Barriers to and enablers of postpartum health behaviours among women from diverse cultural backgrounds with prior gestational diabetes: A systematic review and qualitative synthesis applying the theoretical domains framework.

AIMS: Racial and ethnic disparities exist in gestational diabetes prevalence and risk of subsequent type 2 diabetes mellitus (T2DM). Postpartum engagement in healthy behaviours is recommended for prevention and early detection of T2DM, yet uptake is low among women from diverse cultural backgrounds. Greater understanding of factors impacting postpartum health behaviours is needed. Applying the Theoretical Domains Framework (TDF) and Capability, Opportunity, Motivation-Behaviour (COM-B) model, our aim was to synthesise barriers to and enablers of postpartum health behaviours among women from diverse cultural backgrounds with prior GDM and identify relevant intervention components. METHODS: Databases, reference lists and grey literature were searched from September 2017 to April 2021. Two reviewers screened articles independently against inclusion criteria and extracted data. Using an inductive-deductive model, themes were mapped to the TDF and COM-B model. RESULTS: After screening 5148 citations and 139 full texts, we included 35 studies (N = 787 participants). The main ethnicities included Asian (43%), Indigenous (15%) and African (11%). Barriers and enablers focused on Capability (e.g. knowledge), Opportunity (e.g. competing demands, social support from family, friends and healthcare professionals, culturally appropriate education and resources) and Motivation (e.g. negative emotions, perceived consequences and necessity of health behaviours, social/cultural identity). Five relevant intervention functions are identified to link the barriers and enablers to evidence-based recommendations for communications to support behaviour change. CONCLUSIONS: We provide a conceptual model to inform recommendations regarding the development of messaging and interventions to support women from diverse cultural backgrounds in engaging in healthy behaviours to reduce risk of T2DM.

Effectiveness of nutrition and dietary interventions for people with serious mental illness: systematic review and meta-analysis.

OBJECTIVE: To review recent published trials of nutrition and dietary interventions for people with serious mental illness; to assess their effectiveness in improving metabolic syndrome risk factors. STUDY DESIGN: Systematic review and meta-analysis of randomised and non-randomised controlled trials of interventions with a nutrition/diet-related component delivered to people with serious mental illness, published 1 January 2010 - 6 September 2021. Primary outcomes were weight, body mass index (BMI), and waist circumference. Secondary outcomes were total serum cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglyceride, and blood glucose levels. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL databases. In addition, reference lists of relevant publications were examined for further additional studies. DATA SYNTHESIS: Twenty-five studies encompassing 26 intervention arms were included in our analysis. Eight studies were at low or some risk of bias, seventeen were deemed to be at high risk. Eight of seventeen intervention arms found statistically significant intervention effects on weight, ten of 24 on BMI, and seven of seventeen on waist circumference. The pooled effects of nutrition interventions on metabolic syndrome risk factors were statistically non-significant. However, we identified small size effects on weight for interventions delivered by dietitians (five studies; 262 intervention, 258 control participants; standardised mean difference [SMD], -0.28; 95% CI, -0.51 to -0.04) and interventions consisting of individual sessions only (three studies; 141 intervention, 134 control participants; SMD, -0.30; 95% CI, -0.54 to -0.06). CONCLUSIONS: We found only limited evidence for nutrition interventions improving metabolic syndrome risk factors in people with serious mental illness. However, they may be more effective when delivered on an individual basis or by dietitians. PROSPERO REGISTRATION: CRD42021235979 (prospective).

Should antidiabetic medicines be considered to reduce cardiometabolic risk in patients with serious mental illness?

Substantially reduced life expectancy for people with serious mental illness compared with the general population is primarily driven by physical health issues, of which cardiovascular disease is the leading cause. In this narrative review, we examine the evidence base for use of metformin and other antidiabetic agents as a means for reducing this excess cardiometabolic disease burden. Evidence from randomised controlled trials (RCTs) suggests substantial potential for metformin to prevent or manage weight gain and glycaemic impairment induced by atypical antipsychotic medications, whereas the impact of metformin on other cardiometabolic risk factors is less consistent. Evidence from RCTs also suggests potential benefits from glucagon-like peptide-1 receptor agonists (GLP-1RAs), particularly for addressing cardiometabolic risk factors in people using atypical antipsychotic medications, but this is based on a small number of trials and remains an emerging area of research. Trials of both metformin and GLP-1RAs suggest that these medications are associated with a high prevalence of mild-moderate gastrointestinal side effects. The heterogeneous nature of participant eligibility criteria and of antipsychotic and antidiabetic drug regimens, alongside short trial durations, small numbers of participants and paucity of clinical endpoints as trial outcomes, warrants investment in definitive trials to determine clinical benefits for both metformin and GLP-1RAs. Such trials would also help to confirm the safety profile of antidiabetic agents with respect to less common but serious adverse effects. The weight of RCT evidence suggests that an indication for metformin to address antipsychotic-induced weight gain is worth considering in Australia. This would bring us into line with other countries.

