdose: A medical chart review.

PURPOSE: A standardized definition for serious opioid overdose has not been clearly established for disease surveillance or assessing the impact of risk mitigation strategies. The purpose of this study was to use medical chart review to clinically validate a claims-based algorithm to identify serious opioid overdose events. METHODS: The algorithm for serious opioid overdose required an opioid poisoning or external cause ICD-9-CM code occurring within 1 day of (a) an adverse effect code for serious central nervous system or respiratory depression or (b) a mechanical ventilation or critical care CPT code. The claims coding algorithm identified a sample of 145 individuals 18 years or older among patients that presented to the emergency department of two large hospitals in metropolitan Atlanta, Georgia from January 2014 to August 2015. Claims-defined cases were evaluated against rigorous clinical definitions for serious opioid overdose using (a) literature-based criteria for typical clinical manifestations of opioid overdose and/or (b) clinical response to the opioid-specific reversal agent naloxone. The positive predictive value (PPV) for a serious opioid overdose was calculated as the percentage of clinically confirmed cases (definite or probable). RESULTS: Among 140 evaluable claims-defined cases, 107 fulfilled clinical criteria for a serious opioid overdose [95 definite and 12 probable; PPV of 76.4% (95% CI 69.4%, 83.5%)]. Among 30 nonconfirmed cases, 20 were polyintoxications involving one or more nonopioid psychoactive agents. CONCLUSIONS: An administrative claims coding algorithm for serious opioid overdose had high clinical predictive performance in a medical chart review.

Alignment and political will: upscaling an Australian respectful relationships program.

Many small scale efficacious programs and interventions need to be 'scaled-up' in order to reach a larger population. Although it has been argued that interventions deemed suitable for upscaling need to have demonstrated effectiveness, be able to be implemented cost-effectively and be accepted by intended recipients, these factors alone are insufficient in explaining which programs are adopted more broadly. Upscaling research often identifies political will as a key factor in explaining whether programs are supported and up-scaled, but this research lacks any depth into how political will is formed and has not applied policy theories to understanding the upscaling process. This article uses a political science lens to examine the key factors in the upscaling process of a Respectful Relationships in Schools Program. Focus groups and interviews were conducted with project staff, managers and community organizations involved in the program. The results reveal how a key focusing event related to a highly profiled personal tragedy propelled family violence into the national spotlight. At the same time, the organization leading the respectful relationships program leveraged their networks to position the program within the education department which enabled the government to quickly respond to the issue. The study highlights that political will is not a stand-alone factor as depicted by up-scaling models, but rather is the end point of a complex process that involves many elements including the establishment of networks and aligned programs that can capitalize when opportunities arise.

The influence of contextual factors on implementation fidelity in a whole school approach to prevention of violence against women.

ISSUE ADDRESSED: Implementation fidelity relates to the degree of adherence to implementation protocols and content and helps to guide replication of evidence-based programs. In settings-based research, notions of fidelity have been applied more often to delivery of education content rather than whole of setting change. The aims of this paper were firstly, to analyse how contextual factors influenced implementation of a whole school program on respectful relationships education, and secondly given the findings, discuss whether a more flexible approach to implementation fidelity may have yielded increased school engagement. METHODS: The project was conducted in 19 secondary schools in Victoria in 2015. This paper reports on focus groups and interviews which were conducted with 81 school staff and 28 staff from the lead agency, community agency partners, and departmental staff to understand the contextual factors influencing implementation. RESULTS: The program followed a traditional implementation fidelity approach of considering core elements and some minor scope for adaption which engaged some regions and schools but not others. CONCLUSION: An alternative notion of implementation fidelity, "fidelity to function," may have permitted increased flexibility to tailor the intervention components to suit different school and community contexts and potentially, increasing both the reach and impact of the program. SO WHAT?: Understanding how to apply notions of fidelity to guide whole of setting change are important considerations if programs are to be replicated to have wider reach and greater impact and effectiveness.

