Interventions to prevent or manage obesity in Maori and Pacific adults: a systematic review and narrative synthesis.

OBJECTIVES: Obesity and its sequelae are an increasing problem, disproportionally affecting Maori and Pacific peoples, secondary to multifactorial systemic causes, including the effects of colonisation and the impact of globalisation. There is limited synthesised evidence on interventions to address obesity in these populations. The objective of this review is to identify evaluated interventions for prevention and management of obesity amongst Maori and Pacific adults, assess the effectiveness of these interventions, and identify enablers and barriers to their uptake. DESIGN: Systematic review of databases (Medline, PubMed, EMBASE, CINAHL, Scopus, CENTRAL), key non-indexed journals, and reference lists of included articles were searched from inception to June 2021. Eligibility criteria defined using a Population, Intervention, Control, Outcome format and study/publication characteristics. Quantitative and qualitative data were extracted and analysed using narrative syntheses. Study quality was assessed using modified GRADE approach. RESULTS: From the 8190 articles identified, 21 were included, with 18 eligible for quantitative and five for qualitative analysis. The studies were heterogenous, with most graded as low quality. Some studies reported small but statistically significant improvements in weight and body mass index. Key enablers identified were social connection, making achievable sustainable lifestyle changes, culturally-centred interventions and incentives including money and enjoyment. Barriers to intervention uptake included difficulty in maintaining adherence to a programme due to intrinsic programme factors such as lack of social support and malfunctioning or lost equipment. CONCLUSIONS: Normal weight trajectory is progressive increase over time. Modest weight loss or no weight gain after several years may have a positive outcome in lowering progression to diabetes, or improvement of glycaemic control in people with diabetes. We recommend urgent implementation of Maori and Pacific-led, culturally-tailored weight loss programmes that promote holistic, small and sustainable lifestyle changes delivered in socially appropriate contexts.

Reaching out to reduce health inequities for Maori youth.

AIM: This paper describes an initiative facilitating comprehensive assessment and delivery of brief interventions for Maori youth in Northland, New Zealand. BACKGROUND: The population in Northland is predominantly Maori and is one of New Zealand's most deprived populations. Maori youth have the highest youth suicide rate in the developed world and elevated numbers of youth displaying mental health issues and/or risk behaviours are of grave national concern. Like Indigenous peoples worldwide, inequities persist for Maori youth accessing and engaging with healthcare services. DESCRIPTION: Taking services out to Maori youth in remote and isolated areas, Northland's youth specialist nurses are reducing some barriers to accessing health care. The youth version of the Case-finding and Help Assessment Tool is a New Zealand-developed, e-screening tool for youth psychosocial issues, facilitating comprehensive assessment and brief intervention delivery. DISCUSSION: Early detection of, and timely intervention for, mental health and risk behaviours can significantly improve health outcomes in youth. However, for this to happen barriers preventing youth from accessing appropriate care need to be overcome. CONCLUSION: Youth specialist nurses could improve access to care for youth from ethnic minorities, rural and isolated regions, and areas of high deprivation without overwhelming the medical profession. IMPLICATIONS FOR NURSING POLICY: Specialist nurses are trained and empowered to practice at the top of their scope. With general practitioner oversight and standing order sign off specialist nurses can work autonomously to improve access to health services, without increasing the workload of doctors. IMPLICATIONS FOR NURSING PRACTICE: Encouraging continuous self-reflection of the nurse's effectiveness in meeting patient needs, holistically and culturally, facilitates the provision of accessible care that is patient-centred and culturally safe.

Health-related behaviours and mental health in Hong Kong employees.