Peer-facilitated interventions for improving the physical health of people with schizophrenia spectrum disorders: systematic review and meta-analysis.

OBJECTIVES: To evaluate the efficacy of peer-facilitated interventions for improving the physical health of people with schizophrenia spectrum disorders. STUDY DESIGN: Systematic review and random effects meta-analysis of peer-facilitated interventions for people with serious mental illness, including schizophrenia spectrum disorders, in which physical health outcomes were assessed. DATA SOURCES: MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science, Scopus, CENTRAL, and PubMed. In addition, reference lists of reviews were examined for further relevant studies published to 10 November 2021. DATA SYNTHESIS: We included fourteen publications (thirteen randomised controlled trials of ten peer-facilitated interventions, and one secondary analysis; total of 2099 participants) that assessed physical health outcomes for people with mental health conditions, including schizophrenia spectrum disorders. Intervention duration ranged from three to eighteen months; peers were involved as sole or co-leaders of the programs in group or individual sessions. Meta-analysis identified a statistically significant pooled effect on physical activity and capacity (various measures; six studies; 468 intervention, 461 control participants; standardised mean difference, +0.19 standard deviation [SD]; 95% CI, +0.06-0.32 SD; I2  = 0%); overall GRADE certainty of evidence was low. Marked study heterogeneity precluded secure conclusions regarding intervention effects on self-rated physical health, healthy eating, and body mass index. CONCLUSIONS: Peer-facilitated interventions for improving physical outcomes are feasible for people with schizophrenia spectrum disorders, a group at particular risk of certain physical health conditions. Further research is required to assess the effects of such interventions on other health-related parameters. PROSPERO REGISTRATION: CRD42021283578 (retrospective).

Implementing primary care diabetes prevention for women with previous gestational diabetes: a mixed-methods study.

BACKGROUND: The implementation of diabetes prevention for women with previous gestational diabetes (GDM) has been stymied by many barriers that are located within routine general practice (GP). We aimed to unpack the GP factors and understand the mechanisms that explain why a diabetes prevention intervention for this population succeeds or fails. METHODS: We performed a mixed-methods study with a Normalization Process Theory framework that included clinical audits, semistructured interviews, and focus groups within mixed urban and rural primary care practices in Victoria, Australia. Staff of primary care practices and external support staff who provide services to women with previous GDM participated in a 12-month quality improvement collaborative intervention. We compared diabetes screening and prevention activity planning with the strategies and factors identified through a process evaluation of full-, moderate-, and low-active participating practices. RESULTS: The intervention doubled screening rates (26%-61%) and 1-in-10 women received a diabetes prevention planning consultation. Critical improvement factors were: mothers being seen as participants in the quality improvement work; staff collectively building care strategies; staff taking a long-term care of a community perspective rather than episodic service delivery; and feedback processes being provided and acted on across the practice. The observable factors from the external perspective were: leadership by identified practice staff, reminder systems in action and practice staff driving the process collectively. CONCLUSIONS: Successful engagement in diabetes prevention for women with previous GDM requires proactive building of the critical improvement factors and audit feedback into routine GP.

Health professional perspectives on the management of multimorbidity and polypharmacy for older patients in Australia.

