Including health impacts in environmental impact assessments for three Australian coal-mining projects: a documentary analysis.

Notwithstanding the historical benefits of coal in aiding human and economic development, the negative health and environmental impacts of coal extraction and processing are of increasing concern. Environmental impact assessments (EIAs) are a regulated policy mechanism that can be used to predict and consider the health impacts of mining projects to determine if consent is given. The ways in which health is considered within EIA is unclear. This research investigated 'How and to what extent are health, well-being and equity issues considered in Environmental Impact Assessments (EIAs) of major coal mining projects in New South Wales, Australia'. To this end we developed and applied a comprehensive coding framework designed to interrogate the publicly available environmental impact statements (EISs) of three mines in New South Wales (NSW), Australia, for their inclusion of health, well-being and equity issues. Analysis of the three EISs demonstrates that: the possible impacts of each mine on health and well-being were narrowly and inadequately considered; when health and well-being were considered there was a failure to assess the possible impacts specific to the particular mine and the communities potentially affected; the cumulative impacts on human health of multiple mines in the same geographical area were almost completely ignored; the discussions of intragenerational and intergenerational equity did not demonstrate a sound understanding of equity and, it is essential that governments' requirements for the EIA include detailed analysis of the health, well-being, equity and cumulative impacts specific to the proposed mine and relevant communities.

Evidence-based medicine: is it a bridge too far?

AIMS: This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science. RESULTS: The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context. CONCLUSION: EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.

The global response to diabetes: action or apathy?

Diabetes and related non-communicable diseases (NCDs) account for over 60% of the world's annual deaths, untold personal suffering, and an economically crippling burden of lost productivity. Despite the body of evidence and various calls to action, historically, the global response has bordered on apathy. Although diabetes and related NCDs remain disproportionately underfunded, the United Nations now recognises them as a major challenge to human and economic development, resulting in an action-oriented policy, frameworks and monitoring requirements that are being driven by the UN and the World Health Organization. Australia is at the forefront of many of these initiatives and is currently developing a new national diabetes strategy.

Priority actions for the non-communicable disease crisis.

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US$9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

Individual patient education for people with type 2 diabetes mellitus.

BACKGROUND: Type 2 diabetes is a common and costly chronic disease which is associated with significant premature mortality and morbidity. Although patient education is an integral component of diabetes care, there remain uncertainties regarding the effectiveness of different methods and modes of education. OBJECTIVES: To evaluate the effectiveness of individual patient education on metabolic control, diabetes knowledge and psychosocial outcomes. SEARCH STRATEGY: Multiple electronic bibliographic databases were searched, including The Cochrane Library, MEDLINE, Premedline, ERIC, Biosis, AMED, Psychinfo, EMBASE, CINAHL, APAIS-health, Australian Medical Index, Web of Science, dissertation abstracts and Biomed Central. SELECTION CRITERIA: Randomized controlled and controlled clinical trials which evaluated individual education for adults with type 2 diabetes. The intervention was individual face-to-face patient education while control individuals received usual care, routine treatment or group education. Only studies that assessed outcome measures at least six months from baseline were included. DATA COLLECTION AND ANALYSIS: Information was extracted by two reviewers who summarized both study characteristics and outcome statistics. A meta-analysis using a fixed-effect model was performed if there were adequate studies with a specified outcome of sufficient homogeneity. For outcomes where there were too few studies or the assessment measurements were not standardized or variable, the results were summarised qualitatively. MAIN RESULTS: Nine studies involving 1359 participants met the inclusion criteria. Six studies compared individual education to usual care and three compared individual education to group education (361 participants). There were no long-term studies and overall the quality of the studies was not high. In the six studies comparing individual face-to-face education to usual care, individual education did not significantly improve glycaemic control (weighted mean difference (WMD) in HbA1c -0.1% (95% confidence interval (CI) -0.3 to 0.1, P = 0.33) over a 12 to 18 month period. However, there did appear to be a significant benefit of individual education on glycaemic control in a subgroup analysis of three studies involving participants with a higher mean baseline HbA1c greater than 8% (WMD -0.3% (95% CI -0.5 to -0.1, P = 0.007). In the two studies comparing individual to group education, there was no significant difference in glycaemic control between individual or group education at 12 to 18 months with a WMD in HbA1c of 0.03% (95% CI -0.02 to 0.1, P = 0.22). There was no significant difference in the impact of individual versus usual care or group education on body mass index systolic or diastolic blood pressure. There were too few studies to perform a meta-analysis on the effect of individual education on dietary self management, diabetes knowledge, psychosocial outcomes and smoking habits. No data were available on the other main outcome measures of diabetes complications or health service utilization and cost analysis in these studies. AUTHORS' CONCLUSIONS: This systematic review suggests a benefit of individual education on glycaemic control when compared with usual care in a subgroup of those with a baseline HbA1c greater than 8%. However, overall there did not appear to be a significant difference between individual education and usual care. In the small number of studies comparing group and individual education, there was an equal impact on HbA1c at 12 to 18 months. Additional studies are needed to delineate these findings further.

