The Barriers and Facilitators of Sport and Physical Activity Participation for Aboriginal Children in Rural New South Wales, Australia: A Photovoice Project.

Participating in physical activity is beneficial for health. Whilst Aboriginal children possess high levels of physical activity, this declines rapidly by early adolescence. Low physical activity participation is a behavioral risk factor for chronic disease, which is present at much higher rates in Australian Aboriginal communities compared to non-Aboriginal communities. Through photos and 'yarning', the Australian Aboriginal cultural form of conversation, this photovoice study explored the barriers and facilitators of sport and physical activity participation perceived by Aboriginal children (n = 17) in New South Wales rural communities in Australia for the first time and extended the limited research undertaken nationally. Seven key themes emerged from thematic analysis. Four themes described physical activity barriers, which largely exist at the community and interpersonal level of children's social and cultural context: the physical environment, high costs related to sport and transport, and reliance on parents, along with individual risk factors such as unhealthy eating. Three themes identified physical activity facilitators that exist at the personal, interpersonal, and institutional level: enjoyment from being active, supportive social and family connections, and schools. Findings highlight the need for ongoing maintenance of community facilities to enable physical activity opportunities and ensure safety. Children held strong aspirations for improved and accessible facilities. The strength of friendships and the family unit should be utilized in co-designed and Aboriginal community-led campaigns.

Does Patient Preference for Mode of Intervention Delivery Impact Intervention Efficacy and Attrition?

PURPOSE: To explore whether there was a difference in objectively measured physical activity and study participation between people who received their preferred study group allocation (matched) and those who did not receive their preferred study group (mismatched). DESIGN: Secondary data from the NewCOACH randomized controlled trial. SETTING: Insufficiently active patients in the primary care settings in Sydney and Newcastle, Australia. PARTICIPANTS: One hundred seventy-two adults aged 20 to 81 years. INTERVENTION: Participants indicated their intervention preference at baseline for (1) five face-to-face visits with an exercise specialist, (2) one face-to-face visit and 4 telephone follow-ups with an exercise specialist, (3) written material, or (4) slight-to-no preference. Participants were then allocated to an intervention group and categorized as either "matched" or "mismatched" based on their indications. Participants who reported a slight-to-no preference was categorized as "matched." MEASURES: Daily step count as measured by pedometers and study participation. ANALYSIS: Mean differences between groups in daily step count at 3 and 12 months (multiple linear regression models) and study participation at baseline, 3 months, and 12 months (χ2 tests). RESULTS: Preference for an intervention group prior to randomization did not significantly (all P's > .05 using 95% confidence interval) impact step counts (differences of <600 steps/day between groups) or study participation. CONCLUSION: Future research should continue to address whether the strength of preferences influence study outcome and participation and whether the study preferences change over time.

A systematic review of adherence to diabetes self-care behaviours: Evidence from low- and middle-income countries.

AIMS: To determine diabetes patient's adherence to five self-care behaviours (diet, exercise; medication, self-monitoring of blood glucose [SMBG] and foot care) in low- and middle-income countries. DESIGN: Systematic review. DATA SOURCES: We searched MEDLINE, CINAHL, PUBMED, SCOPUS, PsycINFO, EMBASE, Cochrane library and EMCARE for the period January 1990 - June 2017. REVIEW METHODS: Title, abstract and full text screening were done according to eligibility criteria. A narrative synthesis of the literature was conducted. RESULTS: A total of 7,109 studies were identified of which 27 met the review eligibility criteria and were included. All the studies used self-report of adherence to diabetes self-care. Studies reported adherence rates in two major forms: (a) mean number of days participants performed a recommended dietary behaviour/activity during the past week; and (b) proportions of participants adhering to a recommended self-care behaviour. Mean number of days per week participants adhered to a self-care behaviour ranged from 2.34.6 days per week for diet, 5.5-6.8 days per week for medication, 1.8-5.7 days per week for exercise, 0.2-2.2 days per week for SMBG and 2.2-4.3 days per week for foot care. Adherence rates ranged from 29.9%-91.7% for diet, 26.0%-97.0% for medication taking, 26.7%-69.0% for exercise, 13.0%-79.9% for self-monitoring of blood glucose and 17.0%-77.4% for foot care. CONCLUSION: Although most diabetes patients do not adhere to recommended self-care behaviours, adherence rates vary widely and were found to be high in some instances. IMPACT: Health services in low- and middle-income countries should monitor adherence to diabetes self-care behaviours rather than assume adherence and resources should be invested in improving adherence to the self-care behaviours. Large-scale accurate monitoring of adherence to diabetes self-care behaviour is needed and consideration should be given to choice of measurement tool for such exercise.

