Relative risks of childhood developmental vulnerabilities in three Australian communities with exposure to per- and polyfluoroalkyl substances: data linkage study.

Background: Aqueous film forming foams (AFFF) containing per- and polyfluoroalkyl substances (PFAS) caused local environmental contamination in three Australian residential areas: Katherine in the Northern Territory (NT), Oakey in Queensland (Qld) and Williamtown in New South Wales (NSW). We examined whether children who lived in these areas had higher risks of developmental vulnerabilities than children who lived in comparison areas without known contamination. Methods: All children identified in the Medicare Enrolment File-a consumer directory for Australia's universal healthcare insurance scheme-who ever lived in exposure areas, and a sample of children who ever lived in selected comparison areas, were linked to the Australian Early Development Census (AEDC). The AEDC data were available from four cycles: 2009, 2012, 2015 and 2018. For each exposure area, we estimated relative risks (RRs) of developmental vulnerability on each of five AEDC domains and a summary measure, adjusting for sociodemographic characteristics and other potential confounders. Findings: We included 2,429 children from the NT, 2,592 from Qld and 510 from NSW. We observed lower risk of developmental vulnerability in the Communication skills and general knowledge domain in Katherine (RR = 0.74, 95% confidence interval (CI) 0.57 to 0.97), and higher risks of developmental vulnerability in the same domain (RR = 1.49, 95% CI 1.18 to 1.87) and in the Physical health and wellbeing domain in Oakey (RR = 1.31, 95% CI 1.06 to 1.61). Risks of developmental vulnerabilities on other domains were not different from those in the relevant comparison areas or were uncertain due to small numbers of events. Conclusion: There was inadequate evidence for increased risks of developmental vulnerabilities in children who ever lived in three PFAS-affected areas in Australia.

Relative Risks of Adverse Perinatal Outcomes in Three Australian Communities Exposed to Per- and Polyfluoroalkyl Substances: Data Linkage Study.

INTRODUCTION: Firefighting foams containing per- and polyfluoroalkyl substances (PFAS) have caused environmental contamination in several Australian residential areas, including Katherine in the Northern Territory (NT), Oakey in Queensland (Qld), and Williamtown in New South Wales (NSW). We examined whether the risks of adverse perinatal outcomes were higher in mothers living in these exposure areas than in selected comparison areas without known contamination. METHODS: We linked residential addresses in exposure areas to addresses collected in the jurisdictional Perinatal Data Collections of the NT (1986-2017), Qld (2007-2018), and NSW (1994-2018) to select all pregnancies from mothers who gave birth while living in these areas. We also identified one comparison group for each exposure area by selecting pregnancies where the maternal address was in selected comparison areas. We examined 12 binary perinatal outcomes and three growth measurements. For each exposure area, we estimated relative risks (RRs) of adverse outcomes and differences in means of growth measures, adjusting for sociodemographic characteristics and other potential confounders. RESULTS: We included 16,970 pregnancies from the NT, 4654 from Qld, and 7475 from NSW. We observed elevated risks of stillbirth in Oakey (RR = 2.59, 95% confidence interval (CI) 1.25 to 5.39) and of postpartum haemorrhage (RR = 1.94, 95% CI 1.13 to 3.33) and pregnancy-induced hypertension (RR = 1.88, 95% CI 1.30 to 2.73) in Williamtown. The risks of other perinatal outcomes were not materially different from those in the relevant comparison areas or were uncertain due to small numbers of events. CONCLUSIONS: There was limited evidence for increased risks of adverse perinatal outcomes in mothers living in areas with PFAS contamination from firefighting foams. We found higher risks of some outcomes in individual areas, but these were not consistent across all areas under study and could have been due to chance, bias, or confounding.

Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study.