BACKGROUND: Poor physical and mental health in employees can result in a serious loss of productivity. Early detection and management of unhealthy behaviours and mental health symptoms can prevent productivity loss and foster healthy workplaces. AIMS: To examine health-related behaviours, mental health status and help-seeking patterns in employees, across different industries in Hong Kong. METHODS: Participants were telephone-interviewed and assessed using the Case-finding and Help Assessment Tool (CHAT) with employee lifestyle risk factors, mental health issues and help-seeking intentions screened across eight industries. Subsequent data analysis involved descriptive statistics and chi-square tests. RESULTS: There were 1031 participants. Key stressors were work (30%), family (19%), money (14%) and interpersonal issues (5%). Approximately 18, 9 and 9% of participants were smokers, drinkers and gamblers, respectively, and only 51% exercised regularly. Depressive and anxiety symptoms were reported by 24 and 31% of employees, respectively. Issues for which they wanted immediate help were interpersonal abuse (16%), anxiety (15%), anger control (14%) and depression (14%). Employees with higher educational attainment were less likely to smoke, drink and gamble than those with lower attainment. Lifestyle and mental health status were not associated with income. Employees in construction and hotel industries smoked more and those in manufacturing drank more than those in other industries. CONCLUSIONS: Physical and mental health of Hong Kong employees are concerning. Although employee assistance programmes are common among large companies, initiation of proactive engagement approaches, reaching out to those employees in need and unlikely to seek help for mental health issues, may be useful.

Criterion validity of the PHQ-9 (Malay version) in a primary care clinic in Malaysia.

OBJECTIVE: This study was conducted to determine the validity of the 9-item Patient Health Questionnaire (PHQ-9) (Malay version) as a case-finding instrument for depression among women in a primary care clinic. METHODS: A cross sectional study was conducted in a primary care clinic in Malaysia. Consecutive adult women patients who attended the clinic during data collection were given self-administered questionnaires, which included the PHQ-9 (Malay version). Systematic weighted random sampling was used to select participants for Composite International Diagnostic Interviews (CIDI). The PHQ-9 was validated against the CIDI reference standard. RESULTS: The response rate was 87.5% for the questionnaire completion (895/1023), and 96.8% for the CIDI interviews (151/156). The prevalence of depression was 12.1% (based on PHQ-9 scores of 10 and above). The PHQ-9 had a sensitivity of 87% (95% confidence interval 71% to 95%), a specificity of 82% (74% to 88%), positive LR 4.8 (3.2 to 7.2) and negative LR 0.16 (0.06 to 0.40). CONCLUSIONS: The Malay version of the PHQ-9 was found to be a valid and reliable case-finding instrument for depression in this study. Together with its brevity, it is a suitable case-finding instrument to be used in Malaysian primary care clinics.

Parents and nurses during the immunization of children--where is the power? A conversation analysis.

BACKGROUND: Best practice for health care practitioners is considered patient-centred approaches which empower patients. Immunization of young children requires maintaining this approach while retaining professional management. OBJECTIVE: The objectives were to assess situations within the immunization event with discordance between health provider and caregiver and evaluate strategies used to empowering parents while obtaining the desired clinical outcome. METHODS: This was a qualitative study nested within a larger study of immunization rates in 124 randomly selected primary care practices. Interactions between immunizing practice nurses, caregivers and children were videotaped and transcribed and underwent conversation analysis. Six purposively sampled primary care practices in Auckland, New Zealand, served as the setting. The participants were eight practice nurses immunizing 10 children and their parents. Normative pattern of interactions and 'deviant cases' involving discordance between nurse and parent. RESULTS: A total of 168 minutes of video-recorded conversation from 10 immunization sessions provided strong 'typical' pattern and equally striking 'deviant cases'. Parents mostly treated nurses as 'experts' and accepted asymmetry of knowledge over medical matters. Nurses demonstrated skilful strategies in delineating their area of medical expertise from areas in which patients are expert-their knowledge of themselves and their children. CONCLUSION: While patient centredness and empowering patients are contemporary goals of primary health care delivery, these attributes are not precisely defined. Patients may wish to be informed, but many trust their health professionals to direct their decision making. Although health professionals may impart as much knowledge as they can, asymmetry of knowledge remains. However, patients hold expertise beyond their clinical situation in the social and economic world in which they live.

Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study.