Do socio-economic factors influence supermarket content and shoppers' purchases?

ISSUE ADDRESSED: Obesity is at crisis proportions. Individuals of low socio-economic status (SES) are more likely to consume higher energy dense diets than their high socio-economic status counterparts. The contribution of supermarket purchases of energy dense, nutrient poor foods has not been well-researched and has largely depended on unverified self-report. METHODS: We estimated the proportion of supermarket shelf space dedicated to non-core foods in nine supermarkets (in five high and four low SES areas) in metropolitan Sydney. We analysed 204 shoppers' dockets (102 from high and 102 from low SES areas) for purchases of confectionery; sugar sweetened, carbonated beverages and cordials, sweet biscuits and cakes, and crisps and popcorn. RESULTS: After adjusting for the number of people shopped for, low SES shoppers purchased significantly more non-core foods than high SES shoppers (p=0.039), especially chips and sugar sweetened, carbonated beverages and cordials. There was no difference in the shelf space dedicated to non-core foods, or between non-core foods purchased and the proportion of shelf space occupied by them in either low or high SES areas. CONCLUSIONS: Increased purchase of non-core foods by low SES shoppers who are already at higher risk of obesity than high SES shoppers is cause for concern. Further research is required to explore underlying reasons for this association.

The answer to diabetes prevention: science, surgery, service delivery, or social policy?

The diabetes and obesity epidemics are closely intertwined. International randomized controlled trials demonstrate that, in high-risk individuals, type 2 diabetes can be prevented or at least delayed through lifestyle modification and, to a lesser degree, medication. We explored the relative roles of science, surgery, service delivery, and social policy in preventing diabetes. Although it is clear that there is a role for all, diabetes is a complex problem that demands commitment across a range of government and nongovernment agencies to be effectively controlled. Accordingly, we argue that social policy is the key to achieving and sustaining social and physical environments required to achieve widespread reductions in both the incidence and prevalence of diabetes.

Comparing metabolic control and complications in type 2 diabetes in two Pacific Islands at baseline and following diabetes care intervention.

AIM: To compare metabolic control and complications in people with type 2 diabetes in Nauru and the Solomon Islands before and after a project intervention. METHODS: This follow-up study compared metabolic control and complications in a cohort of 216 people with diabetes (81 from Nauru and 135 from the Solomon Islands) at baseline and 15 months following a project intervention (upgrading and equipping the existing diabetes centres, and providing training and clinical support systems) aimed at improving the quality of clinical diabetes care. Subjects were screened using a standardised protocol which gathered information on demographics, treatment, physical and biochemical parameters and their outcomes. RESULTS: At follow-up, glycaemic control had improved and mean HbA1c had decreased in study participants in both Nauru (mean difference (MD) = -0.9 ± 2.3%) and the Solomon Islands (MD = -0.6 ± 1.4%), P < 0.001. Mean blood pressure was reduced in the Solomon Islands (systolic MD = -11.6 ± 19.2 mmHg and diastolic MD = -5.4 ± 10.5 mmHg), P < 0.001. There were no significant changes in mean blood lipids or albumin-creatinine ratio. Overall the percentage of subjects achieving recommended clinical targets increased. However these percentages remained low, e.g. 23.5% of participants in Nauru and 20.7% in the Solomon Islands achieved an HbA1c target <7% (53 mmol/mol). A trend towards lower complications rates of foot problems was observed but there were no significant changes in the prevalence of other diabetes complications. CONCLUSIONS: This study indicates improved metabolic control but little change in diabetes complications 15 months after intervention. Efforts to improve and evaluate the ongoing quality and accessibility of diabetes care in Pacific Island settings need to be further strengthened.