Background: delivering appropriate care for patients with multimorbidity and polypharmacy is increasingly challenging. Challenges for individual healthcare professions are known, but only little is known about overall healthcare team implementation of best practice for these patients. Objective: to explore current approaches to multimorbidity management, and perceived barriers and enablers to deliver appropriate medications management for community-dwelling patients with multimorbidity and polypharmacy, from a broad range of healthcare professional (HCP) perspectives in Australia. Methods: this qualitative study used semi-structured interviews to gain in-depth understanding of HCPs' perspectives on the management of multimorbidity and polypharmacy. The interview guide was based on established principles for the management of multimorbidity in older patients. HCPs in rural and metropolitan Victoria and South Australia were purposefully selected to obtain a maximum variation sample. Twenty-six HCPs, from relevant medical, dentistry, nursing, pharmacy and allied health backgrounds, were interviewed between October 2013 and February 2014. Fourteen were prescribers and 12 practiced in primary care. Interviews were digitally audio-taped, transcribed verbatim and analysed using a constant comparison approach. Results: most participants did not routinely use structured approaches to incorporate patients' preferences in clinical decision-making, address conflicting prescriber advice, assess patients' adherence to treatment plans or seek to optimise care plans. Most HCPs were either unaware of medical decision aids and measurements tools to support these processes or disregarded them as not being user-friendly. Challenges with coordination and continuity of care, pressures of workload and poorly defined individual responsibilities for care, all contributed to participants' avoiding ownership of multimorbidity management. Potential facilitators of improved care related to improved culture, implementation of electronic health records, greater engagement of pharmacists, nurses and patients, families in care provision, and the use of care coordinators. Conclusion: extensive shortcomings exist in team-based care for the management of multimorbidity. Delegating coordination and review responsibilities to specified HCPs may support improved overall care.

Using local clinical educators and shared resources to deliver simulation training activities across rural and remote South Australia and south-west Victoria: A distributed collaborative model.

PROBLEM: There is a lack of access to simulation-based education (SBE) for professional entry students (PES) and health professionals at rural and remote locations. DESIGN: A descriptive study. SETTING: Health and education facilities in regional South Australia and south-west Victoria. KEY MEASURES FOR IMPROVEMENT: Number of training recipients who participated in SBE; geographical distribution and locations where SBE was delivered; number of rural clinical educators providing SBE. STRATEGIES FOR CHANGE: A distributed model to deliver SBE in rural and remote locations in collaboration with local health and community services, education providers and the general public. Face-to-face meetings with health services and education providers identified gaps in locally delivered clinical skills training and availability of simulation resources. Clinical leadership, professional development and community of practice strategies were implemented to enhance capacity of rural clinical educators to deliver SBE. EFFECTS OF CHANGE: The number of SBE participants and training hours delivered exceeded targets. The distributed model enabled access to regular, localised training for PES and health professionals, minimising travel and staff backfill costs incurred when attending regional centres. The skills acquired by local educators remain in rural areas to support future training. LESSONS LEARNT: The distributed collaborative model substantially increased access to clinical skills training for PES and health professionals in rural and remote locations. Developing the teaching skills of rural clinicians optimised the use of simulation resources. Consequently, health services were able to provide students with flexible and realistic learning opportunities in clinical procedures, communication techniques and teamwork skills.

Improving follow-up care for women with a history of gestational diabetes: perspectives of GPs and patients.

This paper investigates factors influencing women's engagement with diabetes preventative care after a pregnancy with gestational diabetes (GDM) from the perspectives of GPs and women and explores the role of the GP in that care. Qualitative research using semi-structured interviews with women who had experienced GDM (n=16) and GPs (n=18) were conducted and a thematic content analysis conducted. Women's interviews explored their experience of GDM, factors influencing, and engagement with, follow-up care for diabetes prevention and role of the GP in that care. GP interviews explored postnatal care provided to women with GDM, the role of the GP in that care and perceived factors influencing a mother's engagement in her self-care. Three themes were identified: (1) advice and testing; (2) role of the GP; and (3) barriers and enablers to care. Significant consensus about the role of the GP and barriers and enablers to care existed. Both groups believed post GDM follow-up is best done by GPs and suggested recall and reminders would improve care. GPs gave consistent exercise advice, but lacked consensus on follow-up testing, dietary and weight-loss advice. Women's health literacy influenced how they viewed their GPs role. Consensus guidelines on follow-up testing and diabetes prevention advice, tailored advice according to health literacy and addressing barriers to care would likely improve the capacity of GPs to prevent unnecessary conversion to type 2 diabetes in these at-risk women.

Mothers after Gestational Diabetes in Australia (MAGDA): A Randomised Controlled Trial of a Postnatal Diabetes Prevention Program.