OBJECTIVE: To determine the validity of two written screening questions for depression with the addition of a question inquiring if help is needed. DESIGN: Cross sectional validation study. SETTING: 19 general practitioners in six clinics in New Zealand. PARTICIPANTS: 1025 consecutive patients receiving no psychotropic drugs. MAIN OUTCOME MEASURES: Sensitivity, specificity, and likelihood ratios of the two screening questions, the help question, combinations of the screening and help questions, and diagnosis by general practitioners. RESULTS: The help question alone had a sensitivity of 75% (95% confidence interval 60% to 85%) and a specificity of 94% (93% to 96%). The positive likelihood ratio for the help question was 13.0 (9.5 to 17.8) and the negative likelihood ratio was 0.27 (0.17 to 0.44). The likelihood ratio for patients wanting help today was 17.5 (11.8 to 31.9). The general practitioner diagnosis had a sensitivity of 79% (65% to 88%) and a specificity of 94% (92% to 95%). CONCLUSION: Adding a question inquiring if help is needed to the two screening questions for depression improves the specificity of a general practitioner diagnosis of depression.

Health and safety issues pertaining to genetically modified foods.

Genetic modification involves the insertion of genes from other organisms (within or between species) into host cells to select for desirable qualities. Potential benefits of GM foods include increased nutritional value; reduced allergenicity; pest and disease-resistance; and enhanced processing value. Possible detrimental outcomes include producing foods with novel toxins, allergens or reduced nutritional value, and development of antibiotic resistance or herbicide-resistant weeds. Benefits to individuals or populations need to be weighed against adverse health and environmental risks, and may differ between developing and Westernised countries. Whether testing and monitoring should exceed requirements for conventional foods is under debate. While not necessarily scientifically justifiable, consumer concerns have resulted in Australian and New Zealand requirements to label foods containing GM-produced proteins. Dissatisfied consumer advocacy groups are calling for all foods involving GM technology to be labelled, irrelevant of whether the final product contains novel protein. Goals to improve the quantity, quality and safety of foods are laudable; however, the primary aim of the bio-food industry is financial gain. GM foods may be as safe as conventional foods but public distrust runs high. It is important that discussion is informed by science and that claims of both benefits and risks are evidence-based, to ensure that the process is driven neither by the vested interest of the bio-technical multinational companies on the one hand, nor ill-informed public fears on the other.

Rehabilitation after arthroscopic meniscectomy: a critical review of the clinical trials.

We reviewed the literature on patient management following arthroscopic meniscal surgery. A critical appraisal of the literature produced 8 randomized controlled trials evaluating the use of non-steroidal anti-inflammatory drugs or various forms of physiotherapy and pain control. Different treatments and outcome measures precluded meta-analysis. The limited evidence suggests that this is a relatively pain-free procedure with rapid recovery, and that in most cases simple analgesia in the first 1-2 days following surgery and a well-planned home-based exercise program should be sufficient. It is possible that routine daily non-steroidal anti-inflammatory drugs post-operatively for 3-6 weeks may enhance recovery rates. One study found that physiotherapy was beneficial for regaining muscle strength and on pain assessment but this did not translate into functional improvement. Descriptive studies are required to ascertain the types and duration of treatments being offered to patients after arthroscopic meniscectomy. Further research is needed to perform well-designed studies of current treatments that take into account predisposing factors and their impact on outcome, including use of prerandomization and real-life functional outcome measures.

Coping strategies in the self-management of chronic heart failure.

BACKGROUND: A patient's psychological adaptation to heart failure can influence its impact on his or her life. However, attempts to understand how patients cope mentally with severe emotional strain have led to inconsistent use of a plethora of concepts, making communication and clinical care difficult. OBJECTIVES: The aim of the present study was to develop a framework for conceptualizing how patients with chronic heart failure cope mentally with their illness, and then use the framework to suggest how GPs can facilitate patient self-care. METHODS: We systematically reduced and reassembled the narrative texts of personal, semi-structured interviews until their interpretation was complete. The interviews were conducted during late 1999 with 62 heart failure patients under GP care in 30 practices across central Auckland, New Zealand. RESULTS: Our framework describes four coping strategies: avoidance, disavowal, denial and acceptance. Disavowal provides a distinct coping strategy through which patients, who basically understand the threat to their life situations, seek hope through positively reconstructing this threat. Use of this strategy was highly salient regardless of patients' age, the length of time since their recorded diagnosis or the degree of self-reported limitation of recent physical function due to heart failure. Only over age 70 were avoidance and acceptance also highly salient among patients whose heart failure was diagnosed at least 3 years previously and had mildly limited their recent physical function. CONCLUSION: Many different heart failure patients use disavowal to palliate the emotional strain and find hope. Disavowal is not a problem to deal with but a process GPs can facilitate by implementing a range of suggested strategies through methods such as story telling.