Introduction: Poor adoption of stroke guidelines is a problem internationally. The Quality in Acute Stroke Care (QASC) trial demonstrated significant reduction in death and disability with facilitated implementation of nurse-initiated. Methods: This was a multi-country, multi-centre, pre-test/post-test study (2017-2021) comparing post implementation data with historically collected pre-implementation data. Hospital clinical champions, supported by the Angels Initiative conducted multidisciplinary workshops discussing pre-implementation medical record audit results, barriers and facilitators to FeSS Protocol implementation, developed action plans and provided education, with ongoing support co-ordinated remotely from Australia. Prospective audits were conducted 3-month after FeSS Protocol introduction. Pre-to-post analysis and country income classification comparisons were adjusted for clustering by hospital and country controlling for age/sex/stroke severity. Results: Data from 64 hospitals in 17 countries (3464 patients pre-implementation and 3257 patients post-implementation) showed improvement pre-to-post implementation in measurement recording of all three FeSS components, all p < 0.0001: fever elements (pre: 17%, post: 51%; absolute difference 33%, 95% CI 30%, 37%); hyperglycaemia elements (pre: 18%, post: 52%; absolute difference 34%; 95% CI 31%, 36%); swallowing elements (pre: 39%, post: 67%; absolute difference 29%, 95% CI 26%, 31%) and thus in overall FeSS Protocol adherence (pre: 3.4%, post: 35%; absolute difference 33%, 95% CI 24%, 42%). In exploratory analysis of FeSS adherence by countries' economic status, high-income versus middle-income countries improved to a comparable extent. Discussion and conclusion: Our collaboration resulted in successful rapid implementation and scale-up of FeSS Protocols into countries with vastly different healthcare systems.

Psychological distress in three Australian communities living with environmental per- and polyfluoroalkyl substances contamination.

BACKGROUND: Environmental chemical contamination is a recognised risk factor for psychological distress, but has been seldom studied in the context of per- and polyfluoroalkyl substances (PFAS) contamination. We examined psychological distress in a cross-sectional study of three Australian communities exposed to PFAS from the historical use of aqueous film-forming foam in firefighting activities, and three comparison communities without environmental contamination. METHODS: Participation was voluntary following recruitment from a PFAS blood-testing program (exposed) or random selection (comparison). Participants provided blood samples and completed a survey on their exposure history, sociodemographic characteristics, and four measures of psychological distress (Kessler-6, Distress Questionnaire-5, Patient Health Questionnaire-15, and Generalised Anxiety Disorder-7). We estimated prevalence ratios (PR) of clinically-significant psychological distress scores, and differences in mean scores: (1) between exposed and comparison communities; (2) per doubling in PFAS serum concentrations in exposed communities; (3) for factors that affect the perceived risk of living in a community exposed to PFAS; and (4) in relation to self-reported health concerns. RESULTS: We recruited 881 adults in exposed communities and 801 in comparison communities. We observed higher levels of self-reported psychological distress in exposed communities than in comparison communities (e.g., Katherine compared to Alice Springs, Northern Territory: clinically-significant anxiety scores, adjusted PR = 2.82, 95 % CI 1.16-6.89). We found little evidence to suggest that psychological distress was associated with PFAS serum concentrations (e.g., Katherine, PFOS and anxiety, adjusted PR = 0.85, 95 % CI 0.65-1.10). Psychological distress was higher among exposed participants who were occupationally exposed to firefighting foam, used bore water on their properties, or were concerned about their health. CONCLUSION: Psychological distress was substantially more prevalent in exposed communities than in comparison communities. Our findings suggest that the perception of risks to health, rather than PFAS exposure, contribute to psychological distress in communities with PFAS contamination.