BACKGROUND: Gestational diabetes mellitus (GDM) is an increasingly prevalent risk factor for type 2 diabetes. We evaluated the effectiveness of a group-based lifestyle modification program in mothers with prior GDM within their first postnatal year. METHODS AND FINDINGS: In this study, 573 women were randomised to either the intervention (n = 284) or usual care (n = 289). At baseline, 10% had impaired glucose tolerance and 2% impaired fasting glucose. The diabetes prevention intervention comprised one individual session, five group sessions, and two telephone sessions. Primary outcomes were changes in diabetes risk factors (weight, waist circumference, and fasting blood glucose), and secondary outcomes included achievement of lifestyle modification goals and changes in depression score and cardiovascular disease risk factors. The mean changes (intention-to-treat [ITT] analysis) over 12 mo were as follows: -0.23 kg body weight in intervention group (95% CI -0.89, 0.43) compared with +0.72 kg in usual care group (95% CI 0.09, 1.35) (change difference -0.95 kg, 95% CI -1.87, -0.04; group by treatment interaction p = 0.04); -2.24 cm waist measurement in intervention group (95% CI -3.01, -1.42) compared with -1.74 cm in usual care group (95% CI -2.52, -0.96) (change difference -0.50 cm, 95% CI -1.63, 0.63; group by treatment interaction p = 0.389); and +0.18 mmol/l fasting blood glucose in intervention group (95% CI 0.11, 0.24) compared with +0.22 mmol/l in usual care group (95% CI 0.16, 0.29) (change difference -0.05 mmol/l, 95% CI -0.14, 0.05; group by treatment interaction p = 0.331). Only 10% of women attended all sessions, 53% attended one individual and at least one group session, and 34% attended no sessions. Loss to follow-up was 27% and 21% for the intervention and control groups, respectively, primarily due to subsequent pregnancies. Study limitations include low exposure to the full intervention and glucose metabolism profiles being near normal at baseline. CONCLUSIONS: Although a 1-kg weight difference has the potential to be significant for reducing diabetes risk, the level of engagement during the first postnatal year was low. Further research is needed to improve engagement, including participant involvement in study design; it is potentially more effective to implement annual diabetes screening until women develop prediabetes before offering an intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12610000338066.

Utilisation of general practitioner services and achievement of guideline targets by people with diabetes who joined a peer-support program in Victoria, Australia.

This paper describes the use of general practitioner (GP) services and achievement of guideline targets by 285 adults with type 2 diabetes in urban and regional areas of Victoria, Australia. Anthropometric and biomedical measures and responses to a self-administered questionnaire were collected. Findings indicate that almost all participants had visited a GP and had had their hypoglycated haemoglobin (HbA1c) measured in the past 6 months; less than one-third had visited a practice nurse. Fifty per cent achieved a HbA1c target of 7.0%; 40%, a total cholesterol ≤ 4.00 mmol/L; 39%, BP Systolic ≤ 130 mmHg; 51%, BP Diastolic ≤ 80 mmHg; 15%, body mass index ≤ 25 kg/m2; and 34% reported a moderately intense level of physical activity, that is, ≥ 30 min, 5 days a week. However, 39% of individuals achieved at least two targets and 18% achieved at least three of these guideline targets. Regional participants were more likely to report having a management plan and having visited a practice nurse, but they were less likely to have visited other health professionals. Therefore, a more sustained effort that also includes collaborative care approaches is required to improve the management of diabetes in Australia.

Patients' and carers' perceptions of safety in rural general practice.

OBJECTIVES: To explore patients' and carers' experiences of rural general practice to identify their perceptions of safety of care. DESIGN, PARTICIPANTS AND SETTING: Four focus group interviews were conducted with 26 rural patients and carers in south-west Victoria between September and December 2012. Frequent users of general practice were recruited from local allied health self-management programs and a mothers' group. Focus groups were audio recorded, transcripts were independently analysed and interpreted using narrative methodologies. RESULTS: Participants who had experienced some level of harm were able to comment more extensively on safety aspects of care. Several key themes related to safety were identified from the analysis of all participant narratives. An assumed sense of safety in general practice was predominant, and was influenced by participants' level of risk awareness and trust in their general practitioner. Additional unique themes included feelings of vulnerability, desire for an explanation and apology, a forgiving view of mistakes, and preference for GP interpersonal skills over competence. CONCLUSIONS: This study revealed new insights into the factors that influence patients' and carers' perspectives of safety, and demonstrated the value of incorporating the patient voice into safety research. An assumed sense of safety due to a default position of trust, coupled with limited risk perception, directly contests the current literature on patient involvement in safety. Further exploration is required to determine how patients and carers can effectively engage in and assist with improving safety in general practice.

Surveyors' perceptions of the impact of accreditation on patient safety in general practice.