Attitudes towards, facilitators and barriers to the provision of diabetes self-care support: A qualitative study among healthcare providers in Ghana.

STATEMENT OF THE PROBLEM: Self-care support provided by healthcare providers (HCPs) is critical to diabetes self-care. However, a number of barriers prevent HCPs from providing self-care support to people with diabetes. We explored attitudes towards, barriers and facilitators of the provision of diabetes self-care support among Ghanaian HCPs. METHODS: Fourteen semi-structured interviews were conducted among HCPs recruited from three diabetes clinics in Tamale, Ghana. All interviews were digitally recorded and transcribed verbatim. Transcripts were coded and analysed thematically. RESULTS: HCPs reported a sense of responsibility and urgency to provide self-care education to diabetes patients; while believing it was the patients' responsibility to self-care for their diabetes condition. Accordingly, HCPs perceived their role to be limited to information sharing rather than behaviour change interventions. Facilitators to the provision of self-care support included patients' motivation, and team work among healthcare professionals. Barriers that hindered self-care support included language barriers and poor inter-professional collaboration. Furthermore, HCPs discussed that they felt inadequately trained to provide self-care support. Healthcare-system-related barriers were inadequate office space, lack of professional development programmes, high patient numbers, inadequate staff numbers, inadequate health insurance and a lack of sufficient supplies and equipment in the hospital. CONCLUSION: HCPs attitudes were generally favourable towards supporting self-care, albeit with a focus on information provision rather than behaviour change. Training in effective strategies for providing self-care support are needed, and better use of the resources that are available.

Barriers to diabetic self-care: A qualitative study of patients' and healthcare providers' perspectives.

AIMS AND OBJECTIVES: To explore patient and healthcare provider (HCP) perspectives about patients' barriers to the performance of diabetic self-care behaviours in Ghana. BACKGROUND: Sub-Saharan African urban populations are increasingly affected by type 2 diabetes due to nutrition transition, sedentary lifestyles and ageing. Diabetic self-care is critical to improving clinical outcomes. However, little is known about barriers to diabetic self-care (diet, exercise, medication taking, self-monitoring of blood glucose and foot care) in sub-Saharan Africa. DESIGN: Qualitative study that followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. METHODS: Semi-structured interviews were conducted among 23 people living with type 2 diabetes and 14 HCPs recruited from the diabetes clinics of three hospitals in Tamale, Ghana. Interviews were audiotaped and transcribed verbatim. The constant comparative method of data analysis was used and identified themes classified according to constructs of the theory of planned behaviour (TPB): attitudes/behavioural beliefs, subjective norms and perceived behavioural control. RESULTS: Barriers relating to attitudes included misconceptions that diabetes was caused by spiritual forces or curses, use of herbal medicines, intentional nonadherence, difficulty changing old habits, and feeling or lacking motivation to exercise. Barriers relating to subjective norms were inadequate family support, social stigma (usually by spouses and other members of the community) and cultural beliefs. Perceived behavioural control barriers were poor income levels, lack of glucometers, busy work schedules, long distance to the hospital and inadequate access to variety of foods due to erratic supply of foods or seasonality. CONCLUSIONS: Both patients and HCPs discussed similar barriers and those relating to attitude and behavioural control were commonly discussed. RELEVANCE TO CLINICAL PRACTICE: Interventions to improve adherence to diabetic self-care should focus on helping persons with diabetes develop favourable attitudes and how to overcome behavioural control barriers. Such interventions should have both individualised and community-wide approaches.

Psychometric evaluation of the summary of diabetes self-care activities measure in Ghanaian adults living with type 2 diabetes.