The prevalence of diabetes in the kingdom of Tonga.

OBJECTIVE: To determine the prevalence of diabetes, impaired glucose metabolism, and related risk factors in Tonga. RESEARCH DESIGN AND METHODS: A randomly selected representative national sample of 1,024 people aged >15 years was surveyed. Each participant had fasting blood glucose and HbA(1c) measured. Subjects with a fasting blood glucose >5.0 mmol/l (90 mg/dl) and <11.1 mmol/l (200 mg/dl) or a fasting blood glucose < or =5.0 mmol/l and an HbA(1c) >6.0% and every fifth subject with a fasting blood glucose < or =5.0 mmol/l and a normal HbA(1c) had a 75-g oral glucose tolerance test (OGTT). A total of 472 individuals had an OGTT based on these criteria. Subjects with a fasting blood glucose > or =11.1 mmol/l and an elevated HbA(1c) were diagnosed as having diabetes. RESULTS: The mean age was 41.3 years, and the mean BMI was 32.3 kg/m(2). The age-standardized prevalence of diabetes was 15.1% (CI 12.5-17.6), 12.2% (8.7-15.8) in men and 17.6% (14.0-21.1) in women (NS), of which only 2.1% was previously diagnosed. A total of 75% of people with newly diagnosed diabetes had a fasting plasma glucose > or =7.0 mmol/l (126 mg/dl). The prevalence of impaired glucose tolerance was 9.4% (7.3-11.5) and of impaired fasting glycemia 1.6% (0.7-2.6). Undiagnosed diabetes was significantly associated with increasing age, obesity, hypertension, and a family history of diabetes. CONCLUSIONS: The current prevalence of diabetes in Tonga is 15.1%, of which 80% is undiagnosed. A similar survey in 1973 reported a 7.5% diabetes prevalence, indicating a doubling of diabetes over the past 25 years. In addition, lesser degrees of glucose intolerance are common, and much of the community is overweight

Research Priorities for NCD Prevention and Climate Change: An International Delphi Survey.

Climate change and non-communicable diseases (NCDs) are arguably the greatest global challenges of the 21st Century. However, the confluence between them remains under-examined and there is little evidence of a comprehensive, systematic approach to identifying research priorities to mitigate their joint impact. Consequently, we: (i) convened a workshop of academics (n = 25) from the Worldwide Universities Network to identify priority areas at the interface between NCDs and climate change; (ii) conducted a Delphi survey of international opinion leaders in public health and relevant other disciplines; and (iii) convened an expert panel to review and advise on final priorities. Three research areas (water security; transport; conceptualising NCD harms to support policy formation) were listed among the top 10 priorities by >90% of Delphi respondents, and ranked among the top 12 priorities by >60% of respondents who ranked the order of priority. A fourth area (reducing the carbon footprint of cities) was ranked highest by the same >60% of respondents. Our results are consistent with existing frameworks on health and climate change, and extends them by focusing specifically on NCDs. Researching these priorities could progress understanding of climate change and NCDs, and inform global and national policy decisions for mitigating associated harms.

Counting the Cost of Diabetes in the Solomon Islands and Nauru.

AIM: To determine the costs associated with diabetes to governments, people with diabetes and their carers, and its impact on quality of life in two Pacific Island countries--the Solomon Islands and Nauru. MATERIALS AND METHODS: This cross-sectional cost of illness study was conducted on 330 people with type 2 diabetes (197 from the Solomon Islands and 133 from Nauru) using a structured cost of illness survey questionnaire adapted from the Australian DiabCo$t study. Quality of life was measured by the EQ-5D Visual Analogue Scale. RESULTS: There were 330 respondents (50% female; mean duration of diabetes 10.9 years; mean age 52.6 years). The estimated annual national cost of diabetes incurred by the Solomon Islands government was AUD 12.8 million (AUD 281 per person/year) and by Nauru government was AUD 1.2 million (AUD 747 per person/year). The major contribution to the government costs was inpatient services cost (71% in the Solomon Islands and 83% in Nauru). Annual expenditure for diabetes was approximately 20% of the governments' annual health care expenditure. Considerable absenteeism and retirement from work due to diabetes was found. CONCLUSIONS: This study found substantial public and personal costs associated with diabetes. The findings provide objective data on which health policy, funding and planning decisions about the prevention and control of diabetes in the Solomon Islands and Nauru can be reliably based and subsequently evaluated.

