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1.  Cluster randomised controlled trial of a peer-led lifestyle intervention program: study protocol for the Kerala diabetes prevention program 
BMC Public Health  2013;13:1035.
India currently has more than 60 million people with Type 2 Diabetes Mellitus (T2DM) and this is predicted to increase by nearly two-thirds by 2030. While management of those with T2DM is important, preventing or delaying the onset of the disease, especially in those individuals at ‘high risk’ of developing T2DM, is urgently needed, particularly in resource-constrained settings. This paper describes the protocol for a cluster randomised controlled trial of a peer-led lifestyle intervention program to prevent diabetes in Kerala, India.
A total of 60 polling booths are randomised to the intervention arm or control arm in rural Kerala, India. Data collection is conducted in two steps. Step 1 (Home screening): Participants aged 30–60 years are administered a screening questionnaire. Those having no history of T2DM and other chronic illnesses with an Indian Diabetes Risk Score value of ≥60 are invited to attend a mobile clinic (Step 2). At the mobile clinic, participants complete questionnaires, undergo physical measurements, and provide blood samples for biochemical analysis. Participants identified with T2DM at Step 2 are excluded from further study participation. Participants in the control arm are provided with a health education booklet containing information on symptoms, complications, and risk factors of T2DM with the recommended levels for primary prevention. Participants in the intervention arm receive: (1) eleven peer-led small group sessions to motivate, guide and support in planning, initiation and maintenance of lifestyle changes; (2) two diabetes prevention education sessions led by experts to raise awareness on T2DM risk factors, prevention and management; (3) a participant handbook containing information primarily on peer support and its role in assisting with lifestyle modification; (4) a participant workbook to guide self-monitoring of lifestyle behaviours, goal setting and goal review; (5) the health education booklet that is given to the control arm. Follow-up assessments are conducted at 12 and 24 months. The primary outcome is incidence of T2DM. Secondary outcomes include behavioural, psychosocial, clinical, and biochemical measures. An economic evaluation is planned.
Results from this trial will contribute to improved policy and practice regarding lifestyle intervention programs to prevent diabetes in India and other resource-constrained settings.
Trial registration
Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909.
PMCID: PMC3937241  PMID: 24180316
Diabetes; Incidence; India; Kerala; Peer support; Randomised controlled trial; Prevention; Resource-constrained settings; Rural; Intervention
2.  Application of Variable Life Adjusted Displays (VLAD) on Victorian Admitted Episodes Dataset (VAED) 
The need to improve patient safety has been identified as a major priority for health reform in developed countries, including Australia. We investigated the implementation and appropriateness of Variable Life Adjusted Displays as a quality control procedure to monitor “in-control” versus “out-of-control” processes in Victorian public hospitals.
Victorian Admitted Episode Data from Department of Human Services, Victoria for 2004–7 were used. The VLAD is a plot of a cumulative sum of the difference in expected outcome (range 0–1) and observed outcome (0 or 1) for sequential separations. Three outcomes were assessed: in-hospital mortality for acute myocardial infarction, stroke and heart failure. Logistic regression was used to obtain a realistic measure of expected mortality over the period 2004–5, adjusting for covariates and comorbidities, to estimate expected mortality risk for the separations between 2005–7. VLAD were plotted for the years 2005–7, by the 11 hospitals with the highest frequency of separations. Signalling limits for 30%, 50% and 75% risk decrease and risk increase were determined and plotted for each VLAD utilizing risk-adjusted cumulative sum techniques. This is a likelihood-ratio test statistic for signalling. If the VLAD signalled by intersecting with a limit, the limit was reset.
The three logit models displayed reasonable fit to the observed data. There were n = 2999 separations in the AMI model, n = 3598 in the HF model and n = 1922 in the stroke model. The number of separations plotted by VLAD ranged from n = 126 to n = 648. No signals were observed in 64%, 55% and 18% of VLAD for AMI, HF and stroke respectively. For AMI and HF 9% of hospitals signalled at least once for each of 30%, 50% and 75% risk increase, whereas this was 45% for stroke. Hospitals signalling at least once for risk decrease ranged from 18% to 36% across the levels of risk and outcomes. No VLAD signalled for both risk decrease and increase.
VLAD intersecting with limits to signal “out-of-control” states, may be an appropriate technique to help hospitals assess quality control. Preliminary work displays some between hospital differences. Relevant signals can be used to investigate why a system is potentially performing better than or worse than expected. Types and levels of investigation could depend on the type of signalling. Validation work, for example attempting to correlate signals with clinical notes, prior to VLAD distribution needs to be undertaken.
PMCID: PMC3576249  PMID: 22925089
3.  Non-Clinical Errors Using Voice Recognition Dictation Software for Radiology Reports: A Retrospective Audit 
Journal of Digital Imaging  2010;24(4):724-728.