AIMS: We evaluated the content validity, factorial structure, internal consistency, construct validity, and floor and ceiling effects of the SDSCA among Ghanaian persons with type 2 diabetes. METHODS: The summary of diabetes self-care activities measure (SDSCA) was administered to 187 adults living with type 2 diabetes from three diabetes clinics. RESULTS: A confirmatory factor analysis maintained the four factor structure of the SDSCA. However, two items, 3 (fruit and vegetable servings) and 4 (red meat or full-fat dairy products) had factor loadings of 0.26 and 0.16 respectively. The model also had a statistical power of 0.72 (below acceptable criteria). Modification of the model by removing item 4 resulted in an improved revised model with a power of 0.82. Construct validity was found for the exercise and diet subscales of the SDSCA but not for the self-monitoring of blood glucose and foot care subscales. The internal consistency of the SDSCA measure was 0.68, below acceptable criteria for internal consistency. No floor effects were present but the exercise subscale had ceiling effects. CONCLUSION: The SDSCA measure had content validity, maintained its multidimensionality and met the criteria for floor effects but not for construct validity, internal consistency and ceiling effects. The SDSCA measure may require improvements to evaluate self-care behaviours of adult type 2 diabetes patients in Ghana and probably in other sub-Saharan countries.

Predictors of adherence to a physical activity counseling intervention delivered by exercise physiologists: secondary analysis of the NewCOACH trial data.

BACKGROUND: General practitioners (GPs) cite time as a barrier to physical activity counseling. An alternative for time-poor GPs in Australia is the referral of insufficiently active patients to exercise physiologists (EPs). As data on the predictors of adherence to physical activity counseling interventions are limited, this study aimed to identify the sociodemographic, medical, health, and psychological characteristics of insufficiently active primary care patients who adhered to a physical activity counseling intervention delivered by EPs. METHODS: This secondary analysis of data from the NewCOACH randomized trial used logistic regression to identify predictors of adherence, defined as patient participation in at least four of the five physical activity counseling sessions. EPs provided information about the number of sessions, while other potential predictors were obtained from the self-administered baseline questionnaire and medical summary sheets provided by the GPs. RESULTS: Of the 132 patients referred to an EP, 102 (77%) were adherent: 91 (69%) and eleven (8.3%) participated in all, or all but one, of the sessions, respectively. Of the remainder, seven (5.3%) patients participated in three sessions, seven (5.3%) participated in two sessions, five (3.8%) participated in one session, and eleven (8.3%) did not participate in any session. The odds of being adherent were 5.84 (95% CI 1.46-23.4, P≤0.05) times higher among retired participants than in those who were not in paid employment. The odds of being adherent 1) increased as the positive outcome expectation score increased (OR 1.89, 95% CI 1.12-3.18, P≤0.05) and 2) decreased as the duration (days) between referral and the initial counseling session increased (OR 0.95, 95% CI 0.92-0.98, P<0.01). CONCLUSION: More than three quarters of the patients participated in all, or all but one, of the sessions. Being retired, positive outcome expectations, and having a shorter wait between referral and the initial appointment predicted adherence.

Effect of electronic screening and brief intervention on hazardous or harmful drinking among adults in the hospital outpatient setting: A randomized, double-blind, controlled trial.

BACKGROUND: Most trials of electronic alcohol screening and brief intervention (e-SBI) have been conducted in young people. The aim of this study was to evaluate the effect of e-SBI in adults with hazardous or harmful drinking. METHODS: This individually randomized, parallel, two-group, double-blind controlled trial was conducted in the outpatient department of a large public hospital in Australia. Consenting adults who scored 5-9 on the AUDIT-C (837/3225; 26%) were randomized in a 1:1 ratio by computer to screening alone (442/837; 53%) or to 10 min of assessment and personalized feedback on their alcohol consumption (comparisons with medical guidelines and age and sex-specific norms), peak blood alcohol concentration, expenditure on alcohol, and risk of alcohol dependence (395/837; 47%). The two primary outcomes, assessed six months after randomization, were the number of standard drinks (10 g ethanol) consumed by participants in the last seven days and their AUDIT score. RESULTS: 693/837 (83%) and 635/837 (76%) participants were followed-up at 6 and 12 months, respectively. There was no statistically significant difference between the groups in the median number of standard drinks consumed in the last seven days (intervention: 12; control: 10.5; rate ratio, 1.12 [95% confidence interval, 0.96-1.31]; P = .17) or in their median AUDIT score (intervention: 7; control: 7; mean difference, 0.28 [-0.42 to 0.98]; P = .44). CONCLUSION: These results do not support the implementation of an e-SBI program comprising personalized feedback and normative feedback for adults with hazardous or harmful drinking in the hospital outpatient setting.

