Supporting healthy lifestyles for First Nations women and communities through co-design: lessons and early findings from remote Northern Australia.

Background: The period before, during, and after pregnancy presents an opportunity to reduce diabetes-related risks, which in Australia disproportionately impact Aboriginal and Torres Strait Islander women. Collaboration with Aboriginal and Torres Strait Islander women/communities is essential to ensure acceptability and sustainability of lifestyle modifications. Using a novel co-design approach, we aimed to identify shared priorities and potential lifestyle strategies. We also reflected on learnings from this approach. Methods: We conducted 11 workshops and 8 interviews at two sites in Australia's Northern Territory (Central Australia and Top End), using experience-based co-design (EBCD) and incorporating principles of First Nations participatory research. Workshops/interviews explored participant' experiences and understanding of diabetes in pregnancy, contextual issues, and potential lifestyle strategies. Participants included three groups: 1) Aboriginal and Torres Strait Islander women of reproductive age (defined as aged 16-45 years); 2) Aboriginal and Torres Strait Islander community members; and 3) health/community services professionals. The study methodology sought to amplify the voices of Aboriginal women. Findings: Participants included 23 women between ages 16-45 years (9 with known lived experience of diabetes in pregnancy), 5 community members and 23 health professionals. Key findings related to identified priority issues, strategies to address priorities, and reflections on use of EBCD methodology. Priorities were largely consistent across study regions: access to healthy foods and physical activity; connection to traditional practices and culture; communication regarding diabetes and related risks; and the difficulty for women of prioritising their health among competing priorities. Strategies included implementation of a holistic women's program in Central Australia, while Top End participants expressed the desire to improve nutrition, peer support and community awareness of diabetes. EBCD provided a useful structure to explore participants' experiences and collectively determine priorities, while allowing for modifications to ensure co-design methods were contextually appropriate. Challenges included the resource-intensive nature of stakeholder engagement, and collaborating effectively with services and communities when researchers were "outsiders". Conclusions: A hybrid methodology using EBCD and First Nations participatory research principles enabled collaboration between Aboriginal women, communities and health services to identify shared priorities and solutions to reduce diabetes-related health risks. Genuine co-design processes support self-determination and enhance acceptability and sustainability of health strategies.

Does social pension buy improved mental health and mortality outcomes for senior citizens? Evidence from South Africa's 2008 pension reform.

In South Africa, men were traditionally eligible to receive government pensions at 65 years. However, that eligibility criterion was changed in 2008 to allow men to receive a pension payout at 60 years. This study is designed to quantify the impact of the 2008 pension reform on mental health outcomes (depression and traumatic stress) and deaths among 60-year-old men from disadvantaged households without advanced education. This analysis used secondary data issued by Statistic South Africa- General Household Survey. Men who reported earning a pension at 60 years from 2008 to 2014 were exposed to the 2008 pension reform and thus were classified as the treatment group. The 60-year-old men during 2002-2007 were ineligible to earn the pension, therefore considered the control group. We then used a Two-stage Least Squared Model (2SLS) to quantify the impact of the 2008 pension reform on healthcare utilization, depression cases, traumatic stress cases, and deaths among 60-year-old men. The model shows that the 2008 pension reform improved healthcare utilization by 3 % in the cohorts of men who benefitted from the 2008 reform. The 2008 pension reform averted depression cases, traumatic stress cases, and deaths among 60-year-old men by 3 %, 4 %, and 5 %, respectively. The impact of the 2008 pension reform in averting deaths among 60-year-old men was higher in urban regions than rural regions. We concluded that the 2008 pension reform successfully bought improved mental health outcomes and prevented depression, traumatic stress, and deaths among 60-year-old men.

Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation.

OBJECTIVE: To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia. METHODS: A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff. RESULTS: Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy. CONCLUSION: The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.

Primary Health Care for Aboriginal Australian Women in Remote Communities after a Pregnancy with Hyperglycaemia.

BACKGROUND: Hyperglycaemia in pregnancy contributes to adverse outcomes for women and their children. The postpartum period is an opportune time to support women to reduce cardiometabolic and diabetes risk in subsequent pregnancies. AIMS: To identify strengths and gaps in current care for Aboriginal women after a pregnancy complicated by hyperglycaemia. METHODS: A retrospective review of the 12 month postpartum care provided by primary health centres in remote Australia in 2013-2014 identified 195 women who experienced hyperglycaemia in pregnancy (gestational diabetes (GDM) (n = 147), type 2 diabetes (T2D) (n = 39), and unclear diabetes status (n = 9)). RESULTS: Only 80 women (54%) with GDM had postpartum glycaemic checks. Of these, 32 women were diagnosed with prediabetes (n = 24) or diabetes (n = 8). Compared to women with GDM, women with T2D were more likely to have their weight measured (75% vs. 52%, p <0.01), and smoking status documented as "discussed" (65% vs. 34%, p < 0.01). Most women (97%) accessed the health centre at least once in the 12 month postpartum period but, during these visits, only 52% of women had service provision, either structured or opportunistic, related to diabetes. CONCLUSION: High rates of dysglycaemia among women screened for T2D after GDM in the 12 month postpartum period highlight the need for increased screening and early intervention to prevent the development of T2D and its complications. Whilst a clear strength was high postpartum attendance, many women did not attend health services for diabetes screening or management.