The purpose of this study is to ascertain the error rates of using a voice recognition (VR) dictation system. We compared our results with several other articles and discussed the pros and cons of using such a system. The study was performed at the Southern Health Department of Diagnostic Imaging, Melbourne, Victoria using the GE RIS with Powerscribe 3.5 VR system. Fifty random finalized reports from 19 radiologists obtained between June 2008 and November 2008 were scrutinized for errors in six categories namely, wrong word substitution, deletion, punctuation, other, and nonsense phrase. Reports were also divided into two categories: computer radiography (CR = plain film) and non-CR (ultrasound, computed tomography, magnetic resonance imaging, nuclear medicine, and angiographic examinations). Errors were divided into two categories, significant but not likely to alter patient management and very significant with the meaning of the report affected, thus potentially affecting patient management (nonsense phrase). Three hundred seventy-nine finalized CR reports and 631 non-CR finalized reports were examined. Eleven percent of the reports in the CR group had errors. Two percent of these reports contained nonsense phrases. Thirty-six percent of the reports in the non-CR group had errors and out of these, 5% contained nonsense phrases. VR dictation system is like a double-edged sword. Whilst there are many benefits, there are also many pitfalls. We hope that raising the awareness of the error rates will help in our efforts to reduce error rates and strike a balance between quality and speed of reports generated.
PMCID: PMC3138931  PMID: 20976612
Voice recognition; Reporting; Productivity; Speech recognition; Workflow; Radiology reporting
4.  A poisson regression approach for modelling spatial autocorrelation between geographically referenced observations 
Analytic methods commonly used in epidemiology do not account for spatial correlation between observations. In regression analyses, omission of that autocorrelation can bias parameter estimates and yield incorrect standard error estimates.
We used age standardised incidence ratios (SIRs) of esophageal cancer (EC) from the Babol cancer registry from 2001 to 2005, and extracted socioeconomic indices from the Statistical Centre of Iran. The following models for SIR were used: (1) Poisson regression with agglomeration-specific nonspatial random effects; (2) Poisson regression with agglomeration-specific spatial random effects. Distance-based and neighbourhood-based autocorrelation structures were used for defining the spatial random effects and a pseudolikelihood approach was applied to estimate model parameters. The Bayesian information criterion (BIC), Akaike's information criterion (AIC) and adjusted pseudo R2, were used for model comparison.
A Gaussian semivariogram with an effective range of 225 km best fit spatial autocorrelation in agglomeration-level EC incidence. The Moran's I index was greater than its expected value indicating systematic geographical clustering of EC. The distance-based and neighbourhood-based Poisson regression estimates were generally similar. When residual spatial dependence was modelled, point and interval estimates of covariate effects were different to those obtained from the nonspatial Poisson model.
The spatial pattern evident in the EC SIR and the observation that point estimates and standard errors differed depending on the modelling approach indicate the importance of accounting for residual spatial correlation in analyses of EC incidence in the Caspian region of Iran. Our results also illustrate that spatial smoothing must be applied with care.
PMCID: PMC3191333  PMID: 21961693
Cancer incidence; Dietary pattern; Disease mapping; Multilevel generalised linear model; Socio-economic status; Spatial analysis
5.  Modelling Long Term Disability following Injury: Comparison of Three Approaches for Handling Multiple Injuries 
PLoS ONE  2011;6(9):e25862.
Injury is a leading cause of the global burden of disease (GBD). Estimates of non-fatal injury burden have been limited by a paucity of empirical outcomes data. This study aimed to (i) establish the 12-month disability associated with each GBD 2010 injury health state, and (ii) compare approaches to modelling the impact of multiple injury health states on disability as measured by the Glasgow Outcome Scale – Extended (GOS-E).
12-month functional outcomes for 11,337 survivors to hospital discharge were drawn from the Victorian State Trauma Registry and the Victorian Orthopaedic Trauma Outcomes Registry. ICD-10 diagnosis codes were mapped to the GBD 2010 injury health states. Cases with a GOS-E score >6 were defined as “recovered.” A split dataset approach was used. Cases were randomly assigned to development or test datasets. Probability of recovery for each health state was calculated using the development dataset. Three logistic regression models were evaluated: a) additive, multivariable; b) “worst injury;” and c) multiplicative. Models were adjusted for age and comorbidity and investigated for discrimination and calibration.
A single injury health state was recorded for 46% of cases (1–16 health states per case). The additive (C-statistic 0.70, 95% CI: 0.69, 0.71) and “worst injury” (C-statistic 0.70; 95% CI: 0.68, 0.71) models demonstrated higher discrimination than the multiplicative (C-statistic 0.68; 95% CI: 0.67, 0.70) model. The additive and “worst injury” models demonstrated acceptable calibration.
The majority of patients survived with persisting disability at 12-months, highlighting the importance of improving estimates of non-fatal injury burden. Additive and “worst” injury models performed similarly. GBD 2010 injury states were moderately predictive of recovery 1-year post-injury. Further evaluation using additional measures of health status and functioning and comparison with the GBD 2010 disability weights will be needed to optimise injury states for future GBD studies.