Process redesign of a surgical pathway improves access to cataract surgery for Aboriginal and Torres Strait Islander people in South East Queensland.

The Institute for Urban Indigenous Health (IUIH) aimed to improve access to cataract surgery in urban South East Queensland (SEQ) for Indigenous Australians, without compromising clinical visual outcomes. The Penchansky and Levesque concept of access as the 'fit' between the patient's needs and the ability of the system to meet those needs was used to inform the redesign of the mainstream cataract surgical pathway. The IUIH staff and community stakeholders mapped the traditional external cataract surgical pathway and then innovatively redesigned it to reduce the number of patients being removed by the system at key transition points. The integration of eye health within the primary health care (PHC) clinic has improved the continuity and coordination of care along the surgical pathway, and ensured the sustainability of collaborative partnerships with key external organisations. Audit data demonstrated a significant increase in utilisation of cataract surgical services after the process redesign. Previous studies have found that PHC models involving integration, coordination and continuity of care enhance patient health outcomes; however, the IUIH surgical model extends this to tertiary care. There is scope to apply this model to other surgical pathways and communities who experience access inequity.

Effect of electronic brief intervention on uptake of specialty treatment in hospital outpatients with likely alcohol dependence: Pilot randomized trial and qualitative interviews.

BACKGROUND: A large proportion of hospital outpatients are alcohol dependent (AD) but few are engaged in treatment for their drinking. Brief intervention, designed to raise patients' awareness of their drinking, might encourage uptake of referral to specialty treatment. We assessed the feasibility of conducting a randomized trial evaluating the effectiveness of electronic brief intervention on the uptake of specialty treatment in hospital outpatients with likely AD. METHODS: This study was conducted in the outpatient department of a large public hospital in Newcastle, Australia. We randomly assigned adults who scored ≥10 on the AUDIT-C and were not currently receiving treatment for their drinking to electronic brief intervention (comprising an assessment of their drinking and personalized feedback) and referral (n = 59), or to referral alone (n = 64). We pre-specified two co-primary outcomes as the proportions of patients who (1) accepted and (2) attended a Drug and Alcohol outpatient clinic appointment. We interviewed 15 study participants to investigate why they had declined the appointment and what sort of help they might prefer to receive. RESULTS: Ten patients (five in each group) accepted an appointment, and one patient (control) attended. Most interviewees' did not see their drinking as a problem or were confident they could manage it by themselves. Those who identified a preferred source of help expressed a preference for treatment by a GP. CONCLUSION: Uptake of specialty treatment in hospital outpatients with likely AD was low regardless of whether they received brief intervention. Accordingly, a large randomized trial does not appear to be feasible.

Referral for Expert Physical Activity Counseling: A Pragmatic RCT.

INTRODUCTION: Primary care physicians are well placed to offer physical activity counseling, but insufficient time is a barrier. Referral to an exercise specialist is an alternative. In Australia, exercise specialists are publicly funded to provide face-to-face counseling to patients who have an existing chronic illness. This trial aimed to (1) determine the efficacy of primary care physicians' referral of insufficiently active patients for counseling to increase physical activity, compared with usual care, and (2) compare the efficacy of face-to-face counseling with counseling predominantly via telephone. STUDY DESIGN: Three-arm pragmatic RCT. SETTING/PARTICIPANTS: Two hundred three insufficiently active (<7,000 steps/day) primary care practice patients (mean age 57 years; 70% female) recruited in New South Wales, Australia, in 2011-2014. INTERVENTION: (1) Five face-to-face counseling sessions by an exercise specialist, (2) one face-to-face counseling session followed by four telephone calls by an exercise specialist, or (3) a generic mailed physical activity brochure (usual care). The counseling sessions operationalized social cognitive theory via a behavior change counseling framework. MAIN OUTCOME MEASURES: Change in average daily step counts between baseline and 12 months. Data were analyzed in 2016. RESULTS: Forty (20%) participants formally withdrew; completion rates at 3 and 6 months were 64% and 58%, respectively. Intervention attendance was high (75% received five sessions). The estimated mean difference between usual care and the combined intervention groups at 12 months was 1,002 steps/day (95% CI=244, 1,759, p=0.01). When comparing face-to-face with predominantly telephone counseling, the telephone group had a non-significant higher mean daily step count (by 619 steps) at 12 months. CONCLUSIONS: Provision of expert physical activity counseling to insufficiently active primary care patients resulted in a significant increase in physical activity (approximately 70 minutes of walking per week) at 12 months. Face-to-face only and counseling conducted predominantly via telephone were both effective. This trial provides evidence to expand public funding for expert physical activity counseling and for delivery via telephone in addition to face-to-face consultations. TRIAL REGISTRATION: This trial is registered at www.anzctr.org.au/ ACTRN12611000884909.