A profile of diabetes in Pacific Island Countries and Territories.

AIM: To examine the available evidence about the epidemiology, health, social, and economic impact of diabetes in Pacific Island Countries and Territories (PICTs). METHODS: We conducted a systematic review of the peer-reviewed literature published in English from January 1990 to January 2014, and relevant technical reports. RESULTS: A total of 1548 articles were identified of which 35 studies of type 2 diabetes met the inclusion criteria. Eighteen technical reports were also included. We found no articles reporting on type 1 diabetes or gestational diabetes that met the inclusion criteria. The prevalence, risk factors and complications of diabetes were substantial. Diabetes prevalence rate of around 40% was common. Physical inactivity, overweight and obesity were leading risk factors. High rates of diabetes complications were reported e.g. up to 69% retinopathy. Poor clinical outcomes were also reported with over 70% not meeting glycaemic control targets and approximately 50% not meeting blood pressure and cholesterol targets. CONCLUSION: This review highlights the burden of diabetes in PICTs and the need for more intensive interventions to improve the quality and outcomes of diabetes care. Overall, further research is needed to monitor secular diabetes trends in PICTs using standardised criteria for diagnosing diabetes and its complications.

Framing of scientific knowledge as a new category of health care research.

RATIONALE: The new area of health system research requires a revision of the taxonomy of scientific knowledge that may facilitate a better understanding and representation of complex health phenomena in research discovery, corroboration and implementation. METHOD: A position paper by an expert group following and iterative approach. RESULTS: 'Scientific evidence' should be differentiated from 'elicited knowledge' of experts and users, and this latter typology should be described beyond the traditional qualitative framework. Within this context 'framing of scientific knowledge' (FSK) is defined as a group of studies of prior expert knowledge specifically aimed at generating formal scientific frames. To be distinguished from other unstructured frames, FSK must be explicit, standardized, based on the available evidence, agreed by a group of experts and subdued to the principles of commensurability, transparency for corroboration and transferability that characterize scientific research. A preliminary typology of scientific framing studies is presented. This typology includes, among others, health declarations, position papers, expert-based clinical guides, conceptual maps, classifications, expert-driven health atlases and expert-driven studies of costs and burden of illness. CONCLUSIONS: This grouping of expert-based studies constitutes a different kind of scientific knowledge and should be clearly differentiated from 'evidence' gathered from experimental and observational studies in health system research.

The prevalence of diabetes complications and associated risk factors in Pacific Islands countries.

AIM: To determine the prevalence of diabetes complications and associated risk factors among people with type 2 diabetes in three Pacific Island countries, Nauru, Solomon Islands and Vanuatu. METHODS: This cross-sectional study was carried out on a sample of 459 people with diabetes. Subjects were screened for complications using a standardised protocol which gathered information on demographics, physical and biochemical parameters. RESULTS: Of the 459 subjects, 47% were female, mean age was 54 years and mean duration of diabetes was eight years. The prevalence of diabetes complications was significantly higher in Nauru compared with the Solomon Islands and Vanuatu - microalbuminuria 71%, 36% and 51% respectively (P<0.001), retinopathy 69%, 40% and 42% respectively (P<0.001), and abnormal foot sensation 30%, 23% and 19% respectively (P=0.036). The prevalences of hypertension, overweight/obesity and poor glycaemic control were high. The percentages of subjects achieving recommended clinical targets were low. Microalbuminuria was significantly associated with duration of diabetes, hypertension and glycaemic control. Diabetic retinopathy was significantly associated with duration of diabetes whereas abnormal foot sensation was significantly associated with duration of diabetes and glycaemic control. CONCLUSIONS: This study found a high prevalence of diabetes complications and associated risk factors, which indicate the need to improve diabetes care and strengthen preventive efforts to reduce complications.

