A nurse-led Asthma Care Team transitioning patients from hospital to home improves asthma control: A pilot study exploring an alternative model of care.

INTRODUCTION: Recurrent asthma admissions are frequent in our patients at a tertiary Australian hospital and are commonly related to poor health literacy and medication adherence. A need exists to improve these asthma self-management skills within our current model of care, especially during the vulnerable postdischarge period. AIM: To examine if the addition of a nurse-led Asthma Care Transition Team (ACTT) compared with usual care alone (UC) (1) improves asthma control at 12 weeks posthospital discharge; the number of patients using a Written Action Plan (WAP), compliance with inhaler therapy at 12 weeks, and readmission rates at 6 months. METHODS: Adults admitted with asthma were randomised to either: UC: involving review of asthma medication and self-management skills by the ward team prior to discharge; a standard 6-week post discharge clinic visit and a 12-week study visit where an independent assessor assessed outcomes; or ACTT: In addition to UC, involved ACTT nurse-led review at 1 week and 6 weeks. Key aspects included a pre defined, structured review reinforcing education and self-management skills, and telephone support during working hours. RESULT: Sixty participants (UC and ACTT) had similar baseline characteristics: Mean age: 41 vs 38 years, asthma duration: 20 vs 18 years, baseline Asthma Control Questionnaire 3.1 vs 3.4. At 12 weeks Asthma Control Questionnaire (ACQ) improved significantly in both groups but more so with ACTT; ACTT group had a higher uptake of WAP and a trend to reduced readmissions. CONCLUSION AND PRACTICE IMPLICATION: A nurse-led ACTT improves asthma control and self-management skills following discharge and may lead to fewer readmissions.

Factors influencing place of delivery: Evidence from three south-Asian countries.

BACKGROUND: High maternal mortality is still a significant public health challenge in many countries of the South-Asian region. The majority of maternal deaths occur due to pregnancy and delivery-related complications, which can mostly be prevented by safe facility delivery. Due to the paucity of existing evidence, our study aimed to examine the factors associated with place of delivery, including women's preferences for such in three selected South-Asian countries. METHODS: We extracted data from the most recent demographic and health surveys (DHS) conducted in Bangladesh (2014), Nepal (2016), and Pakistan (2017-18) and analyzed to identify the association between the outcome variable and socio-demographic characteristics. A total of 16,429 women from Bangladesh (4278; mean age 24.57 years), Nepal (3962; mean age 26.35 years), and Pakistan (8189; mean age 29.57 years) were included in this study. Following descriptive analyses, bivariate and multivariate logistic regressions were conducted. RESULTS: Overall, the prevalence of facility-based delivery was 40%, 62%, and 69% in Bangladesh, Nepal, and Pakistan, respectively. Inequity in utilizing facility-based delivery was observed for women in the highest wealth quintile. Participants from Urban areas, educated, middle and upper household economic status, and with high antenatal care (ANC) visits were significantly associated with facility-based delivery in all three countries. Interestingly, watching TV was also found as a strong determinant for facility-based delivery in Bangladesh (aOR = 1.31, 95% CI:1.09-1.56, P = 0.003), Nepal (aOR = 1.42, 95% CI:1.20-1.67, P<0.001) and Pakistan (aOR = 1.17, 95% CI: 1.03-1.32, P = 0.013). Higher education of husband was a significant predictor for facility delivery in Bangladesh (aOR = 1.73, 95% CI:1.27-2.35, P = 0.001) and Pakistan (aOR = 1.19, 95% CI: 0.99-1.43, P = 0.065); husband's occupation was also a significant factor in Bangladesh (aOR = 1.30, 95% CI:1.04-1.61, P = 0.020) and Nepal (aOR = 1.26, 95% CI:1.01-1.58, P = 0.041). CONCLUSION: Our findings suggest that the educational status of both women and their husbands, household economic situation, and the number of ANC visits influenced the place of delivery. There is an urgent need to promote facility delivery by building more birthing facilities, training and deployment of skilled birth attendants in rural and hard-to-reach areas, ensuring compulsory female education for all women, encouraging more ANC visits, and providing financial incentives for facility deliveries. There is a need to promote facility delivery by encouraging health facility visits through utilizing social networks and continuing mass media campaigns. Ensuring adequate Government funding for free maternal and newborn health care and local community involvement is crucial for reducing maternal and neonatal mortality and achieving sustainable development goals in this region.