Validation of a Screening Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in a US Commercial Health Plan Claims Database.

Objective: To validate a risk index that estimates the likelihood of overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids. Subjects and Methods: A case-control analysis of 18,365,497 patients with an opioid prescription from 2009 to 2013 in the IMS PharMetrics Plus commercially insured health plan claims database (CIP). An OIRD event occurred in 7,234 cases. Four controls were selected per case. Validity of the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD), developed previously using Veterans Health Administration (VHA) patient data, was assessed. Multivariable logistic regression was used within the CIP study population to develop a slightly refined RIOSORD. The composition and performance of the CIP-based RIOSORD was evaluated and compared with VHA-based RIOSORD. Results: VHA-RIOSORD performed well in discriminating OIRD events in CIP (C-statistic = 0.85). Additionally, re-estimation of logistic model coefficients in CIP yielded a 0.90 C-statistic. The resulting comorbidity and pharmacotherapy variables most highly associated with OIRD and retained in the CIP-RIOSORD were largely concordant with VHA-RIOSORD. These variables included neuropsychiatric and cardiopulmonary disorders, impaired drug excretion, opioid characteristics, and concurrent psychoactive medications. The average predicted probability of OIRD ranged from 2% to 83%, with excellent agreement between predicted and observed incidence across risk classes. Conclusions: RIOSORD had excellent predictive accuracy in a large population of US medical users of prescription opioids, similar to its performance in VHA. This practical risk index is designed to support clinical decision-making for safer opioid prescribing, and its clinical utility should be evaluated prospectively.

Risk Factors for Serious Prescription Opioid-Induced Respiratory Depression or Overdose: Comparison of Commercially Insured and Veterans Health Affairs Populations.

Objective: To characterize the risk factors associated with overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids in a commercially insured population (CIP) and to compare risk factor profiles between the CIP and Veterans Health Administration (VHA) population. Subjects and Methods: Analysis of data from 18,365,497 patients in the IMS PharMetrics Plus health plan claims database (CIP) who were dispensed a prescription opioid in 2009 to 2013. Baseline factors associated with an event of serious OIRD among 7,234 cases and 28,932 controls were identified using multivariable logistic regression. The CIP risk factor profile was compared with that from a corresponding logistic regression among 817 VHA cases and 8,170 controls in 2010 to 2012. Results: The strongest associations with serious OIRD in CIP were diagnosed substance use disorder (odds ratio [OR] = 10.20, 95% confidence interval [CI] = 9.06-11.40) and depression (OR = 3.12, 95% CI = 2.84-3.42). Other strongly associated factors included other mental health disorders; impaired liver, renal, vascular, and pulmonary function; prescribed fentanyl, methadone, and morphine; higher daily opioid doses; and concurrent psychoactive medications. These risk factors, except depression, vascular disease, and specific opioids, largely aligned with VHA despite CIP being substantially younger, including more females and less chronic disease, and having greater prescribing prevalence of higher daily opioid doses, specific opioids, and most selected nonopioids. Conclusions: Risk factor profiles for serious OIRD among US medical users of prescription opioids with private or public health insurance were largely concordant despite substantial differences between the populations in demographics, clinical conditions, health care delivery systems, and clinical practices.

Evaluating for impact: what type of data can assist a health promoting school approach?

There is debate within the health promoting school (HPS) movement on whether schools should monitor health behaviour outcomes as part of an evaluation or rely more on process type measures, such as changes to school policies and the physical and social environment which yield information about (in)effective implementation. The debate is often framed around ideological considerations of the role of schools and there is little empirical work on how these indicators of effective implementation can influence change at a policy and practice level in real world settings. Information has potentially powerful effects in motivating a change process, but this will vary according to the type of information and the type of organizational culture into which it is presented. The current predominant model relies on process data, policy and environmental audit monitoring and benchmarking approaches, and there is little evidence of whether this engages school communities. Theoretical assertions on the importance of monitoring data to motivate change need to be empirically tested and, in doing so, we can learn which types of data influence adoption of HPS in which types of school and policy contexts.