Liver and cardiometabolic markers and conditions in a cross-sectional study of three Australian communities living with environmental per- and polyfluoroalkyl substances contamination.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) have been associated with higher cholesterol and liver function markers in some studies, but the evidence for specific cardiometabolic conditions has been inconclusive. OBJECTIVES: We quantified the associations of single and combined PFAS with cardiometabolic markers and conditions in a cross-sectional study of three Australian communities with PFAS-contaminated water from the historical use of aqueous film-forming foam in firefighting activities, and three comparison communities. METHODS: Participants gave blood samples for measurement of nine PFAS, four lipids, six liver function markers, and completed a survey on sociodemographic characteristics and eight cardiometabolic conditions. We estimated differences in mean biomarker concentrations per doubling in single PFAS concentrations (linear regression) and per interquartile range increase in the PFAS mixture (Bayesian kernel machine regression). We estimated prevalence ratios of biomarker concentrations outside reference limits and self-reported cardiometabolic conditions (Poisson regression). RESULTS: We recruited 881 adults in exposed communities and 801 in comparison communities. We observed higher mean total cholesterol with higher single and mixture PFAS concentrations in blood serum (e.g., 0.18 mmol/L, 95% credible interval -0.06 to 0.42, higher total cholesterol concentrations with an interquartile range increase in all PFAS concentrations in Williamtown, New South Wales), with varying certainty across communities and PFAS. There was less consistency in direction of associations for liver function markers. Serum perfluorooctanoic acid (PFOA) concentrations were positively associated with the prevalence of self-reported hypercholesterolemia in one of three communities, but PFAS concentrations were not associated with self-reported type II diabetes, liver disease, or cardiovascular disease. DISCUSSION: Our study is one of few that has simultaneously quantified the associations of blood PFAS concentrations with multiple biomarkers and cardiometabolic conditions in multiple communities. Our findings for total cholesterol were consistent with previous studies; however, substantial uncertainty in our estimates and the cross-sectional design limit causal inference.

Impact of market-based home fortification with micronutrient powder on childhood anemia in Bangladesh: a modified stepped wedge design.

Background: Anemia poses a significant public health problem, affecting 1.6 billion people and contributing to the loss of 68.4 million disability-adjusted life years. We assessed the impact of a market-based home fortification program with micronutrient powder (MNP) called Pushtikona-5 implemented by Bangladesh Rural Advancement Committee (BRAC) on the prevalence of anemia among children aged 6-59 months in Bangladesh. Methods: We used a modified stepped wedged design and conducted three baseline, two midline, and three endline surveys to evaluate the Pushtikona-5 program implemented through three BRAC program platforms. We interviewed children's caregivers, and collected finger-prick blood samples from children to measure hemoglobin concentration. We also collected data on coverage of Pushtikona-5 and infant and young child feeding (IYCF) practices. We performed bivariate and multivariable analysis and calculated adjusted risk ratios (ARRs) to assess the effect of program outcomes. Results: A total of 16,936 households were surveyed. The prevalence of anemia was 46.6% at baseline, dropping to 32.1% at midline and 31.2% at endline. These represented adjusted relative reductions of 34% at midline (RR 0.66, 95%CI 0.62 to 0.71, value of p <0.001) and 32% at endline (RR 0.68, 95%CI 0.64 to 0.71, value of p <0.001) relative to baseline. Regarding MNP coverage, at baseline, 43.5% of caregivers surveyed had heard about MNP; 24.3% of children had ever consumed food with MNP, and only 1.8% had consumed three or more sachets in the 7 days preceding the survey. These increased to 63.0, 36.9, and 4.6%, respectively, at midline and 90.6, 68.9, and 11.5%, respectively, at endline. Conclusion: These results show evidence of a reduction in the prevalence of anemia and an improvement in coverage. This study provides important evidence of the feasibility and potential for impact of linking market-based MNP distribution with IYCF promotion through community level health workers.

45 and Up COVID Insights: a dynamic and collaborative approach to evidence-making during the COVID-19 pandemic.