Poor general health and lower levels of vitality are associated with persistent, high-intensity low back pain and disability in community-based women: A prospective cohort study.

While low back pain significantly impacts on an individual's well-being, our understanding of the role of well-being in the natural history of low back pain is limited. This cohort study aimed to investigate the association between psychological and general well-being and the development and progression of low back pain and disability in community-based women over a 2-year period. 506 women recruited from a research database were invited to participate. Overall psychological and general well-being and its subdomains were assessed at baseline using the Psychological General Well-Being Index (PGWB). The intensity of and degree of disability arising from low back pain were examined using the Chronic Pain Grade Questionnaire at baseline and at 2-year follow-up. Participants were categorized as having no, developing, resolving, or persistent high-intensity pain and disability. 444 participants (87.8%) completed the study. Women with persistent high-intensity pain had lower PGWB scores at baseline than those with no high-intensity pain at follow-up, after adjusting for confounders (M(SE) = 69.9(2.55) vs 80.1(2.63), p < 0.005). Furthermore, women with persistent high disability scores had lower well-being scores than those without persistent high disability scores (M(SE) = 69.1(3.49) vs. 81.2(0.802), p = 0.001). Moreover, lower scores in the well-being subdomains of general health and vitality were associated with persistent high pain intensity and disability (all p < 0.007). In summary, lower levels of general health and vitality were associated with persistent high-intensity low back pain and disability, suggesting that improving these aspects of well-being has the potential to reduce high levels of chronic low back pain and disability in community-based women.

Negative beliefs about back pain are associated with persistent, high levels of low back disability in community-based women.

OBJECTIVES: Although pessimistic beliefs about back pain are associated with low back pain and disability, our understanding of their role in the natural history of the condition is limited. This study examined the association between beliefs about back pain and the development and progression of low back pain and disability over a 2-year period in community-dwelling women. METHODS: A total of 506 women were recruited at baseline to participate in a 2-year cohort study. Beliefs about back pain were measured at baseline using the Back Beliefs Questionnaire, and low back pain and disability were assessed at baseline and 2 years using the Chronic Pain Grade Questionnaire (CPG). Participants were categorized into the following groups based on their CPG scores: no, developing, resolving, and persistent high-intensity pain and disability. RESULTS: Of the 442 (87.4%) women who participated in the 2-year follow up study, 108 (24.4%) and 69 (15.6%) reported high levels of low back pain and disability, respectively. Negative beliefs about low back pain were associated with persistent, high levels of low back disability (M(SE) = 26.1(1.4) vs 31.3(0.31), P = 0.002), but not persistent, high-intensity pain (M(SE) = 28.9(1.02) vs 31.2(0.33), P = 0.2), after adjusting for confounders. Women with persistent high-intensity pain and disability had more negative responses to belief statements about the future consequences of the condition compared with those with no, resolving, or developing pain and disability (P < 0.001-0.03). CONCLUSIONS: This study found that pessimistic beliefs about back pain were associated with persistent high levels of low back disability, suggesting that strategies aimed at improving negative beliefs may reduce the chronicity associated with this condition.

eMAP:CKD: electronic diagnosis and management assistance to primary care in chronic kidney disease.

Background: The increasing burden of chronic kidney disease (CKD) underpins the importance for improved early detection and management programs in primary care to delay disease progression and reduce mortality rates. eMAP:CKD is a pilot program for primary care aimed at addressing the gap between current and best practice care for CKD. Methods: Customized software programs were developed to integrate with primary care electronic health records (EHRs), allowing real-time prompting for CKD risk factor identification, testing, diagnosis and management according to Kidney Health Australia's (KHA) best practice recommendations. Primary care practices also received support from a visiting CKD nurse and education modules. Patient data were analyzed at baseline (150 910 patients) and at 15 months (175 917 patients) following the implementation of the program across 21 primary care practices. Results: There was improvement in CKD risk factor recognition (29.40 versus 33.84%; P < 0.001) and more complete kidney health tests were performed (3.20 versus 4.30%; P < 0.001). There were more CKD diagnoses entered into the EHR (0.48 versus 1.55%; P < 0.001) and more patients achieved KHA's recommended management targets (P < 0.001). Conclusion: The eMAP:CKD program has shown an improvement in identification of patients at risk of CKD, appropriate testing and management of these patients, as well as increased documentation of CKD diagnosis entered into the EHRs. We have demonstrated efficacy in overcoming the verified gap between current and best practice in primary care. The success of the pilot program has encouraging implications for use across the primary care community as a whole.