Adherence to self-care behaviours and associated barriers in type 2 diabetes patients of low-and middle-income countries: a systematic review protocol.

BACKGROUND: Diabetes has become a global health emergency affecting high-, middle- and low-income countries. Previous systematic reviews have either focused on patients' adherence to diabetes self-care behaviours only or barriers to diabetes care (including self-care) only in the published literature and have not also analysed data separately for low- and middle-income countries (LMICs). Thus, none have focused on adherence with, and barriers to, self-care behaviours from the perspectives of both patient and providers in low- and middle-income countries (LMICs). This systematic review will evaluate the published literature on adherence to five diabetes self-care behaviours (i.e., diet, exercise, self-monitoring of blood glucose, medication taking and foot care) and associated barriers in type 2 diabetes patients in LMICs. Healthcare providers' barriers to the provision of diabetes self-care support will also be reviewed. METHODS: This narrative review will be reported in accordance with the guidelines of the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P). The electronic databases, MEDLINE, EMBASE, CINAHL, SCOPUS, PsycINFO, Cochrane Library and the British Nursing Index will be searched. Qualitative and quantitative studies reporting on type 2 diabetes patients' adherence to self-care behaviours and associated barriers in LMICs will be included. Studies also reporting on barriers encountered by providers in LMICs providing diabetes care and supporting patients to adhere to self-care behaviours will also be included. Cross-sectional studies, observational cohort studies, baseline data of randomised controlled trials and qualitative studies will be eligible. Two independent reviewers will screen articles for inclusion, undertake quality assessment of included studies and execute data extraction using standardised forms. Discrepancies will be discussed to reach consensus, and another reviewer will adjudicate if the need arises. The Guidance of Narrative Synthesis in Systematic Reviews will be employed to explore relationships within and between included studies. DISCUSSION: This review will provide evidence on adherence to self-care behaviours by type 2 diabetes patients in LMICs. Barriers experienced by patients in LMICs to adhere to recommended self-care behaviours will also be identified. Barriers experienced by healthcare providers in LMICs in providing self-care support patients will also be determined. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016035406.

Adherence to and factors associated with self-care behaviours in type 2 diabetes patients in Ghana.

BACKGROUND: Previous research has failed to examine more than one self-care behaviour in type 2 diabetes patients in Ghana. The purpose of this study is to investigate adult Ghanaian type 2 diabetes patients' adherence to four self-care activities: diet (general and specific), exercise, self-monitoring of blood glucose (SMBG) and foot care. METHODS: Consenting type 2 diabetes patients attending diabetes outpatient clinic appointments at three hospitals in the Tamale Metropolis of Ghana completed a cross-sectional survey comprising the Summary of Diabetes Self-Care Activities Measure, and questions about demographic characteristics and diabetes history. Height and weight were also measured. Multiple linear regression analyses were conducted to identify the factors associated with adherence to each of the four self-care behaviours. RESULTS: In the last 7 days, participants exercised for a mean (SD) of 4.78 (2.09) days and followed diet, foot care and SMBG for a mean (SD) of 4.40 (1.52), 2.86 (2.16) and 2.15 (0.65) days, respectively. More education was associated with a higher frequency of reported participation in exercise (r = 0.168, p = 0.022), following a healthy diet (r = 0.223, p = 0.002) and foot care (r = 0.153, p = 0.037) in the last 7 days. Males reported performing SMBG (r = 0.198, p = 0.007) more frequently than their female counterparts. CONCLUSION: Adherence to diet, SMBG and checking of feet were relatively low. People with low education and women may need additional support to improve adherence to self-care behaviours in this type 2 diabetes population.