Power issues in the doctor-patient relationship.

Power is an inescapable aspect of all social relationships, and inherently is neither good nor evil. Doctors need power to fulfil their professional obligations to multiple constituencies including patients, the community and themselves. Patients need power to formulate their values, articulate and achieve health needs, and fulfil their responsibilities. However, both parties can use or misuse power. The ethical effectiveness of a health system is maximised by empowering doctors and patients to develop 'adult-adult' rather than 'adult-child' relationships that respect and enable autonomy, accountability, fidelity and humanity. Even in adult-adult relationships, conflicts and complexities arise. Lack of concordance between doctors and patients can encourage paternalism but may be best resolved through negotiated care. A further area of conflict involves the 'double agency' of doctors for both patients and the community. Empowerment of all players is not always possible but is most likely where each party considers and acknowledges power issues.

The early experience of general practitioners using Green Prescription.

AIM: Sedentary lifestyle is a significant risk factor for increased morbidity and mortality in many medical conditions. A Hillary Commission initiative, Green Prescription is a written exercise prescription given by general practitioners (GPs) to sedentary patients to encourage physical activity. Our aim was to establish the extent to which GPs in the North Health region in 1997 issued with Green Prescription packages had used them, the circumstances under which they were used, and barriers to their use. METHODS: 433 GPs issued with packs were faxed a one-page questionnaire for immediate completion, with follow-up of non-responders. RESULTS: The response rate was 73%, with 65% of respondents having written Green Prescriptions. Their main reasons for use were patient need for more exercise and presence of high-risk medical conditions such as hypertension, cardiovascular disease, obesity and diabetes. Reasons for non-use were: GP already giving advice about physical activity; concern that Green Prescription was patronising and simplistic; compliance issues and time restraints. Some requested a computerised version. CONCLUSION: Non-responders may be non-users, hence we estimate that 48-65% of targeted GPs used Green Prescription. Barriers identified by GPs have assisted in Green Prescription development, which is now nationwide and assessed by independent researchers tri-annually.

General practitioner management of upper respiratory tract infections: when are antibiotics prescribed?

AIM: To assess General Practice (GP) description and management of upper respiratory tract infections (URTI), including conditions under which they prescribe antibiotics. METHOD: A telephone survey of a randomised sample of Auckland GPs. RESULTS: There was a 61% response rate. 82 of the 100 GPs interviewed agreed that most patients presenting with URTI expected antibiotics. Persistent symptoms and indication of specific infection (tonsillitis, otitis media, sinusitis, pharyngitis, purulent sputum) were common reasons for prescribing. Patients travelling overseas, expecting or requesting antibiotics and prior use of over-the-counter (OTC) medications increased antibiotic prescribing-rates. Most GPs (95%) issued as-needed prescriptions on occasion; 13% did this often. Amoxicillin and amoxicillin/clavulanic acid were most commonly used. Despite wide-ranging antibiotic use for URTI (0 to 90%), only 6% of GPs felt they prescribed more antibiotics than others. CONCLUSIONS: The results suggest over-prescription is common-place, but use of as-needed prescriptions to reduce antibiotic use is encouraging. Exploration of patient expectations in the consultation may assist in decreasing prescribing rates.

Aggressive acts and assaults in intimate relationships: towards an understanding of the literature.

Far more people in relationships are subjected to violent acts than those who receive injuries. The degree of damage sustained may not reflect the perpetrator's intent to deliberately harm a partner. Data documenting aggressive acts determines the population at risk and their prevention and early treatment requirements; whereas data focusing on harm and injury helps determine emergency medical and refuge services. Data from national crime surveys, police records, or clinical populations should not be generalized to the population at large. Even if men perpetrate the majority of serious partner attacks, addressing the issue of female violence will significantly reduce the overall level of domestic violence. Judicial, medical, and social services should take note that while male violence may be more problematic, violence is a relationship issue, not a male issue.

What is an 'intact' hymen? A critique of the literature.