Prevalence of fecal incontinence and its relationship with urinary incontinence in women living in the community.

OBJECTIVE: The aim of this study was to document the age-specific prevalence of fecal incontinence (FI), as well as its relationship to childbirth and urinary incontinence (UI), in a community-based sample of Australian women. METHODS: A total of 444 women aged 26 to 82 years, originally recruited from a community-based research database, completed a self-administered study questionnaire. Prevalence of FI was assessed using the Pelvic Floor Distress Inventory, and UI and its subtypes were determined using the Questionnaire for Urinary Incontinence Diagnosis. Univariate (Pearson's χ tests) and multivariate logistic regression analyses were used to assess the relationship between FI type and UI adjusting for age and body mass index (BMI). RESULTS: Data were analyzed for 442 women. The overall prevalence of any FI was 20.7% (95% CI, 16.9%-24.5%). Loose FI was reported by 91 of 442 women, yielding a prevalence of 20.7% (95% CI, 16.9%-24.5%). Well-formed FI was reported by 20 of 442 women, yielding a prevalence of 4.5% (95% CI, 2.6%-6.4%). All the women with well-formed FI also reported problems of loose FI. The prevalence of FI increased with age up to 75 years for both types of FI. FI was not related to parity (P = 0.9). The highest proportion of any FI (24.4%) occurred in women with a parity of four or greater; however, 20.3% of nulliparous women reported FI. Within parous women, there was no significant association found between FI and history of self-reported instrumental delivery (P = 0.4). About two thirds of the women with loose and well-formed FI also reported coexisting UI. Loose FI was significantly associated with any UI (odds ratio, 2.8; 95% CI, 1.7-4.8) after adjusting for age and BMI (P < 0.001). Well-formed FI was not significantly associated with any UI after adjusting for age and BMI. CONCLUSIONS: FI is a common condition affecting one in five adult women in the community. In our study, women with loose FI, but not well-formed FI, were more likely to have UI independent of their age and BMI. Being parous was not associated with an increased risk of any FI.

Incidence and resolution rates of different types of urinary incontinence in women: findings from a cohort study.

PURPOSE: We determined the incidence and resolution rates of different types of urinary incontinence in Australian women and examined the course of urinary incontinence with or without treatment. MATERIALS AND METHODS: A total of 506 women originally recruited from a community based research database completed a baseline questionnaire in 2006 and a followup questionnaire in 2008. Urinary incontinence incidence and resolution were assessed using the Questionnaire for Urinary Incontinence Diagnosis. The Bristol Female Lower Urinary Tract Symptoms questionnaire was used to assess the impact of urinary incontinence on quality of life. RESULTS: At baseline and followup 442 women provided data. Mean ± SD age was 59.28 ± 12.1 years at followup. The total incidence of any new urinary incontinence was 17% (95% CI 12.4-21.6) in unaffected women and the total resolution rate was 16.8% (95% CI 11.4-22.2) in women with urinary incontinence during 2 years regardless of receiving treatment for urinary incontinence. There was also movement of women among the diagnoses of stress only, urge only and mixed urinary incontinence during followup. A total of 34 women reported having received treatment for urinary incontinence and 5 experienced resolution of the condition. All types of urinary incontinence were associated with impaired quality of life (p <0.001) and adversely impacted daily activity. A negative impact on quality of life (p = 0.02) was also observed in incident cases at followup compared with baseline. CONCLUSIONS: Our study shows that urinary incontinence is a highly dynamic clinical condition with movement among diagnostic subtypes of stress only, urge only and mixed urinary incontinence, and periods of resolution. Any urinary incontinence is significantly associated with impaired quality of life.