Health care frames - from Virchow to Obama and beyond: the changing frames in health care and their implications for patient care.

RATIONALE, AIMS, OBJECTIVES AND METHODS: Framing allows us to highlight some aspects of an issue, thereby bringing them to the forefront of our thinking, talking and acting. As a consequence, framing also distracts our attention away from other issues. Over time, health care has used various frames to explain its activities. This paper traces the emergence of various health care frames since the 1850s to better understand how we reached current ways of thinking and practicing. RESULTS AND CONCLUSIONS: The succession of the most prominent frames can be summarized as: medicine as a social science; the germ theory of disease; health care as a battleground (or the war metaphor); managing health care resources (or the market metaphor); Health for All (the social justice model); evidence-based medicine; and Obama Care. The focus of these frames is causal, instrumental, political/economic or social in nature. All remain relevant; however, recycling individual past frames in response to current problems will not achieve the outcomes we seek. Placing the individual and his/her needs at the centre (the attractor for the health system) of our thinking, as emphasized by the World Health Organization's International Classification of Function framework and the European Society of Person Centered Health Care, may provide the frame to refocus health and health care as interdependent experiences across individual, community and societal domains. Shifting beyond the entrenched instrumental and economic thinking will be challenging but necessary for the sake of patients, health professionals, society and the economy.

Coal mining, social injustice and health: a universal conflict of power and priorities.

Given the current insatiable demand for coal to build and fuel the world's burgeoning cities the debate about mining-related social, environmental and health injustices remains eminently salient. Furthermore, the core issues appear universally consistent. This paper combines the theoretical base for defining these injustices with reports in the international health literature about the impact of coal mining on local communities. It explores and analyses mechanisms of coal mining related injustice, conflicting priorities and power asymmetries between political and industry interests versus inhabitants of mining communities, and asks what would be required for considerations of health to take precedence over wealth.

Diabetes related amputations in Pacific Islands countries: a root cause analysis of precipitating events.

AIM: To identify precipitating events and factors preceding diabetes related amputations in Pacific Islands countries (PICs). METHODS: Using a root cause analysis approach, a questionnaire seeking information on events leading up to amputation was administered to a convenience sample of 85 people with diabetes in three PICs (Solomon Islands, Nauru and Vanuatu) who had a lower limb amputation in the previous five years. RESULTS: There were 85 participants (36% females) with a mean age of 54.1 years and a mean diabetes duration of 10.5 years prior to amputation. The first event was trauma and an infected wound in 55% and a blister in another 41%. Half (51%) did take any action soon after the initial trigger event. The major reasons leading to the amputation included delaying treatment (42%), use of traditional treatments (18%) and insufficient knowledge about foot care (11%). 36% of participants had not received foot care information prior to the amputation and 19% did not attend anywhere for regular treatment. CONCLUSIONS: This study identified key precipitating events and underlying factors which contribute to diabetes related amputations and which, if addressed successfully, have the potential to reduce amputations rates.

The cost of diabetes in adults in Australia.

AIMS: To assess and compare costs associated with diabetes and lesser degrees of glucose intolerance in Australia. METHODS: The Australian Diabetes, Obesity and Lifestyle study collected data on the use of health services and health related expenditure in 2004-2005. Complications data were collected through physical examination and biochemical tests or questionnaire. Data were available on 6101 participants. Age- and sex-adjusted direct healthcare costs, direct non-healthcare costs and government subsidies were estimated according to glucose tolerance status. RESULTS: Annual direct per person costs were A$1898 for those with normal glucose tolerance to A$4390 for those with known diabetes. Costs were substantially higher in people with diabetes and both micro- and macrovascular complications. The total annual cost of diabetes in 2005 for Australians aged ≥30 years was A$10.6 billion (A$4.4 billion in direct costs; A$6.2 billion in government subsidies) which equates to A$14.6 billion in 2010 dollars. Total annual excess cost associated with diabetes in 2005 was A$4.5 billion (A$2.2 billion in direct costs; A$2.3 billion in government subsidies). CONCLUSION: The excess cost of diabetes to individuals and government is substantial and is greater in those with complications. Costs could potentially be reduced by preventing the development of diabetes or its complications.