PMCID: PMC3184172  PMID: 21984951
6.  DNMT3L Is a Regulator of X Chromosome Compaction and Post-Meiotic Gene Transcription 
PLoS ONE  2011;6(3):e18276.
Previous studies on the epigenetic regulator DNA methyltransferase 3-Like (DNMT3L), have demonstrated it is an essential regulator of paternal imprinting and early male meiosis. Dnmt3L is also a paternal effect gene, i.e., wild type offspring of heterozygous mutant sires display abnormal phenotypes suggesting the inheritance of aberrant epigenetic marks on the paternal chromosomes. In order to reveal the mechanisms underlying these paternal effects, we have assessed X chromosome meiotic compaction, XY chromosome aneuploidy rates and global transcription in meiotic and haploid germ cells from male mice heterozygous for Dnmt3L. XY bodies from Dnmt3L heterozygous males were significantly longer than those from wild types, and were associated with a three-fold increase in XY bearing sperm. Loss of a Dnmt3L allele resulted in deregulated expression of a large number of both X-linked and autosomal genes within meiotic cells, but more prominently in haploid germ cells. Data demonstrate that similar to embryonic stem cells, DNMT3L is involved in an auto-regulatory loop in germ cells wherein the loss of a Dnmt3L allele resulted in increased transcription from the remaining wild type allele. In contrast, however, within round spermatids, this auto-regulatory loop incorporated the alternative non-coding alternative transcripts. Consistent with the mRNA data, we have localized DNMT3L within spermatids and sperm and shown that the loss of a Dnmt3L allele results in a decreased DNMT3L content within sperm. These data demonstrate previously unrecognised roles for DNMT3L in late meiosis and in the transcriptional regulation of meiotic and post-meiotic germ cells. These data provide a potential mechanism for some cases of human Klinefelter's and Turner's syndromes.
PMCID: PMC3069080  PMID: 21483837
7.  The spatial distribution of esophageal and gastric cancer in Caspian region of Iran: An ecological analysis of diet and socio-economic influences 
Recent studies have suggested a systematic geographic pattern of esophageal cancer (EC) and gastric cancer (GC) incidence in the Caspian region of Iran. The aims of this study were to investigate the association between these cancers and the region's dietary and socioeconomic risk factors and to map EC and GC after adjustment for the risk factors and the removal of random and geographic variations from area specific age standardised incidence ratios (SIRs).
We obtained cancer data from the Babol cancer registry from 2001 to 2005, socioeconomic indices from the Statistical Centre of Iran, and dietary patterns from the control group in a case control study conducted in the study region. Regression models were fitted to identify significant covariates, and clusters of elevated rates were identified.
We found evidence of systematic clustering for EC and GC in men and women and both sexes combined. EC and GC SIRs were lower in urban areas, and were also lower in areas of high income. EC SIRs were lower in areas with higher proportions of people having unrestricted food choice and higher in areas with higher proportions of people with restricted food choice.
EC and GC were associated with aggregated risk factors, including income, urbanisation, and dietary patterns. These variables represent the influence of improved lifestyle which has coincided with a decrease in upper gastrointestinal cancer frequency over recent decades but which has not necessarily been uniform throughout the region.
PMCID: PMC3050677  PMID: 21324144
8.  A randomised trial of a psychosocial intervention for cancer patients integrated into routine care: the PROMPT study (promoting optimal outcomes in mood through tailored psychosocial therapies) 
BMC Cancer  2011;11:48.
Despite evidence that up to 35% of patients with cancer experience significant distress, access to effective psychosocial care is limited by lack of systematic approaches to assessment, a paucity of psychosocial services, and patient reluctance to accept treatment either because of perceived stigma or difficulties with access to specialist psycho-oncology services due to isolation or disease burden. This paper presents an overview of a randomised study to evaluate the effectiveness of a brief tailored psychosocial Intervention delivered by health professionals in cancer care who undergo focused training and participate in clinical supervision.
Health professionals from the disciplines of nursing, occupational therapy, speech pathology, dietetics, physiotherapy or radiation therapy will participate in training to deliver the psychosocial Intervention focusing on core concepts of supportive-expressive, cognitive and dignity-conserving care. Health professional training will consist of completion of a self-directed manual and participation in a skills development session. Participating health professionals will be supported through structured clinical supervision whilst delivering the Intervention. In the stepped wedge design each of the 5 participating clinical sites will be allocated in random order from Control condition to Training then delivery of the Intervention. A total of 600 patients will be recruited across all sites. Based on level of distress or risk factors eligible patients will receive up to 4 sessions, each of up to 30 minutes in length, delivered face-to-face or by telephone. Participants will be assessed at baseline and 10-week follow-up. Patient outcome measures include anxiety and depression, quality of life, unmet psychological and supportive care needs. Health professional measures include psychological morbidity, stress and burnout. Process evaluation will be conducted to assess perceptions of participation in the study and the factors that may promote translation of learning into practice.