Urinary incontinence is associated with lower psychological general well-being in community-dwelling women.

OBJECTIVE: There are few studies documenting the impact of urinary incontinence (UI) on well-being in women. The aim of this study was to evaluate the relationships between different types of UI and general well-being in women in the community. METHODS: A cross-sectional survey of 542 community-dwelling women, aged 24 to 80 years, was conducted in July 2006. A detailed self-administered questionnaire was mailed to the study participants. UI was assessed using the Questionnaire for Urinary Incontinence Diagnosis, and well-being was assessed using the Psychological General Well-being Index (PGWBI). The relationships between types of UI and PGWBI scores were assessed using multiple regression analyses while adjusting for potential confounders. RESULTS: A total of 506 (94%) women provided data for analysis. Women with incontinence had a lower total PGWBI score (76.9 +/- 16.5) than did women with no UI (81.6 +/- 15.3; P = 0.001). The total PGWBI mean score was significantly lower in women with stress-only UI (77.8 +/- 16.2; P = 0.05) and mixed UI (74.2 +/- 17.8; P < 0.001) compared with women with no UI. There was no significant difference in the mean total scores between women with urge UI and women without UI. Stress-only UI was negatively associated with the PGWBI subdomains of self-control, general health, and vitality, whereas those with mixed UI had lower scores for all the PGWBI subdomains. The associations for UI remained significant after adjustment for age, systemic hormone therapy use, menopause status, smoking status, and regular exercise. CONCLUSIONS: Not only is UI associated with a significant reduction in well-being in community-dwelling women, but also, the relationship between different types of UI and well-being seems to differ.

Postpartum haemorrhage and eclampsia: differences in knowledge and care-seeking behaviour in two districts of Bangladesh.

In high- and low-performing districts of Bangladesh, the study explored the demand-side of maternal healthcare by looking at differences in perceived knowledge and care-seeking behaviours of women in relation to postpartum haemorrhage or eclampsia. Haemorrhage and eclampsia are two major causes of maternal mortality in Bangladesh. The study was conducted during July 2006-December 2007. Both postpartum bleeding and eclampsia were recognized by women of different age-groups as severe and life-threatening obstetric complications. However, a gap existed between perception and actual care-seeking behaviours which could contribute to the high rate of maternal deaths associated with these conditions. There were differences in care-seeking practices among women in the two different areas of Bangladesh, which may reflect sociocultural differences, disparities in economic and educational opportunities, and a discrimination in the availability of care.

Age-specific prevalence of, and factors associated with, different types of urinary incontinence in community-dwelling Australian women assessed with a validated questionnaire.

OBJECTIVE: The aim of this study was to document the age-specific prevalence of different types of urinary incontinence (UI) in women and to identify the risk factors associated with each type of UI. DESIGN: A detailed self-administered questionnaire was mailed to 542 community-dwelling women, aged 24-80 years. The questionnaire included a validated instrument, the Questionnaire for Urinary Incontinence Diagnosis (QUID), for the assessment of stress, urge and mixed UI. RESULTS: Five hundred and six of the 542 women provided data (93.4%). The overall prevalence of any UI was 41.7% [95% confidence interval (CI): 37.2-45.8%]. Of the 210 women reporting UI, 16% [95% CI: 12.9-19.3%] reported stress only; 7.5% [95% CI: 5.2-9.8%] reported urge only and 18% [95% CI: 14.7-21.5%] reported a mixed pattern. Stress incontinence was most common amongst middle-aged women (25.3% of women aged 35-44 years), while urge incontinence was most common in women over the age of 75 years (24.2%). In logistic regression analyses, obesity (p<0.001) and being parous (p=0.019) were found to be significantly associated with stress incontinence, increasing age (p=0.002) with urge incontinence, and being overweight (p=0.035) or obese (p<0.001) and having had a hysterectomy (p=0.021) with mixed incontinence. CONCLUSIONS: UI is a highly prevalent condition in women living in the community. Stress, urge and mixed incontinence have different age distributions and risk factors. These data are important in understanding the etiology, management and possible prevention of these conditions.

Reducing maternal mortality and improving maternal health: Bangladesh and MDG 5.