Genetic feedback to reduce alcohol consumption in hospital outpatients with risky drinking: feasibility and acceptability.

OBJECTIVE: There have been no trials in healthcare settings of genetic susceptibility feedback in relation to alcohol consumption. The purpose of this study was to determine the feasibility and acceptability of conducting a full-scale randomised trial estimating the effect of personalised genetic susceptibility feedback on alcohol consumption in hospital outpatients with risky drinking. METHODS: Outpatients ≥18 years of age who reported drinking more than 14 standard drinks in the past week or in a typical week were asked to provide a saliva sample for genetic testing. Genetic susceptibility feedback was posted to participants 6 months after recruitment. The co-primary outcomes were the proportion of participants who (i) provided a saliva sample that could be genotyped, and (ii) spoke with a genetic counsellor. Secondary outcomes included changes in patients' weekly alcohol consumption; scores on scales measuring readiness to change, importance of changing and confidence in ability to change drinking habits; knowledge about which cancers are alcohol-attributable; and acceptability of the saliva collection procedure and the genetic-feedback intervention. McNemar's test and paired t-tests were used to test for differences between baseline and follow-up in proportions and means, respectively. RESULTS: Of 100 participants who provided a saliva sample, 93 had adequate DNA for at least one genotyping assay. Three participants spoke to a genetic counsellor. Patients' readiness to change their drinking, their views on the importance of changing and their stated confidence in their ability to change increased between baseline and follow-up. There was no increase in patients' knowledge about alcohol-attributable cancers nor any reduction in how much alcohol they drank 4 months after receiving the feedback. Most participants (80%) were somewhat comfortable or very comfortable with the process used to collect saliva, 84% understood the genetic feedback, 54% found it useful, 10% had sought support to reduce their drinking after receiving the feedback, and 37% reported that the feedback would affect how much they drink in the future. CONCLUSION: Results of this study suggest it would be feasible to conduct a methodologically robust trial estimating the effect of genetic susceptibility feedback on alcohol consumption in hospital outpatients with risky drinking.

Effect of telephone follow-up on retention and balance in an alcohol intervention trial.

OBJECTIVES: Telephone follow-up is not currently recommended as a strategy to improve retention in randomized trials. The aims of this study were to estimate the effect of telephone follow-up on retention, identify participant characteristics predictive of questionnaire completion during or after telephone follow-up, and estimate the effect of including participants who provided follow-up data during or after telephone follow-up on balance between randomly allocated groups in a trial estimating the effect of electronic alcohol screening and brief intervention on alcohol consumption in hospital outpatients with hazardous or harmful drinking. METHOD: Trial participants were followed up 6 months after randomization (June-December 2013) using e-mails containing a hyperlink to a web-based questionnaire when possible and by post otherwise. Telephone follow-up was attempted after two written reminders and participants were invited to complete the questionnaire by telephone when contact was made. RESULTS: Retention before telephone follow-up was 62.1% (520/837) and 82.8% (693/837) afterward: an increase of 20.7% (173/837). Therefore, 55% (95% CI 49%-60%) of the 317 participants who had not responded after two written reminders responded during or after the follow-up telephone call. Age < 55 years, a higher AUDIT-C score and provision of a mobile/cell phone number were predictive of questionnaire completion during or after telephone follow-up. Balance between randomly allocated groups was present before and after inclusion of participants who completed the questionnaire during or after telephone follow-up. CONCLUSION: Telephone follow-up improved retention in this randomized trial without affecting balance between the randomly allocated groups.

Prevalence of unhealthy alcohol use in hospital outpatients.