This study will provide important information about the effectiveness of a brief tailored psychological Intervention for patients with cancer and the potential to prevent development of significant distress in patients considered at risk. It will yield data about the feasibility of this model of care in routine clinical practice and identify enablers and barriers to its systematic implementation in cancer settings.
Trial registration
PMCID: PMC3045358  PMID: 21284838
9.  Long-Term Weekly Iron-Folic Acid and De-Worming Is Associated with Stabilised Haemoglobin and Increasing Iron Stores in Non-Pregnant Women in Vietnam 
PLoS ONE  2010;5(12):e15691.
The prevalence of anaemia and iron deficiency in women remains high worldwide. WHO recommends weekly iron-folic acid supplementation where anaemia rates in non-pregnant women of reproductive age are higher than 20%. In 2006, a demonstration project consisting of weekly iron-folic acid supplementation and regular de-worming was set up in two districts in a northern province in Vietnam where anaemia and hookworm rates were 38% and 76% respectively. In 2008 the project was expanded to all districts in the province, targeting some 250,000 women. The objectives of this study were to: 1) examine changes in haemoglobin, iron stores and soil transmitted helminth infection prevalence over three years and 2) assess women's access to and compliance with the intervention.
Methods and Findings
The study was a semi-cross-sectional, semi-longitudinal panel design with a baseline survey, three impact surveys at three-, twelve- and thirty months after commencement of the intervention, and three compliance surveys after ten weeks, eighteen and thirty six months.
After thirty months, mean haemoglobin stabilised at 130.3 g/L, an increase of 8.2 g/L from baseline, and mean serum ferritin rose from 23.9 µg/L to 52 µg/L. Hookworm prevalence fell from 76% to 22% over the same period. After thirty six months, 81% of the target population were receiving supplements and 87% were taking 75% or more of the supplements they received.
Weekly iron-folic acid supplementation and regular de-worming was effective in significantly and sustainably reducing the prevalence of anaemia and soil transmitted helminth infections and high compliance rates were maintained over three years.
PMCID: PMC3012714  PMID: 21209902
10.  Data Linkage: A powerful research tool with potential problems 
Policy makers, clinicians and researchers are demonstrating increasing interest in using data linked from multiple sources to support measurement of clinical performance and patient health outcomes. However, the utility of data linkage may be compromised by sub-optimal or incomplete linkage, leading to systematic bias. In this study, we synthesize the evidence identifying participant or population characteristics that can influence the validity and completeness of data linkage and may be associated with systematic bias in reported outcomes.
A narrative review, using structured search methods was undertaken. Key words "data linkage" and Mesh term "medical record linkage" were applied to Medline, EMBASE and CINAHL databases between 1991 and 2007. Abstract inclusion criteria were; the article attempted an empirical evaluation of methodological issues relating to data linkage and reported on patient characteristics, the study design included analysis of matched versus unmatched records, and the report was in English. Included articles were grouped thematically according to patient characteristics that were compared between matched and unmatched records.
The search identified 1810 articles of which 33 (1.8%) met inclusion criteria. There was marked heterogeneity in study methods and factors investigated. Characteristics that were unevenly distributed among matched and unmatched records were; age (72% of studies), sex (50% of studies), race (64% of studies), geographical/hospital site (93% of studies), socio-economic status (82% of studies) and health status (72% of studies).
A number of relevant patient or population factors may be associated with incomplete data linkage resulting in systematic bias in reported clinical outcomes. Readers should consider these factors in interpreting the reported results of data linkage studies.
PMCID: PMC3271236  PMID: 21176171
11.  Parental weight estimation of their child's weight is more accurate than other weight estimation methods for determining children's weight in an emergency department? 
Emergency Medicine Journal : EMJ  2007;24(11):756-759.
To compare the various paediatric weight estimation methods (Advanced Pediatric Life Support, Broselow Tape, Argall, and Best Guess) and parental estimate to measured weight.
Patients and method
A convenience sample of children aged 1–11 years who presented to the emergency department over a 6 month period were eligible for inclusion. Data collected included height, age, ethnicity, parent estimate of weight and measured weight. Body mass index (BMI) was calculated. The outcome of interest was agreement between estimated weight and measured weight for each method. Data were analysed by descriptive statistics and performance of each weight estimation method was compared using mean difference (MD), root mean square error (RMSE) and agreement within 10%.
410 cases were included in this study. The median age was 4 years, there were more boys (54.4%), and the majority of cases were of Caucasian ethnicity (74.9%). The mean BMI of the sample was 17 kg/m2 and mean actual weight was 21.2 kg. Parent estimate was the most accurate method with 78% of parent estimates within 10% of measured weight and the lowest mean difference (−0.6 kg) and RMSE (3.1 kg). The Broselow tape was the most accurate of the other methods, with 61% of estimations within 10% of measured weight.