Bangladesh is on its way to achieving the MDG 5 target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015, but the annual rate of decline needs to triple. Although the use of skilled birth attendants has improved over the past 15 years, it remains less than 20% as of 2007 and is especially low among poor, uneducated rural women. Increasing the numbers of skilled birth attendants, deploying them in teams in facilities, and improving access to them through messages on antenatal care to women, have the potential to increase such use. The use of caesarean sections is increasing although not among poor, uneducated rural women. Strengthening appropriate quality emergency obstetric care in rural areas remains the major challenge. Strengthening other supportive services, including family planning and delayed first birth, menstrual regulation, and education of women, are also important for achieving MDG 5.

Prevalence and incidence of urinary incontinence in women: review of the literature and investigation of methodological issues.

OBJECTIVES: Urinary incontinence in women is common and has a significant impact on the physical, psychological and socio-economic aspects of life. The aims of this study were to review the published reports on the prevalence and incidence of urinary incontinence in Australian women and to examine the methodological issues associated with these studies. METHODS: Electronic searches of Medline, EMBASE and the Current Index to Nursing and Allied Health Literature databases were undertaken using 'Medical Subject Heading' terms and 'free text' words. We retrieved papers that investigated the prevalence and/or incidence of urinary incontinence in Australian women and were published in English after 1980. Methodological data from each study were tabulated. RESULTS: Seven studies were identified which examined the prevalence of urinary incontinence and two studies that reported its incidence. The prevalence of urinary incontinence varied between 12.8% and 46.0%. Study heterogeneity was a consequence of response rates, the inclusion of women in institutional care, the method of data collection, the questions used to identify different types of urinary incontinence and the way these questions were reported, the period over which the urinary incontinence had occurred and the severity of the incontinence. Two studies which examined incidence provided evidence that urinary incontinence can be a transient phenomenon. CONCLUSIONS: Research into the incidence and prevalence of urinary incontinence in Australian women exhibits significant heterogeneity in the findings due to methodological limitations. There is a need for future studies to employ validated instruments and give careful attention to the selection of participants and the reporting of age-specific data.

Determinants of reduction in maternal mortality in Matlab, Bangladesh: a 30-year cohort study.

BACKGROUND: Research on the effectiveness of strategies to reduce maternal mortality is scarce. We aimed to assess the contribution of intervention strategies, such as skilled attendance at birth, to the recorded reduction in maternal mortality in Matlab, Bangladesh. We examined and compared trends in maternal mortality in two adjacent areas over 30 years, by separate analyses of causes of death, underlying sociodemographic determinants, and areas and time periods in which interventions differed. METHODS: We analysed survey data that was routinely collected between 1976 and 2005 for about 200 000 inhabitants of Matlab, in Bangladesh, in adjacent areas served by either the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) or by the government. We used logistic regression to assess time trends in maternal mortality. We separately analysed deaths due to direct obstetric causes, abortion-related causes, and other causes. FINDINGS: Maternal mortality fell by 68% in the ICDDR,B service area and by 54% in the government service area over 30 years. Maternal mortality remained stable between 1976 and 1989 (crude annual OR 1.00 [0.98-1.01]) but decreased substantially after 1989 (OR 0.95 [0.93-0.97]). The speed of decline was faster after the skilled-attendance strategy was introduced in the ICDDR,B service area in 1990 (p=0.09). Abortion-related mortality fell sharply from 1990 onwards (OR 0.91 [0.86-0.95]). Educational differentials for mortality were substantial; the OR for more than 8 years of schooling compared with no schooling was 0.30 (0.21-0.44) for maternal mortality and 0.09 (0.02-0.37) for abortion mortality. INTERPRETATION: The fall in maternal mortality over 30 years occurred despite a low uptake of skilled attendance at birth. Part of the decline was due to a fall in abortion-related deaths and better access to emergency obstetric care; midwives might also have contributed by facilitating access to emergency care. Investment in midwives, emergency obstetric care, and safe pregnancy termination by manual vacuum aspiration have clearly been important. However, additional policies, such as those that bring about expansion of female education, better financial access for the poor, and poverty reduction, are essential to sustain the successes achieved to date.