OBJECTIVES: In response to the coronavirus 2019 (COVID-19) pandemic, a research project was developed with a cohort of 45 and Up Study participants to generate timely, relevant evidence to guide policy, practice and planning. This paper describes the research model, the cohort establishment and characteristics, and some findings. METHODS: A subgroup of 45 and Up Study participants was invited to enrol in 45 and Up COVID Insights -a series of five online surveys conducted during 2020-22. The model involved a close collaborative partnership with the New South Wales Ministry of Health and a panel of scientific advisers, an agile data collection methodology and rapid dissemination of findings. Frequent, iterative engagement with stakeholders provided a framework for identifying survey themes and questions and ensured wide dissemination of findings. Themes included healthcare use, attitudes toward and uptake of COVID-19 prevention measures, and the impact of the pandemic on mental health, loneliness, and lifestyle behaviours. RESULTS: 45 and Up COVID Insights achieved strong stakeholder engagement through extensive consultation and rapid reporting of results. The project recruited a diverse cohort of 32 115 participants: median age 68 years (range: 56-100+); 8% from outer regional/remote areas; 12% from the most socioeconomically disadvantaged communities; and 9% from culturally and linguistically diverse backgrounds. The first four surveys found that the impact of the pandemic varied across populations and stages of the pandemic. Between February-April (survey 2) 2021, 10% reported missed healthcare in the past month because of the pandemic, rising to 26% by September-November 2021 (survey 4). Quality of life remained high (>90% good-excellent across the surveys). As the pandemic progressed, the proportion reporting worsened mental health as a result increased from 29% (July-December 2020, survey 1) to 46% (survey 4). In survey 2 (February-April 2021), 89% intended to get the COVID-19 vaccine, with 8% unsure. By late 2021, vaccination uptake was high, with 98% of respondents having received at least one vaccination. CONCLUSION: There is great value in harnessing a large longitudinal, well-described, and diverse cohort study to generate evidence in a changing context with evolving information needs. The collaborative model enhanced the value and relevance of the data to inform decisions.

Transitions in health service use among women with poor mental health: a 7-year follow-up.

OBJECTIVE: Women suffering from mental health problems require varied needs of mental health service utilisation. Transition between general practitioner and mental health services use are available through the Better Access Scheme initiative, for those in need of treatment. The study's aim was to identify trajectories of mental health service utilisation by Australian women. DESIGN: The Australian Longitudinal Study on Women's Health data linked to the administrative medical claims dataset were used to identify subgroups of women profiled by their mental health service use from 2006 to 2013. Latent growth mixture model is a statistical method to profile subgroups of individuals based on their responses to a set of observed variables allowing for changes over time. Latent class groups were identified, and used to examine predisposing factors associated with patterns of mental health service use change over time. SETTING: This study was conducted in Australia. PARTICIPANTS: National representative sample of women of born in 1973-1978, who were aged between 28 and 33 years at the start of our study period. RESULTS: Six latent class trajectories of women's mental health service use were identified over the period 2006-2013. Approximately, one-quarter of the sample were classified as the most recent users, while approximate equal proportions were identified as either early users, late/low user or late-high users. Additional, subgroups were defined as the consistent-reduced user and the late-high users, over time. Only 7.2% of the sample was classified as consistent high users who potentially used the services each year. CONCLUSION: These findings suggest that use of the Better Access Scheme mental health services through primary care was varied over time and may be tailored to each individual's needs for the treatment of depressive symptoms.

Sertraline hydrochloride for reducing impulsive behaviour in male, repeat-violent offenders (ReINVEST): protocol for a phase IV, double-blind, placebo-controlled, randomised clinical trial.