Parental estimation of weight is more accurate than the other weight estimation methods studied. When this is not available, the Broselow tape is the most accurate alternative method.
PMCID: PMC2658317  PMID: 17954827
12.  Screening for pre-clinical disability in different residential settings 
BMC Geriatrics  2010;10:52.
Preventing disability and offering effective interventions to older people during early decline in function is most likely to be effective if those most at risk of progressive disablement are able to be identified. Similarly the ability to easily identify a group with similar functional profile from disparate sectors of the community is of significant benefit to researchers. This study aimed to (1) describe the use of a pre-clinical disability screening tool to select a functionally comparable group of older men and women with early functional limitation from different settings, and (2) explore factors associated with function and disability.
Self-reported function and disability measured with the Late-Life Function and Disability Instrument along with a range of physical performance measurements were compared across residential settings and gender in a sample of 471 trial participants identified as pre-clinically disabled after being screened with the Fried pre-clinical disability tool. Factors that might lie on the pathway to progressive disablement were identified using multiple linear regression analysis.
We found that a sample population, screened for pre-clinical disability, had a functional status and disability profile reflecting early functional limitation, regardless of residential setting or gender. Statistical models identified a range of factors associated with function and disability which explained a greater degree of the variation in function, than disability.
We selected a group of people with a comparable function and disability profile, consistent with the pre-clinical stage of disability, from a sample of older Australian men and women from different residential settings using the Fried pre-clinical disability screening tool. The results suggest that the screening tool can be used with greater confidence for research, clinical and population health purposes. Further research is required to examine the validity of the tool. These findings offer insight into the type of impairment factors characterising early functional loss that could be addressed through disability prevention initiatives.
Trial Registration
PMCID: PMC2919540  PMID: 20678235
13.  A low intensity, community based lifestyle programme to prevent weight gain in women with young children: cluster randomised controlled trial 
Objective To develop and evaluate the effectiveness of a community behavioural intervention to prevent weight gain and improve health related behaviours in women with young children.
Design Cluster randomised controlled trial.
Setting A community setting in urban Australia.
Participants 250 adult women with a mean age of 40.39 years (SD 4.77, range 25-51) and a mean body mass index of 27.82 kg/m2 (SD 5.42, range 18-47) were recruited as clusters through 12 primary (elementary) schools.
Intervention Schools were randomly assigned to the intervention or the control. Mothers whose schools fell in the intervention group (n=127) attended four interactive group sessions that involved simple health messages, behaviour change strategies, and group discussion, and received monthly support using mobile telephone text messages for 12 months. The control group (n=123) attended one non-interactive information session based on population dietary and physical activity guidelines.
Main outcome measures The main outcome measures were weight change and difference in weight change between the intervention group and the control group at 12 months. Secondary outcomes were changes in serum concentrations of fasting lipids and glucose, and changes in dietary behaviours, physical activity, and self management behaviours.
Results All analyses were adjusted for baseline values and the possible clustering effect. Women in the control group gained weight over the 12 month study period (0.83 kg, 95% confidence interval (CI) 0.12 to 1.54), whereas those in the intervention group lost weight (−0.20 kg, −0.90 to 0.49). The difference in weight change between the intervention group and the control group at 12 months was −1.13 kg (−2.03 to −0.24 kg; P<0.05) on the basis of observed values and −1.11 kg (−2.17 to −0.04) after multiple imputation to account for possible bias created by missing values. Secondary analyses after multiple imputation showed a difference in the intervention group compared with the control group for total cholesterol concentration (−0.35 mmol/l, −0.70 to −0.001), self management behaviours (diet score 0.18, 0.13 to 0.33; physical activity score 0.24, 0.05 to 0.43), and confidence to control weight (0.40, 0.11 to 0.69). Regular self weighing was associated with weight loss in the intervention group only (−1.98 kg, −3.75 to −0.23).
Conclusions Weight gain in women with young children could be prevented using a low intensity self management intervention delivered in a community setting. Self management of health behaviours improved with the intervention. The response rate of 12%, although comparable with that in other community studies, might limit the ability to generalise to other populations.
Trial registration Australian New Zealand Clinical Trials Registry number ACTRN12608000110381.
PMCID: PMC2903665  PMID: 20627974
14.  Weight, physical activity and dietary behavior change in young mothers: short term results of the HeLP-her cluster randomized controlled trial 
Nutrition Journal  2009;8:17.
Preventing weight gain rather than treating established obesity is an important economic and public health response to the rapidly increasing rates of obesity worldwide. Treatment of established obesity is complex and costly requiring multiple resources. Preventing weight gain potentially requires fewer resources to reach broad population groups, yet there is little evidence for successful interventions to prevent weight gain in the community. Women with children are an important target group because of high rates of weight gain and the potential to influence the health behaviors in family members.