BACKGROUND: Few studies have examined the prevalence of unhealthy alcohol use in the hospital outpatient setting. Our aim was to estimate the prevalence of unhealthy alcohol use among patients attending a broad range of outpatient clinics at a large public hospital in Australia. METHODS: Adult hospital outpatients were invited to complete the Alcohol Use Disorders Identification Test Consumption questions (AUDIT-C) using an iPad as part of a randomised trial testing the efficacy of alcohol electronic screening and brief intervention. Unhealthy alcohol use was defined as an AUDIT-C score ≥5 among men and ≥4 among women. RESULTS: Sixty percent (3616/6070) of invited hospital outpatients consented, of whom 89% (3206/3616) provided information on their alcohol consumption (either reported they had not consumed any alcohol in the last 12 months or completed the AUDIT-C). The prevalence of unhealthy alcohol use was 34.7% (95% confidence interval [CI]: 33.0-36.3%). The prevalence among men aged 18-24 years, 25-39 years, 40-59 years and 60 years and older, was 74.4% (95% CI: 68.4-80.4%), 54.3% (95% CI: 48.7-59.8%), 44.1% (95% CI: 39.9-48.3%), and 27.0% (95% CI: 23.6-30.4%), respectively (43.1% overall; 95% CI: 40.8-45.5%). The prevalence among women aged 18-24 years, 25-39 years, 40-59 years, and 60 years and older, was 48.6% (95% CI: 39.2-58.1%), 36.9% (95% CI: 31.2-42.6%), 25.2% (95% CI: 21.5-29.0%) and 14.5% (95% CI: 11.7-17.3%), respectively (24.9% overall; 95% CI: 22.7-27.1%). CONCLUSION: A large number of hospital outpatients who are not currently seeking treatment for their drinking could benefit from effective intervention in this setting.

Development of an electronic alcohol screening and brief intervention program for hospital outpatients with unhealthy alcohol use.

BACKGROUND: Alcohol screening and brief intervention is recommended for widespread implementation in health care systems, but it is not used routinely in most countries for a variety of reasons. Electronic screening and brief intervention (e-SBI), in which patients complete a Web-based questionnaire and are provided with personalized feedback on their drinking, is a promising alternative to practitioner delivered intervention, but its efficacy in the hospital outpatient setting has not been established. OBJECTIVE: The objective of our study was to establish the feasibility of conducting a full-scale randomized controlled trial to determine whether e-SBI reduces alcohol consumption in hospital outpatients with hazardous or harmful drinking. METHODS: The study was conducted in the outpatient department of a large public hospital in Newcastle (population 540,000), Australia. Adults with appointments at a broad range of medical and surgical outpatient clinics were invited to complete an e-SBI program on a laptop, and to report their impressions via a short questionnaire. Follow-up assessments were conducted 2-8 weeks later by email and post. RESULTS: We approached 172 outpatients and 108/172 (62.8%) agreed to participate. Of the 106 patients capable of self-administering the e-SBI, 7/106 (6.6%) did not complete it (3 due to technical problems and 4 because they were called for their appointment), 15/106 (14.2%) indicated that they had not consumed any alcohol in the past 12 months, 43/106 (40.6%) screened negative for unhealthy alcohol use (scored less than 5 on the Alcohol Use Disorders Identification Test Consumption [AUDIT-C] questions), 33/106 (31.1%) screened positive for hazardous or harmful drinking (AUDIT-C score 5-9), and 8/106 (7.5%) screened positive for possible alcohol dependence (AUDIT-C score 10-12). Among the subgroup with hazardous or harmful drinking, 27/33 (82%) found the feedback on their drinking very, quite, or somewhat useful, 33/33 (100%) thought the intervention would appeal to most or some of the people who attend the service, and 22/30 (73%) completed the follow-up. We also found that some well established procedures used in trials of e-SBI in the primary care setting did not translate to the hospital outpatient setting (1) we experienced delays because the e-SBI program had to be developed and maintained by the health service's information technology staff for security reasons, (2) recruiting patients as they left the reception desk was impractical because patients tended to arrive at the beginning of the clinics with few arrivals thereafter, and (3) use of a laptop in a fixed location resulted in some patients rushing through the e-SBI so they could return to their seat in the area they had been advised to wait in. CONCLUSIONS: e-SBI is acceptable to outpatients and with some adaptation to organizational and physical conditions, it is feasible to recruit and screen patients and to deliver the intervention without disrupting normal service provision. This suggests that e-SBI could be provided routinely in this important setting if shown to be efficacious.