INTRODUCTION: Considerable evidence supports an association between poor impulse control (impulsivity) and violent crime. Furthermore, impulsivity and aggression has been associated with reduced levels of serotonergic activity in the brain. Selective serotonin reuptake inhibitors (SSRIs) are a class of anti-depressants that aim to regulate brain serotonin concentrations. Several small studies in psychiatric populations have administered SSRIs to impulsive--aggressive individuals, resulting in reduced impulsivity, anger, aggression and depression. However, no clinical trial has been undertaken in a criminal justice population. This protocol describes the design and implementation of the first systematic study of the potential benefits of SSRIs in impulsive---violent offenders who are at high risk of reoffending. METHODS AND ANALYSIS: A randomised, double-blinded, multicentre trial to test the clinical efficacy of an SSRI, sertraline hydrochloride, compared with placebo on recidivism and behavioural measures (including impulsivity, anger, aggression, depression and self-reported offending) over 12 months. 460 participants with histories of violence and screening positive for impulsivity are recruited at several local courts and correctional service offices in New South Wales, Australia. ETHICS AND DISSEMINATION: Results will be submitted for publication in a peer-reviewed journal. Possible implications of the effectiveness of this pharmacological intervention include economic benefits of reducing prison costs and societal benefits of improving safety. This study has received ethical approval from the University of New South Wales, Aboriginal Health & Medical Research Council, Corrective Services NSW and the NSW Justice Health and Forensic Mental Health Network. TRIAL REGISTRATION NUMBER: ACTRN12613000442707.

Understanding end-of-life care in Australian hospitals.

ObjectiveTo explore end-of-life care in the ward and intensive care unit (ICU) environment in nine Australian hospitals in a retrospective observational study.MethodsIn total, 1693 in-hospital deaths, 356 in ICU, were reviewed, including patient demographics, advance care plans, life-sustaining treatments, recognition of dying by clinicians and evidence of the palliative approach to patient care.ResultsMost patients (n=1430, 84%) were aged ≥60 years, with a low percentage (n=208, 12%) having an end-of-life care plan on admission. Following admission, 82% (n=1391) of patients were recognised as dying, but the time between recognition of dying to death was short (ICU (staying 4-48h) median 0.34 days (first quartile (Q1), third quartile (Q3): 0.16, 0.72); Ward (staying more than 48h) median 2.1 days (Q1, Q3: 0.96, 4.3)). Although 41% (n=621) patients were referred for specialist palliative care, most referrals were within the last few days of life (2.3 days (0.88, 5.9)) and 62% of patients (n=1047) experienced active intervention in their final 48h.ConclusionsLate recognition of dying can expose patients to active interventions and minimises timely palliative care. To attain alignment to the National Consensus Statement to improve experiences of end-of-life care, a nationally coordinated approach is needed.What is known about the topic?The majority of Australian patient deaths occur in hospitals whose care needs to align to the Australian Commission on Safety and Quality in Health Care's National Consensus Statement, essential elements of safe and high-quality end-of-life care.What does this paper add?The largest Australian study of hospital deaths reveals only 12% of patients have existing advance care plans, recognition of death is predominantly within the last 48h of life, with 60% receiving investigations and interventions during this time with late symptom relief.What are the implications for practitioners?Given the poor alignment with the National Consensus Statement, a nationally coordinated approach would improve the patient experience of end-of-life care.

Patterns and predictors of nicotine replacement therapy use among alcohol and other drug clients enrolled in a smoking cessation randomised controlled trial.

INTRODUCTION: Nicotine replacement therapy (NRT) use to support client smoking quit attempts is low and inconsistent at alcohol and other drug (AOD) treatment services. This study examined predictors of any NRT use and combination NRT use among AOD clients who were smokers. METHODS: The study was part of a cluster-RCT of an organisational change intervention to introduce smoking cessation support as part of routine treatment in 32 AOD services. The intervention provided AOD services with free NRT and training. Service clients completed baseline (n = 896), 8-week (n = 471) and 6.5-month (n = 427) follow-up surveys. Mixed-model logistic regression examined whether baseline socio-demographic and smoking variables were associated with single and combination NRT use. RESULTS: At 8-weeks follow-up 57% (n = 269/471), and at 6.5-months 33% (n = 143/427) of participants reported using at least one form of NRT. Odds of NRT use at 8-weeks follow-up were greater among participants from treatment vs control group (OR = 3.69, 95%CI 1.8-7.4; p < 0.001), higher vs lower nicotine dependence (OR = 1.74 95%CI 1.1-2.8; p = 0.024), or those motivated to quit (OR = 1.18 95%CI 1.0-1.4; p = 0.017). At 6.5-months, only the treatment arm remained significant. Combination NRT use at the 8-week follow-up was higher among those in treatment vs control group (OR = 2.75 95%CI 1.4-5.6; p = 0.005), or with higher vs lower nicotine dependence (OR = 2.12 95%CI 1.2-3.8; p = 0.014). No factors were associated with combination NRT use at 6.5-months. CONCLUSIONS: An organisational change intervention that supplied AOD services with NRT training and products to provide to clients during treatment significantly increases client single form and combination NRT use in the short term.

Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes.

BACKGROUND: Emergency departments (ED) are challenging environments but critical for early management of patients with stroke. PURPOSE: To identify how context affects the provision of stroke care in 26 Australian EDs. METHOD: Nurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes. FINDINGS: Collectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context. DISCUSSION: Future assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.

Developing a conceptual framework for implementation science to evaluate a nutrition intervention scaled-up in a real-world setting.

OBJECTIVE: The aim of this paper is to identify and develop a comprehensive conceptual framework using implementation science that can be applied to assess a nutrition intervention in a real-world setting. DESIGN: We conducted a narrative review using electronic databases and a manual search to identify implementation science frameworks, models and theories published in peer-reviewed journals. We performed a qualitative thematic analysis of these publications to generate a framework that could be applied to nutrition implementation science. RESULTS: Based on this review, we developed a comprehensive framework which we have conceptualised as an implementation science process that describes the transition from the use of scientific evidence through to scaling-up with the aim of making an intervention sustainable. The framework consisted of three domains: Domain i - efficacy to effectiveness trials, Domain ii - scaling-up and Domain iii - sustainability. These three domains encompass five components: identifying an 'effective' intervention; scaling-up and implementation fidelity; course corrections during implementation; promoting sustainability of interventions and consideration of a comprehensive methodological paradigm to identify 'effective' interventions and to assess the process and outcome indicators of implementation. The framework was successfully applied to a nutrition implementation program in Bangladesh. CONCLUSIONS: Our conceptual framework built from an implantation science perspective offers a comprehensive approach supported by a foundational and holistic understanding of its key components. This framework provides guidance for implementation researchers, policy-makers and programme managers to identify and review an effective intervention, to scale it up and to sustain it over time.

Role of home visits by volunteer community health workers: to improve the coverage of micronutrient powders in rural Bangladesh.

OBJECTIVE: We assessed the role of home visits by Shasthya Shebika (SS) - female volunteer community health workers (CHWs) - in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver-provider interaction on coverage variables. DESIGN: We used data from three cross-sectional surveys undertaken at baseline (n 1927), midline (n 1924) and endline (n 1540) as part of an evaluation of a home fortification programme. We defined an exposure group as one that had at least one SS visit to the caregiver's household in the 12 months preceding the survey considering three outcome variables - message (ever heard), contact (ever used) and effective coverage (regular used) of MNP. We performed multiple logistic regressions to explore the determinants of coverage, employed an 'interaction term' and calculated an odds ratio (OR) to assess the modifying effect of SS's home visits on coverage. SETTINGS: Sixty-eight sub-districts from ten districts of Bangladesh. PARTICIPANTS: Children aged 6-59 months and their caregivers. RESULTS: A home visit from an SS positively impacts message coverage at both midline (ratio of OR 1·70; 95 % CI 1·25, 2·32; P < 0·01) and endline (ratio of OR 3·58; 95 % CI 2·22, 5·78; P < 0·001), and contact coverage both at midline (ratio of OR 1·48; 95 % CI 1·06, 2·07; P = 0·021) and endline (ratio of OR 1·74; 95 % CI 1·23, 2·47; P = 0·002). There was no significant effect of a SS's home visit on effective coverage. CONCLUSIONS: The households visited by BRAC's volunteer CHWs have better message and contact coverage among the children aged 6-59 months.