The aim of this cluster randomized controlled trial was to evaluate the short term effect of a community-based self-management intervention to prevent weight gain. Two hundred and fifty mothers of young children (mean age 40 years ± 4.5, BMI 27.9 kg/m2 ± 5.6) were recruited from the community in Melbourne, Australia. The intervention group (n = 127) attended four interactive group sessions over 4 months, held in 12 local primary schools in 2006, and was compared to a group (n = 123) receiving a single, non-interactive, health education session. Data collection included self-reported weight (both groups), measured weight (intervention only), self-efficacy, dietary intake and physical activity.
Mean measured weight decreased significantly in the intervention group (-0.78 kg 95% CI; -1.22 to -0.34, p < 0.001). Comparing groups using self-reported weight, both the intervention and comparison groups decreased weight, -0.75 kg (95% CI; -1.57 to 0.07, p = 0.07) and -0.72 kg (95% CI; -1.59 to 0.14 p = 0.10) respectively with no significant difference between groups (-0.03 kg, 95% CI; -1.32 to 1.26, p = 0.95). More women lost or maintained weight in the intervention group. The intervention group tended to have the greatest effect in those who were overweight at baseline and in those who weighed themselves regularly. Intervention women who rarely self-weighed gained weight (+0.07 kg) and regular self-weighers lost weight (-1.66 kg) a difference of -1.73 kg (95% CI; -3.35 to -0.11 p = 0.04). The intervention reported increased physical activity although the difference between groups did not reach significance. Both groups reported replacing high fat foods with low fat alternatives and self-efficacy deteriorated in the comparison group only.
Both a single health education session and interactive behavioral intervention will result in a similar weight loss in the short term, although more participants in the interactive intervention lost or maintained weight. There were small non-significant changes to physical activity and changes to fat intake specifically replacing high fat foods with low fat alternatives such as fruit and vegetables. Self-monitoring appears to enhance weight loss when part of an intervention.
Trial registration
PMCID: PMC2683875  PMID: 19409085
15.  Attitudes of Australian Heroin Users to Peer Distribution of Naloxone for Heroin Overdose: Perspectives on Intranasal Administration 
Journal of Urban Health   2008;85(3):352-360.
Naloxone distribution to injecting drug users (IDUs) for peer administration is a suggested strategy to prevent fatal heroin overdose. The aim of this study was to explore attitudes of IDUs to administration of naloxone to others after heroin overdose, and preferences for method of administration. A sample of 99 IDUs (median age 35 years, 72% male) recruited from needle and syringe programs in Melbourne were administered a questionnaire. Data collected included demographics, attitudes to naloxone distribution, and preferences for method of administration. The primary study outcomes were attitudes of IDUs to use of naloxone for peer administration (categorized on a five-point scale ranging from “very good idea” to “very bad idea”) and preferred mode of administration (intravenous, intramuscular, and intranasal). The majority of the sample reported positive attitudes toward naloxone distribution (good to very good idea: 89%) and 92% said they were willing to participate in a related training program. Some participants raised concerns about peer administration including the competence of IDUs to administer naloxone in an emergency, victim response on wakening and legal implications. Most (74%) preferred intranasal administration in comparison to other administration methods (21%). There was no association with age, sex, or heroin practice. There appears to be strong support among Australian IDU for naloxone distribution to peers. Intranasal spray is the preferred route of administration.
PMCID: PMC2329742  PMID: 18347990
Naloxone; Heroin; Overdose; Intranasal
16.  Income inequality and alcohol attributable harm in Australia 
BMC Public Health  2009;9:70.
There is little research on the relationship between key socioeconomic variables and alcohol related harms in Australia. The aim of this research was to examine the relationship between income inequality and the rates of alcohol-attributable hospitalisation and death at a local-area level in Australia.
We conducted a cross sectional ecological analysis at a Local Government Area (LGA) level of associations between data on alcohol caused harms and income inequality data after adjusting for socioeconomic disadvantage and remoteness of LGAs.
The main outcome measures used were matched rate ratios for four measures of alcohol caused harm; acute (primarily related to the short term consequences of drinking) and chronic (primarily related to the long term consequences of drinking) alcohol-attributable hospitalisation and acute and chronic alcohol-attributable death. Matching was undertaken using control conditions (non-alcohol-attributable) at an LGA level.
A total of 885 alcohol-attributable deaths and 19467 alcohol-attributable hospitalisations across all LGAs were available for analysis. After weighting by the total number of cases in each LGA, the matched rate ratios of acute and chronic alcohol-attributable hospitalisation and chronic alcohol-attributable death were associated with the squared centred Gini coefficients of LGAs. This relationship was evident after adjusting for socioeconomic disadvantage and remoteness of LGAs. For both measures of hospitalisation the relationship was curvilinear; increases in income inequality were initially associated with declining rates of hospitalisation followed by large increases as the Gini coefficient increased beyond 0.15. The pattern for chronic alcohol-attributable death was similar, but without the initial decrease. There was no association between income inequality and acute alcohol-attributable death, probably due to the relatively small number of these types of death.