Improving postpartum screening after diabetes in pregnancy: Results of a pilot study in remote Australia.

BACKGROUND: The postpartum period is a critical time to improve health outcomes for Aboriginal women, particularly for those who have chronic conditions. AIMS: To assess enhanced support methods (for women following diabetes in pregnancy (DIP)) to improve completion rates of recommended postpartum health checks. MATERIALS AND METHODS: Fifty-three Aboriginal women in the Northern Territory (NT) were contacted in the postpartum period to encourage medical check-ups. Messages were delivered through phone (call or text messages) or other methods (Facebook or email). The primary outcome was postpartum blood glucose testing (oral glucose tolerance testing (OGTT), random or fasting glucose and HbA1c). RESULTS: Establishing contact with women was difficult. Of 137 messages sent to 52 women, 22 responded (42%). Phone was the most common contact method with successful contact made from 16 of 119 (13%) attempts. Rates of postpartum OGTT completion were higher in the group successfully contacted (32% vs 7%). However, for any postpartum glucose testing (including OGTT and HbA1c) rates were 25 of 42 (60%) and neither success in making contact nor the contact method was associated with higher rates. CONCLUSIONS: The small sample size limits our conclusions; however, results highlight that engaging remote women postpartum is difficult. While rates of postpartum OGTT completion differed according to successful contacts, rates of any postpartum blood glucose testing did not. Further research is needed to explore feasible intervention methods to improve postpartum screening after a pregnancy complicated by diabetes.

Bilateral Adrenalectomy in Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis.

CONTEXT: Management of congenital adrenal hyperplasia (CAH) involves suppression of the hypothalamic-pituitary-adrenal axis using supraphysiological doses of exogenous glucocorticoids. This can pose a challenge, with Cushing syndrome a frequent complication of adequate suppression. Bilateral adrenalectomy, with subsequent replacement of glucocorticoids and mineralocorticoids at physiological doses, has been proposed as an alternative therapeutic strategy. OBJECTIVE: To review the outcomes after bilateral adrenalectomy for CAH. DATA SOURCES: A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 January 2018. STUDY SELECTION: Case reports or case series were included if they reported individual patient data from patients with CAH who had undergone bilateral adrenalectomy. DATA EXTRACTION: Information regarding the following was extracted: first author, country, sex, age at adrenalectomy, year of adrenalectomy, diagnosis, molecular abnormality, pre- and postoperative biochemistry, pre- and postoperative medications, pre- and postoperative body mass index, indication for adrenalectomy, surgical technique, gross and microscopic adrenal characteristics, follow-up duration, and short- and long-term postoperative outcomes. DATA SYNTHESIS: We identified 48 cases of bilateral adrenalectomy for CAH, with patients aged from 4 months to 56 years at surgery. The most common indication for surgery was the inability to control hyperandrogenism/virilization and/or Cushing syndrome (n = 30; 62%). Most patients (n = 34; 71%) reported symptomatic improvement postoperatively, with some cases of short-term (n = 5; 10%) and long-term (n = 13; 27%) adverse outcomes. CONCLUSIONS: Bilateral adrenalectomy for CAH appears to be a reasonable therapeutic option for carefully selected patients who have had unsatisfactory outcomes with conventional medical management.

Total cholesterol as a risk factor for coronary heart disease and stroke in women compared with men: A systematic review and meta-analysis.

BACKGROUND: Raised total cholesterol is a strong risk factor for cardiovascular disease (CVD). It remains unknown whether sex differences exist in the relationship between total cholesterol and CVD outcomes. METHODS: PubMed was searched in December 2014 for cohort studies reporting on the relationship between total cholesterol and coronary heart disease (CHD) and total stroke, separately in men and women. Random effects meta-analyses with inverse variance weighting were used to obtain adjusted pooled sex-specific relative risks (RR) and women-to-men ratio of RRs (RRRs). RESULTS: Data from 97 cohorts, 1,022,276 individuals, and 20,176 CHD and 13,067 stroke cases were included. The pooled RR (95% confidence interval) for CHD associated with a 1-mmol/L increase in total cholesterol was 1.20 (1.16; 1.24) in women and 1.24 (1.20; 1.28) in men, resulting in a RRR of 0.96 (0.93; 0.99). Corresponding RRs for the risk of total stroke were 1.01 (0.98; 1.05) in women, and 1.03 (1.00; 1.05) in men, with a pooled RRR of 0.99 (0.93; 1.04). Pooled RRRs (95% CI) comparing individuals in the highest TC category to those in the lowest, such as the highest versus lowest third, were 0.87 (0.79; 0.96) for CHD and 0.86 (0.76; 0.97) for total stroke. CONCLUSION: Raised total cholesterol is a strong risk factor for CHD, with evidence of a small, but significantly stronger, effect in men compared to women. Raised total cholesterol had little effect on the risk of total stroke in both sexes.