Factors associated with home visits by volunteer community health workers to implement a home-fortification intervention in Bangladesh: a multilevel analysis.

OBJECTIVE: BRAC, an international development organization based in Bangladesh, engages community health workers called Shasthya Shebikas (SS) to implement home fortification of foods with micronutrient powders (MNP). We identified factors associated with home visits by SS, at different levels of the BRAC programme-delivery hierarchy, to implement home-fortification interventions. DESIGN: We conducted a cross-sectional survey, semi-structured interviews, and collected programme-related data from sub-districts included in the caregiver survey of BRAC's home-fortification programme and performed multilevel logistic regression modelling to investigate factors associated with home visits by SS. SETTINGS: Sixty-eight sub-districts in Bangladesh. PARTICIPANTS: Caregivers of children aged 6-59 months (n 1408) and BRAC's SS (n 201). RESULTS: Households with older children (0·55; 0·42, 0·72; P < 0·001) and located >300 m from the SS's house (0·67; 0·50, 0·89; P = 0·006) were less likely to have been visited by the SS, whereas those with caregivers who had ≥5 years of schooling (1·53; 1·10, 2·12; P = 0·011) were more likely to have been visited by the SS (adjusted OR; 95 % CI). Households in the catchment area of older SS aged >50 years (0·44; 0·21, 0·90; P = 0·025) were less likely to have been visited by the SS, whereas those with SS who received incentives of >800 BDT (3·00; 1·58, 5·58; P = 0·001) were more likely to have been visited by the SS (adjusted OR; 95 % CI). CONCLUSIONS: The number of home visits is a function of the characteristics of SS, factors that characterize the households they serve and characteristics of their organizational context, particularly to implement home fortification of foods with MNP.

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study.

BACKGROUND: The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. METHODS: Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. RESULTS: Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. CONCLUSIONS: Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).

Thrombolysis implementation intervention and clinical outcome: a secondary analysis of a cluster randomized trial.

BACKGROUND: Multiple studies have attempted to increase the rate of intravenous thrombolysis for ischemic stroke using interventions to promote adherence to guidelines. Still, many of them did not measure individual-level impact. This study aimed to make a posthoc comparison of the clinical outcomes of patients in the "Thrombolysis ImPlementation in Stroke (TIPS)" study, which aimed to improve rates of intravenous thrombolysis in Australia. METHODS: A posthoc analysis was conducted using individual-level patient data. Excellent (Three-month post treatment modified Rankin Score 0-2) and poor clinical outcome (Three-month post treatment modified Rankin Score 5-6) and post treatment parenchymal haematoma were the three main outcomes, and a mixed logistic regression model was used to assess the difference between the intervention and control groups. RESULTS: There was a non-significant higher odds of having an excellent clinical outcome of 57% (odds ratio: 1.57; 95% CI: 0.73-3.39) and 33% (odds ratio: 1.33; 95% CI: 0.73-2.44) during the active-and post-intervention period respectively, for the intervention compared to the control group. A non-significant lower odds of having a poor clinical outcome was also found in the intervention, relative to control group of 4% (odds ratio: 0.96; 95% CI: 0.56-2.07) and higher odds of having poor outcome of 44% (odds ratio: 1.44 95% CI: 0.61-3.41) during both active and post-intervention period respectively. Similarly, a non-significant lower odds of parenchymal haematoma was also found for the intervention group during the both active- (odds ratio: 0.53; 95% CI: 0.21-1.32) and post-intervention period (odds ratio: 0.96; 95% CI: 0.36-2.52). CONCLUSION: The TIPS multi-component implementation approach was not effective in reducing the odds of post-treatment severe disability at 90 days, or post-thrombolysis hemorrhage. TRIAL REGISTRATION: Clinical Trial Registration-URL: http://www.anzctr.org.au/ Unique Identifier: ACTRN12613000939796 .