OBJECTIVES: To explore Australian General Practice Accreditation Limited (AGPAL) surveyors' perceptions of the impact of accreditation on patient safety and to elicit suggestions for improving patient safety in Australian general practices. DESIGN, SETTING AND PARTICIPANTS: We conducted semi-structured telephone interviews with a purposive national sample of 10 AGPAL surveyors from 2 July to 14 December 2012. All interviews were audio recorded, transcribed and summarised. RESULTS: All participants agreed that accreditation has improved general practices' performance in quality and safety. Participants noted specific areas that need further attention, including sufficient evidence for clinical risk management, which half the participants estimated occurs in about 5%-10% of Australian general practices. Tangible evidence of patient safety activities included having a significant incidents register, providing documentation of near misses, slips, lapses or mistakes, and engaging in regular clinical meetings to discuss incidents and how to avoid them in the future. Participants agreed that the accreditation process could be improved through the inclusion of tighter clinical safety indicators and the requirement of verifiable evidence of a working clinical risk management system. CONCLUSIONS: Accreditation has had a positive role in improving quality and safety in general practice. The inclusion of tighter indicators that require verifiable evidence will be a step forward. The Australian Primary Care Collaboratives (APCC) Program has an opportunity to build on its previous success in general practice quality improvement to further enhance patient safety in general practice.

Who's responsible for the care of women during and after a pregnancy affected by gestational diabetes?

Despite its increasing incidence and high conferred risk to women and their children, gestational diabetes mellitus (GDM) is managed inconsistently during and after pregnancy due to an absence of a systemic approach to managing these women. New guidelines for GDM testing and diagnosis are based on stronger evidence, but raise concerns about increased workloads and confusion in a landscape of multiple, conflicting guidelines. Postnatal care and long-term preventive measures are particularly fragmented, with no professional group taking responsibility for this crucial role. Clearer guidelines and assistance from existing frameworks, such as the National Gestational Diabetes Register, could enable general practitioners to take ownership of the management of women at risk of type 2 diabetes following GDM, applying the principles of chronic disease management long term.

Patient engagement strategies used for hypertension and their influence on self-management attributes.

BACKGROUND: Several effective methods to facilitate patient self-management of hypertension are available in primary care. These include direct support from community pharmacists and general practice, and the use of home blood pressure (BP) monitoring. The aim of this study is to establish the prevalence of use of key strategies and to determine their independent relationship with patient self-management attributes. METHODS: A survey of patients with treated hypertension was undertaken in 27 community pharmacies. This established recent use of BP monitoring and advice from health professionals. Patient awareness of BP and targets, appropriateness of BP targets and adherence to anti-hypertensive medications were assessed as indicative self-management outcomes. Predictors of outcomes were determined using binary logistic regression. RESULTS: Overall, 215 surveys were returned. Two-thirds of patients were aged >65 years, and 45% had conditions warranting tighter BP control (<130/80 mmHg). Almost all patients reported monitoring of their BP in the previous year and 63% could report their most recent BP reading. Just 36% reported knowing a target BP, and 78% of reported targets were within guidelines recommendations. One-fifth (22%) monitored their own BP, and 15% reported non-adherence to medication. Doctors provided the large majority of professional advice. Self-monitoring or documentation of BP readings was independently associated with increased likelihood of BP and target BP being known. CONCLUSIONS: Regular monitoring of BP does not automatically translate to professional advice. Increased uptake of patient self-monitoring should be promoted as a means of enabling self-management.

Association of weight misperception with weight loss in a diabetes prevention program.

BACKGROUND: Weight misperception may have an impact on perceived risk and susceptibility for chronic diseases. Little has been reported on the long term effects of this misperception in chronic disease interventions, particularly in field of diabetes prevention. The aim of this study was to investigate the relationship between weight misperception and weight loss during a diabetes prevention project conducted in south-east Australia with individuals at moderate to high risk of developing diabetes. METHODS: A total of n=251 at risk individuals provided self-reported weight during recruitment from 2004-2006. Objectively measured weight was assessed at baseline (0-21 days after recruitment), and subsequently at three months and 12 months after the intervention. Differences between self-reported and actual weight status are presented as percentages. Linear regression was used to investigate the relationship between weight misperception and weight loss, adjusting for baseline weight and BMI. RESULTS: Those who had high levels of under-reporting at baseline had greater weight loss at three and 12 months compared with those who under-reported to some degree, and those over-reporting their weight. A significant association was found between weight misperception and weight loss at the three and the 12 month time points. Baseline weight was not associated with weight loss. CONCLUSIONS: Weight misperception should be acknowledged as a factor to be addressed when screening and identifying individuals at risk for diabetes. Screening and giving feedback is important in terms of awareness of participants' actual weight status and may have an effect on program outcomes.