The hospital outpatient alcohol project (HOAP): protocol for an individually randomized, parallel-group superiority trial of electronic alcohol screening and brief intervention versus screening alone for unhealthy alcohol use.

BACKGROUND: Electronic screening and brief intervention (e-SBI) is a promising alternative to screening and brief intervention by health-care providers, but its efficacy in the hospital outpatient setting, which serves a large proportion of the population, has not been established. The aim of this study is to estimate the effect of e-SBI in hospital outpatients with hazardous or harmful drinking. METHODS/DESIGN: This randomized controlled trial will be conducted in the outpatient department of a large tertiary referral hospital in Newcastle (population 540,000), Australia. Some 772 adults with appointments at a broad range of medical and surgical outpatient clinics who score 5-9 inclusive on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) subscale will be randomly assigned in a 1:1 ratio to electronic alcohol screening alone (control) or to e-SBI. As randomization will be effected by computer, researchers and participants (who will be invited to participate in a study of alcohol use over time) will be blinded to group assignment. The primary analysis will be based on the intention-to-treat principle and compare weekly volume (grams of alcohol) and the full AUDIT score with a six-month reference period between the groups six months post randomization. Secondary outcomes, assessed six and 12 months after randomization, will include drinking frequency, typical occasion quantity, proportion who report binge drinking, proportion who report heavy drinking, and health-care utilization. DISCUSSION: If e-SBI is efficacious in outpatient settings, it offers the prospect of systematically and sustainably reaching a large number of hazardous and harmful drinkers, many of whom do not otherwise seek or receive help. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000905864.

Trends in referral to outpatient cardiac rehabilitation in the Hunter Region of Australia, 2002-2007.

BACKGROUND: Cardiac rehabilitation (CR) is an underutilized evidence-based treatment. We described trends in referral to outpatient CR (OCR) and the factors associated with referral. DESIGN: Cross-sectional survey data provided by Hunter residents aged 20 years or older discharged from public hospitals in the region between 2002 and 2007 with an OCR eligible diagnosis were extracted from the Hunter New England Heart and Stroke Register database. METHODS: Trends in referral were determined using the chi test for trend. Factors associated with referral were examined using multiple logistic regression. RESULTS: Sixty-five percent (4971 of 7678) of patients provided sufficient data for inclusion in the analysis. Approximately half of the patients reported being referred to OCR. No increase over time was observed. Factors associated with referral were age less than 70 years, male sex, being married, urban residence, at least one admission to the tertiary referral hospital for cardiology, at least one admission for acute myocardial infarction, revascularization, no admissions for congestive heart failure, a self-reported history of high cholesterol, and no history of stroke or atrial fibrillation. CONCLUSION: Access to this treatment of proven benefit remained suboptimal despite the provision of new programs and expansion of existing programs. Automatic referral, which is recommended in Australia, should be standard practice.

Association between Participation in Outpatient Cardiac Rehabilitation and Self-Reported Receipt of Lifestyle Advice from a Healthcare Provider: Results of a Population-Based Cross-Sectional Survey.

We test the hypothesis that the odds of self-reported receipt of lifestyle advice from a health care provider will be lower among outpatient cardiac rehabilitation (OCR) nonattendees and nonreferred patients compared to OCR attendees. Logistic regression was used to analyse cross-sectional data provided by 65% (4971/7678) of patients aged 20 to 84 years discharged from public hospitals with a diagnosis indicating eligibility for OCR between 2002 and 2007. Among respondents, 71% (3518) and 55% (2724) recalled advice regarding physical activity and diet, respectively, while 88% (592/674) of smokers recalled quit advice. OCR attendance was low: 36% (1764) of respondents reported attending OCR, 11% (552) did not attend following referral, and 45% (2217) did not recall being invited. The odds of recalling advice regarding physical activity and diet were significantly lower among OCR nonattendees compared to attendees (OR 0.34, 95% CI 0.21, 0.56 and OR 0.33, 95% CI 0.25, 0.44, resp.) and among nonreferred respondents compared to OCR attendees (OR 0.10, 95% CI 0.07, 0.15 and OR 0.17, 95% CI 0.14, 0.22, resp.). Patients hospitalised for coronary heart disease should be referred to OCR or a suitable alternative to improve recall of lifestyle advice that will reduce the risk of further coronary events.