We found a curvilinear relationship between income inequality and the rates of some types of alcohol-attributable hospitalisation and death at a local area level in Australia. While alcohol-attributable harms generally increased with increasing income inequality, alcohol-attributable hospitalisations actually showed the reverse relationship at low levels of income inequality. The curvilinear patterns we observed are inconsistent with monotonic trends found in previous research making our findings incompatible with previous explanations of the relationship between income inequality and health related harms.
PMCID: PMC2658667  PMID: 19239715
17.  Quantifying the profile and progression of impairments, activity, participation, and quality of life in people with Parkinson disease: protocol for a prospective cohort study 
BMC Geriatrics  2009;9:2.
Despite the finding that Parkinson disease (PD) occurs in more than one in every 1000 people older than 60 years, there have been few attempts to quantify how deficits in impairments, activity, participation, and quality of life progress in this debilitating condition. It is unclear which tools are most appropriate for measuring change over time in PD.
Methods and design
This protocol describes a prospective analysis of changes in impairments, activity, participation, and quality of life over a 12 month period together with an economic analysis of costs associated with PD. One-hundred participants will be included, provided they have idiopathic PD rated I-IV on the modified Hoehn & Yahr (1967) scale and fulfil the inclusion criteria. The study aims to determine which clinical and economic measures best quantify the natural history and progression of PD in a sample of people receiving services from the Victorian Comprehensive Parkinson's Program, Australia. When the data become available, the results will be expressed as baseline scores and changes over 3 months and 12 months for impairment, activity, participation, and quality of life together with a cost analysis.
This study has the potential to identify baseline characteristics of PD for different Hoehn & Yahr stages, to determine the influence of disease duration on performance, and to calculate the costs associated with idiopathic PD. Valid clinical and economic measures for quantifying the natural history and progression of PD will also be identified.
Trial Registration
PMCID: PMC2649133  PMID: 19152709
18.  Preventing weight gain: the baseline weight related behaviors and delivery of a randomized controlled intervention in community based women 
BMC Public Health  2009;9:2.
Women aged 25–45 years represent a high risk group for weight gain and those with children are at increased risk because of weight gain associated with pregnancy and subsequent lifestyle change. Average self-reported weight gain is approximately 0.60 kg per year, and weight gain is associated with increased risk of chronic disease. There are barriers to reaching, engaging and delivering lifestyle interventions to prevent weight gain in this population.
This study investigated the baseline weight related behaviors and feasibility of recruiting and delivering a low intensity self-management lifestyle intervention to community based women with children in order to prevent weight gain, compared to standard education. The recruitment and delivery of the cluster-randomized controlled intervention was in conjunction with 12 primary (elementary) schools. Baseline data collection included demographic, anthropometric, behavioral and biological measures.
Two hundred and fifty community based women were randomized as clusters to intervention (n = 127) or control (n = 123). Mean age was 40.4 years (SD 4.7) and mean BMI 27.8 kg/m2 (SD 5.6). All components of this intervention were successfully delivered and retention rates were excellent, 97% at 4 months.
Nearly all women (90%) reported being dissatisfied with their weight and 72% attempted to self-manage their weight. Women were more confident of changing their diet (mean score 3.2) than physical activity (mean score 2.7). This population perceived they were engaging in prevention behaviors, with 71% reporting actively trying to prevent weight gain, yet they consumed a mean of 68 g fat/day (SD30 g) and 27 g saturated fat/day (SD12 g) representing 32% and 13% of energy respectively. The women had a high rate of dyslipidemia (33%) and engaged in an average of 9187 steps/day (SD 3671).
Delivery of this low intensity intervention to a broad cross-section of community based women with children is feasible. Women with children are engaging in lifestyle behaviours which do not confer adequate health benefits. They appear to be motivated to attend prevention programs by their interest in weight management. Interventions are required to strengthen and sustain current attempts at achieving healthy lifestyle behaviours in women to prevent weight gain.
Trial Registration Number
ACTRN 12608000110381
PMCID: PMC2630939  PMID: 19121220
20.  Hair and toenail arsenic concentrations of residents living in areas with high environmental arsenic concentrations. 
Environmental Health Perspectives  2003;111(2):187-193.