Core Training in Low Back Disorders: Role of the Pilates Method.

The Pilates method is a system of exercises developed by Joseph Pilates, which emphasizes recruitment and strengthening of the core muscles, flexibility, and breathing, to promote stability and control of movement. Its focus bears similarity to current evidence-based exercise programs for low back disorders. Spinal stability is a function of three interdependent systems, osseoligamentous, muscular, and neural control; exercise addresses both the muscular and neural function. The "core" typically refers to the muscular control required to maintain functional stability. Prior research has highlighted the importance of muscular strength and recruitment, with debate over the importance of individual muscles in the wider context of core control. Though developed long before the current evidence, the Pilates method is relevant in this setting and clearly relates to current evidence-based exercise interventions. Current literature supports the Pilates method as a treatment for low back disorders, but its benefit when compared with other exercise is less clear.

Alcohol produces distinct hepatic lipidome and eicosanoid signature in lean and obese.

Alcohol- and obesity-related liver diseases often coexist. The hepatic lipidomics due to alcohol and obesity interaction is unknown. We characterized the hepatic lipidome due to 1) alcohol consumption in lean and obese mice and 2) obesity and alcohol interactions. In the French-Tsukamoto mouse model, intragastric alcohol or isocaloric dextrose were fed with either chow (lean) or high-fat, high-cholesterol diet (obese). Four groups (lean, lean alcohol, obese, and obese alcohol) were studied. MS was performed for hepatic lipidomics, and data were analyzed. Alcohol significantly increased hepatic cholesteryl esters and diacyl-glycerol in lean and obese but was more pronounced in obese. Alcohol produced contrasting changes in hepatic phospholipids with significant enrichment in lean mice versus significant decrease in obese mice, except phosphatidylglycerol, which was increased in both lean and obese alcohol groups. Most lysophospholipids were increased in lean alcohol and obese mice without alcohol use only. Prostaglandin E2; 5-, 8-, and 11-hydroxyeicosatetraenoic acids; and 9- and 13-hydroxyoctadecadienoic acids were considerably increased in obese mice with alcohol use. Alcohol consumption produced distinct changes in lean and obese with profound effects of obesity and alcohol interaction on proinflammatory and oxidative stress-related eicosanoids.

Applying systems theory to the evaluation of a whole school approach to violence prevention.

Issue addressed Our Watch led a complex 12-month evaluation of a whole school approach to Respectful Relationships Education (RRE) implemented in 19 schools. RRE is an emerging field aimed at preventing gender-based violence. This paper will illustrate how from an implementation science perspective, the evaluation was a critical element in the change process at both a school and policy level. Methods Using several conceptual approaches from systems science, the evaluation sought to examine how the multiple systems layers - student, teacher, school, community and government - interacted and influenced each other. A distinguishing feature of the evaluation included 'feedback loops'; that is, evaluation data was provided to participants as it became available. Evaluation tools included a combination of standardised surveys (with pre- and post-intervention data provided to schools via individualised reports), reflection tools, regular reflection interviews and summative focus groups. Results Data was shared during implementation with project staff, department staff and schools to support continuous improvement at these multiple systems levels. In complex settings, implementation can vary according to context; and the impact of evaluation processes, tools and findings differed across the schools. Interviews and focus groups conducted at the end of the project illustrated which of these methods were instrumental in motivating change and engaging stakeholders at both a school and departmental level and why. Conclusion The evaluation methods were a critical component of the pilot's approach, helping to shape implementation through data feedback loops and reflective practice for ongoing, responsive and continuous improvement. Future health promotion research on complex interventions needs to examine how the evaluation itself is influencing implementation. So what? The pilot has demonstrated that the evaluation, including feedback loops to inform project activity, were an asset to implementation. This has implications for other health promotion activities, where evaluation tools could be utilised to enhance, rather than simply measure, an intervention. The findings are relevant to a range of health promotion research activities because they demonstrate the importance of meta-evaluation techniques that seek to understand how the evaluation itself was influencing implementation and outcomes.