The purpose of this study was to establish medico-legal guidelines based upon medical findings which support or refute allegations of sexual penetration, taking into account non-sexual explanations for positive physical findings. A review of the literature was undertaken to examine what has been determined about the range of usual findings which can be expected if the hymen has been penetrated. While a large body of literature is available on the topic, some findings are ambiguous, and further research is required to advance and clarify our knowledge base in these areas. In only a minority of non-acute cases can definitive statements be made as to whether an alleged molestation has occurred. A non-scarred hymen that will not admit a finger is 'intact'; a hymenal opening accommodating two fingers or a vaginal speculum, with evidence of a deficit or scarring at the lower pole, indicates past sexual or, possibly, non-sexual penetration. Other findings are not definitive and, at best, can estimate only relative probability of occurrence of penetration. Findings within the normal range should be presented as 'neither confirm nor deny abuse', not 'consistent with abuse'. Often, it is impossible to establish whether a hymen is 'intact' in regard to past sexual intercourse.

Parents and other relatives accused of sexual abuse on the basis of recovered memories: a New Zealand family survey.

AIM: To survey New Zealand families where an alleged perpetrator and/or other family member denies an accusation involving the childhood molestation of one family member by another, based on a memory recovered in adulthood. As the validity of such memories is crucial, our aim was to develop a profile of such families and to compare it with New Zealand epidemiological data. METHOD: Information was collected by questionnaire regarding family demographics, characteristics of the accuser, family life, events surrounding and leading up to the accusations, consequences of the accusations and details of the accuser's current life situation. The 73 subjects included fathers, mothers, siblings and other relatives of the accusing adults. RESULTS: Most accusers were highly educated white women, frequently first born or older children from relatively large families, statistically different proportions from those expected. Many accusations involved events of low base-rate probability including satanic ritual abuse. Proportions differed from those of another New Zealand prevalence survey of 1019 18-year-olds in almost every way. CONCLUSION: The data suggest that it is unlikely that many, if not most, of the memories of child sexual abuse recovered in adulthood are a true reflection of history. Memories recovered during therapy should be treated with respect as part of the patient's narrative truth, but not assumed to be factually accurate without corroborative evidence.

Can tampon use cause hymen changes in girls who have not had sexual intercourse? A review of the literature.

Since tampon availability has become ubiquitous, several authors have opined about their effect on the virginal hymen, but only one paper has scientifically addressed the subject of tampon use and clefts in the hymens of never-sexually-active adolescent girls. It naturally has become an authority used by the courts. The Emans et al. (1994) study asserts that 'for physicians testifying in court about sexual assault cases, complete clefts in adolescents cannot be attributed to prior tampon use'. On closer inspection, however, it appears that the authors have interpreted their statistical finding using a strict scientific convention (chi 2, P = 0.06 as not having statistical significance) that may mislead in a clinical or legal situation. Indeed, there is a definite possibility that tampon use compared to not having used tampons in their never-sexually-active sample was associated with an increased percentage of complete hymenal clefts (14% vs. 6%; P = 0.06). Nevertheless, clefts were found in both the sexually active and the never-active groups: 20 of their 200 never-sexually-active subjects possessed complete hymenal clefts, as did only 84 of their 100 sexually active subjects. Caution should be used by all physicians asked to testify in courts regarding possible causes of a hymenal cleft.

Memory recovery and repression: what is the evidence?

Both the theory that traumatic childhood memories can be repressed, and the reliability of the techniques used to retrieve these memories are challenged in this paper. Questions are raised about the robustness of the theory and the literature that purports to provide scientific evidence for it. Evidence to this end is provided by the authors which surveyed New Zealand families in which one member had accused another (or others) of sexual abuse on the basis of recovered memories. It is shown that a number of these allegations involve very low probability events. Since memory repression theory is not currently scientifically substantiated it is argued that care needs to be taken in the mental health, legal and insurance compensation arenas. Memories recalled during therapy may be treated as metaphorical but, in the absence of corroborative evidence, should not be considered factually true. Clinicians who wish to use memory recovery techniques should inform patients of their experimental and controversial nature, point out adverse effects, and obtain consent before proceeding.