Surface soil and groundwater in Australia have been found to contain high concentrations of arsenic. The relative importance of long-term human exposure to these sources has not been established. Several studies have investigated long-term exposure to environmental arsenic concentrations using hair and toenails as the measure of exposure. Few have compared the difference in these measures of environmental sources of exposure. In this study we aimed to investigate risk factors for elevated hair and toenail arsenic concentrations in populations exposed to a range of environmental arsenic concentrations in both drinking water and soil as well as in a control population with low arsenic concentrations in both drinking water and soil. In this study, we recruited 153 participants from areas with elevated arsenic concentrations in drinking water and residential soil, as well as a control population with no anticipated arsenic exposures. The median drinking water arsenic concentrations in the exposed population were 43.8 micro g/L (range, 16.0-73 micro g/L) and median soil arsenic concentrations were 92.0 mg/kg (range, 9.1-9,900 mg/kg). In the control group, the median drinking water arsenic concentration was below the limit of detection, and the median soil arsenic concentration was 3.3 mg/kg. Participants were categorized based on household drinking water and residential soil arsenic concentrations. The geometric mean hair arsenic concentrations were 5.52 mg/kg for the drinking water exposure group and 3.31 mg/kg for the soil exposure group. The geometric mean toenail arsenic concentrations were 21.7 mg/kg for the drinking water exposure group and 32.1 mg/kg for the high-soil exposure group. Toenail arsenic concentrations were more strongly correlated with both drinking water and soil arsenic concentrations; however, there is a strong likelihood of significant external contamination. Measures of residential exposure were better predictors of hair and toenail arsenic concentrations than were local environmental concentrations.
PMCID: PMC1241349  PMID: 12573904
21.  Population based intervention to change back pain beliefs and disability: three part evaluation 
BMJ : British Medical Journal  2001;322(7301):1516-1520.
To evaluate the effectiveness of a population based, state-wide public health intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and costs of compensation.
Quasi-experimental, non-randomised, non-equivalent, before and after telephone surveys of the general population and postal surveys of general practitioners with an adjacent state as control group and descriptive analysis of claims database.
Two states in Australia.
4730 members of general population before and two and two and a half years after campaign started, in a ratio of 2:1:1; 2556 general practitioners before and two years after campaign onset.
Main outcome measures
Back beliefs questionnaire, knowledge and attitude statements about back pain, incidence of workers' financial compensation claims for back problems, rate of days compensated, and medical payments for claims related to back pain and other claims.
In the intervention state beliefs about back pain became more positive between successive surveys (mean improvement in questionnaire score 1.9 (95% confidence interval 1.3 to 2.5), P<0.001 and 3.2 (2.6 to 3.9), P<0.001, between baseline and the second and third survey, respectively). Beliefs about back pain also improved among doctors. There was a clear decline in number of claims for back pain, rates of days compensated, and medical payments for claims for back pain over the duration of the campaign.
A population based strategy of provision of positive messages about back pain improves population and general practitioner beliefs about back pain and seems to influence medical management and reduce disability and workers' compensation costs related to back pain.
What is already known on this topicThe number of people with disability from back pain has risen rapidly in the past 50 yearsMost attempts to limit this disability include modification of occupational risk factors or dealing with the problem once it has developedPatients' attitudes and beliefs play an important part in the development of such chronic disabilityWhat this study addsA population based primary prevention intervention that provided explicit advice about back pain improved beliefs about back pain in the general population and knowledge and attitudes in general practitionersThe number of workers' compensation claims for back pain decreased and the rate of days compensated and medical payments for back claims were reduced
PMCID: PMC33390  PMID: 11420272
22.  Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme 
BMJ : British Medical Journal  1999;319(7211):683-687.
To establish the effect of an educational intervention for general practitioners on the health behaviours and wellbeing of elderly patients.
Randomised controlled trial with 1 year follow up.
Metropolitan general practices in Melbourne, Australia.
42 general practitioners and 267 of their patients aged over 65 years.
Educational and clinical practice audit programme for general practitioners on health promotion for elderly people.
Main outcome measures
Patients’ physical activity, functional status, self rated health, immunisation status, social contacts, psychological wellbeing, drug usage, and rate of influenza vaccination. Primary efficacy variables were changes in outcome measures over 1 year period.
Patients in the intervention group had increased (a) walking by an average of 88 minutes per fortnight, (b) frequency of pleasurable activities, and (c) self rated health compared with the control group. No change was seen in drug usage, rate of influenza vaccination, functional status, or psychological wellbeing as a result of the intervention. Extrapolations of the known effect of these changes in behaviour suggest mortality could be reduced by 22% if activity was sustained for 5 years.
Education of the general practitioners had a positive effect on health outcomes of their elderly patients. General practitioners may have considerable public health impact in promotion of health for elderly patients.
Key messages Few educational interventions for doctors have shown benefit to the health of patients Elderly people were identified in the UK health initiatives as in need of additional attention, and levels of health protective behaviours were low in community surveys A multifaceted educational intervention for general practitioners was effective in improving walking behaviour, self rated health status, and the frequency of social contacts in elderly patients General practitioners are effective in improving health and health behaviours in their elderly patients
PMCID: PMC28221  PMID: 10480825

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