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1.  Evaluation of pseudoephedrine pharmacy sales before and after mandatory recording requirements in Western Australia: a case study 
Background
A community pharmacy real-time electronic recording program, ProjectSTOP, enables Australian community pharmacists to verify pseudoephedrine requests. In Western Australia the program was available for voluntary use from April 2007 and became mandatory November 2010. This case study explores the effectiveness of the program by reviewing the total requests for pseudoephedrine products, and the proportion of requests which were classified as ‘denied sales’ before and after mandatory implementation. Seasonal and annual trends in these measures are also evaluated.
Methods
ProjectSTOP data recordings for Western Australia pharmacies between 1 December 2007 and 28 February 2014 were analysed. Data included a de-identified pharmacy number and date of each pseudoephedrine product request. The total number of requests and sale classification (allowed, denied, safety, or not recorded) were calculated for each month/pharmacy. The potential influence of mandatory reporting using ProjectSTOP was investigated using a Regression Discontinuity Design. Correlations between sales from the same pharmacy were taken into account by classifying the pharmacy number as a random effect. The main effects of year (continuous variable), and season (categorical variable) were also included in the model.
Results
There was a small but steady decline in the total requests for pseudoephedrine per month per 100,000 population (per pharmacy) from the time of mandatory reporting. The number of denied sales showed a steady increase up until mandatory reporting, after which it showed a significant decline over time. Total sales were heavily influenced by season, as expected (highest in winter, least in summer). The seasonal pattern was less pronounced for denied sales, which were highest in winter and similar across other seasons. The pattern over time for safety sales was similar to that for denied sales, with a clear change occurring around the time of mandatory reporting.
Conclusion
Results indicate a decrease in pseudoephedrine product requests in Western Australia community pharmacies. Findings suggest ProjectSTOP has been successful in addressing suspicious sales and potential diversion however ongoing data review is recommended.
doi:10.1186/s13011-016-0075-0
PMCID: PMC5004257  PMID: 27577258
3.  Eye gaze performance for children with severe physical impairments using gaze-based assistive technology—A longitudinal study 
Assistive Technology  2015;28(2):93-102.
ABSTRACT
Gaze-based assistive technology (gaze-based AT) has the potential to provide children affected by severe physical impairments with opportunities for communication and activities. This study aimed to examine changes in eye gaze performance over time (time on task and accuracy) in children with severe physical impairments, without speaking ability, using gaze-based AT. A longitudinal study with a before and after design was conducted on 10 children (aged 1–15 years) with severe physical impairments, who were beginners to gaze-based AT at baseline. Thereafter, all children used the gaze-based AT in daily activities over the course of the study. Compass computer software was used to measure time on task and accuracy with eye selection of targets on screen, and tests were performed with the children at baseline, after 5 months, 9–11 months, and after 15–20 months. Findings showed that the children improved in time on task after 5 months and became more accurate in selecting targets after 15–20 months. This study indicates that these children with severe physical impairments, who were unable to speak, could improve in eye gaze performance. However, the children needed time to practice on a long-term basis to acquire skills needed to develop fast and accurate eye gaze performance.
doi:10.1080/10400435.2015.1092182
PMCID: PMC4867850  PMID: 26496529
assistive devices; computer access; physical disability
4.  Is Using the Strengths and Difficulties Questionnaire in a Community Sample the Optimal Way to Assess Mental Health Functioning? 
PLoS ONE  2016;11(1):e0144039.
An important characteristic of a screening tool is its discriminant ability or the measure’s accuracy to distinguish between those with and without mental health problems. The current study examined the inter-rater agreement and screening concordance of the parent and teacher versions of SDQ at scale, subscale and item-levels, with the view of identifying the items that have the most informant discrepancies; and determining whether the concordance between parent and teacher reports on some items has the potential to influence decision making. Cross-sectional data from parent and teacher reports of the mental health functioning of a community sample of 299 students with and without disabilities from 75 different primary schools in Perth, Western Australia were analysed. The study found that: a) Intraclass correlations between parent and teacher ratings of children’s mental health using the SDQ at person level was fair on individual child level; b) The SDQ only demonstrated clinical utility when there was agreement between teacher and parent reports using the possible or 90% dichotomisation system; and c) Three individual items had positive likelihood ratio scores indicating clinical utility. Of note was the finding that the negative likelihood ratio or likelihood of disregarding the absence of a condition when both parents and teachers rate the item as absent was not significant. Taken together, these findings suggest that the SDQ is not optimised for use in community samples and that further psychometric evaluation of the SDQ in this context is clearly warranted.
doi:10.1371/journal.pone.0144039
PMCID: PMC4714886  PMID: 26771673
5.  An evaluation of community pharmacy-based services for type 2 diabetes in an Indonesian setting: patient survey 
PeerJ  2015;3:e1449.