Development of a Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in Veterans' Health Administration Patients.

OBJECTIVE: Develop a risk index to estimate the likelihood of life-threatening respiratory depression or overdose among medical users of prescription opioids. SUBJECTS, DESIGN, AND METHODS: A case-control analysis of administrative health care data from the Veterans' Health Administration identified 1,877,841 patients with a pharmacy record for an opioid prescription between October 1, 2010 and September 30, 2012. Overdose or serious opioid-induced respiratory depression (OSORD) occurred in 817. Ten controls were selected per case (n = 8,170). Items for an OSORD risk index (RIOSORD) were selected through logistic regression modeling, with point values assigned to each predictor. Modeling of risk index scores produced predicted probabilities of OSORD; risk classes were defined by the predicted probability distribution. RESULTS: Fifteen variables most highly associated with OSORD were retained as items, including mental health disorders and pharmacotherapy; impaired drug metabolism or excretion; pulmonary disorders; specific opioid characteristics; and recent hospital visits. The average predicted probability of experiencing OSORD ranged from 3% in the lowest risk decile to 94% in the highest, with excellent agreement between predicted and observed incidence across risk classes. The model's C-statistic was 0.88 and Hosmer-Lemeshow goodness-of-fit statistic 10.8 (P > 0.05). CONCLUSION: RIOSORD performed well in identifying medical users of prescription opioids within the Veterans' Health Administration at elevated risk of overdose or life-threatening respiratory depression, those most likely to benefit from preventive interventions. This novel, clinically practical, risk index is intended to provide clinical decision support for safer pain management. It should be assessed, and refined as necessary, in a more generalizable population, and prospectively evaluated.

A qualitative exploration of the emotional wellbeing and support needs of new mothers from Afghanistan living in Melbourne, Australia.

BACKGROUND: The Afghan community is a priority population for many health and social services within the southeast region of Melbourne, which is home to the largest population of Afghanistan-born people within the state of Victoria. The majority of Afghan women arriving in Australia are of childbearing age, and evidence suggests that they are at increased risk of emotional challenges following birth as a result of the refugee and migration experience. This research aimed to explored the experiences of Afghan women living in Melbourne throughout pregnancy, birth, and early motherhood, and gain insight into the aspects of their experiences that they perceive as positively and negatively impacting their emotional wellbeing. METHODS: This qualitative study collected data through two focus group discussions (conducted in Dari) and 10 in-depth interviews (conducted in Dari or English). Thirty-eight Afghanistan-born women aged 18 years and older, who recently migrated to Australia and have at least one Australian-born child, were purposively selected to participate. A trained bicultural worker assisted in recruitment, data collection and translation. Thematic analysis was performed, and findings were confirmed with a subgroup of participants prior to being included within reporting. RESULTS: Participants consistently discussed experiencing emotional challenges following birth, identifying symptoms commonly associated with postnatal depression. Women largely attributed this emotional state to separation from family and culture, leading to loneliness, isolation, and disconnection. Participants expressed resistance towards professional support due to cultural stigma associated with mental illness. Partner support was seen to be positive but difficult to negotiate. Religion, strong relationship with child, forming friendships, education, and utilising childcare were identified as positive influences on the emotional wellbeing of women. CONCLUSIONS: This study highlighted social and cultural factors contributing towards the emotional wellbeing of Afghan mothers. Findings confirm the need for innovative community-based models to support the mental health of Afghan women. This is particularly pertinent given the identified resistance towards discussing emotional wellbeing with healthcare professionals. Further research and investment is required in this area.