An Internet-Based Intervention Augmented With a Diet and Physical Activity Consultation to Decrease the Risk of Dementia in At-Risk Adults in a Primary Care Setting: Pragmatic Randomized Controlled Trial.

BACKGROUND: There is a need to develop interventions to reduce the risk of dementia in the community by addressing lifestyle factors and chronic diseases over the adult life course. OBJECTIVE: This study aims to evaluate a multidomain dementia risk reduction intervention, Body Brain Life in General Practice (BBL-GP), targeting at-risk adults in primary care. METHODS: A pragmatic, parallel, three-arm randomized trial involving 125 adults aged 18 years or older (86/125, 68.8% female) with a BMI of ≥25 kg/m2 or a chronic health condition recruited from general practices was conducted. The arms included (1) BBL-GP, a web-based intervention augmented with an in-person diet and physical activity consultation; (2) a single clinician-led group, Lifestyle Modification Program (LMP); and (3) a web-based control. The primary outcome was the Australian National University Alzheimer Disease Risk Index Short Form (ANU-ADRI-SF). RESULTS: Baseline assessments were conducted on 128 participants. A total of 125 participants were randomized to 3 groups (BBL-GP=42, LMP=41, and control=42). At immediate, week 18, week 36, and week 62 follow-ups, the completion rates were 43% (18/42), 57% (24/42), 48% (20/42), and 48% (20/42), respectively, for the BBL-GP group; 71% (29/41), 68% (28/41), 68% (28/41), and 51% (21/41), respectively, for the LMP group; and 62% (26/42), 69% (29/42), 60% (25/42), and 60% (25/42), respectively, for the control group. The primary outcome of the ANU-ADRI-SF score was lower for the BBL-GP group than the control group at all follow-ups. These comparisons were all significant at the 5% level for estimates adjusted for baseline differences (immediate: difference in means -3.86, 95% CI -6.81 to -0.90, P=.01; week 18: difference in means -4.05, 95% CI -6.81 to -1.28, P<.001; week 36: difference in means -4.99, 95% CI -8.04 to -1.94, P<.001; and week 62: difference in means -4.62, 95% CI -7.62 to -1.62, P<.001). CONCLUSIONS: A web-based multidomain dementia risk reduction program augmented with allied health consultations administered within the general practice context can reduce dementia risk exposure for at least 15 months. This study was limited by a small sample size, and replication on a larger sample with longer follow-up will strengthen the results. TRIAL REGISTRATION: Australian clinical trials registration number (ACTRN): 12616000868482; https://anzctr.org.au/ACTRN12616000868482.aspx.

Syphilis testing performance in Aboriginal primary health care: exploring impact of continuous quality improvement over time.

Data from 110 primary healthcare clinics participating in two or more continuous quality improvement (CQI) cycles in preventive care, which included syphilis testing performance (STP) for Aboriginal and Torres Strait Islander people aged between 15 and 54 years, were used to examine whether the number of audit cycles including syphilis testing was associated over time with STP improvement at clinic level in this specific measure of public health importance. The number of cycles per clinic ranged from two to nine (mode 3). As shown by medical record audit at entry to CQI, only 42 (38%) clinics had tested or approached 50% or more of their eligible clients for syphilis in the prior 24 months. Using mixed effects logistic regression, it was found that the odds of a clinic's STP relative to its first cycle increased only modestly. Counterintuitively, clinics undertaking the most preventive health CQI cycles tended to have the lowest STP throughout. Participation in a general preventive care CQI tool was insufficient to achieve and sustain high rates of STP for Aboriginal and Torres Strait Islander people required for public health benefit. Improving STP requires dedicated effort and greater understanding of barriers to effective CQI within and beyond clinic control.