Background. Diabetes is an emerging chronic disease in developing countries. Its management in developing countries is mainly hospital/clinic based. The increasing diabetes burden in developing countries provides opportunities for community pharmacists to deliver a range of services. Since the management of diabetes requires the patient’s own involvement, it is important to gain their views in order to develop pharmacy-based diabetes services. Studies on diabetes patients’ views have been limited to developed countries.
Objectives. To investigate, within a developing country setting (Indonesia), current use of pharmacy services by type 2 diabetes patients, and to evaluate their views regarding community pharmacists’ roles, and the characteristics that influence their views.
Methods. A questionnaire survey was conducted within 10 purposefully selected community pharmacies in Surabaya, Indonesia. Each pharmacy recruited approximately 20 patients seeking antidiabetic medications. Usage of pharmacy services was identified using binary responses (‘yes’/‘no’) and views on pharmacists’ roles were rated using Likert scales; an open-ended question was used to identify patient perceived priority roles. Logistic regression models were used to determine characteristics associated with patients’ views.
Results. A total of 196 pharmacy patients with type 2 diabetes responded (58.3% response rate). Most patients used community pharmacies for dispensing (100%) and education on how to use medications (79.6%). There were mixed views towards pharmacists providing services beyond dispensing. The highest priorities identified were from the ‘patient education’ domain: education on medications (i.e., directions for use (64.5%), storage (26.6%), common/important adverse effects (25.5%)); and the ‘monitoring’ domain: monitoring medication compliance (37.3%). Patients with higher incomes or who were working were less supportive of these expanded services, whereas patients who previously used a service, those with risk factors for complications or having poor/unknown glycaemic control were more supportive.
Conclusions. Community pharmacies in Surabaya, Indonesia in this study were mainly utilised for dispensing. However, many type 2 diabetes patients using these pharmacies report limited monitoring of blood glucose levels and poor glycaemic control, which indicates an opportunity for greater pharmacist involvement. Yet for this to occur, patients’ limited expectations of pharmacists roles will need to be broadened. Characteristics influencing these views should inform the development of pharmacy-based diabetes services in the environment of the burgeoning burden of diabetes.
doi:10.7717/peerj.1449
PMCID: PMC4690368  PMID: 26713231
Pharmacy services; Indonesia; Community pharmacy; Diabetes; Patient views
6.  A questionnaire study of injections prescribed and dispensed for patients diagnosed with mild/moderate community-acquired pneumonia in Mongolia 
PeerJ  2015;3:e1375.
Purpose. The study aimed to determine the extent of and factors influencing the prescribing of injections for the treatment of mild/moderate community acquired pneumonia (CAP) in Mongolia.
Methods. Questionnaires were developed and administered to medication providers (34 Pharmacists, 27 pharmacy technicians) and prescribers (22 general doctors and 49 medical specialists) working in Mongolia.
Results. Cefalosporins were prescribed for patients with mild pneumonia and doctors tended to prescribe injectable cefalosporins (cefazolin) rather than oral dosage forms. This was supported by the questionnaire study with pharmacists and pharmacy technicians. Additionally, 23 pharmacists and pharmacy technicians indicated that OTC injectable cefalosporins (37.7%) and injectable aminopenicillins (33,9%) were frequently sold by pharmacies for the treatment of mild/moderate CAP. Doctors and particularly pharmacists in the questionnaire studies indicated choosing an injection was to avoid non-compliance problems.
Conclusion. High levels of injectable prescribing of antibiotics were found in non-hospitalized patients with CAP in Mongolia. This prevalence level indicated that inappropriate injection prescribing is a public health hazard for Mongolia and requires consideration by the appropriate authorities.
doi:10.7717/peerj.1375
PMCID: PMC4671187  PMID: 26644968
Injections; Pneumonia; Prescribing; Dispensing; Parenteral medication; Developing country; Mongolia
7.  Do Patients Treated for Colorectal Cancer Benefit from General Practitioner Support? A Video Vignette Study 
Background
Patients who have been treated for colorectal cancer in Australia can consult their general practitioner (GP) for advice about symptoms or side effects at any time following their treatment. However, there is no evidence that such patients are consistently advised by GPs, and patients experience substantial unmet need for reassurance and advice.
Objective
To explore the patient management options selected by GPs to treat a set of patients describing their symptoms following treatment for colorectal cancer.
Methods
This was an Internet-based survey. Participants (GPs) viewed 6 video vignettes of actors representing patients who had been treated for colorectal cancer. The actor-patients presented problems that resulted from their treatment. Participants indicated their diagnosis and stated if they would prescribe, refer, or order tests, based on that diagnosis. These responses were then rated against the management decisions for those vignettes as recommended by a team of colorectal cancer experts.
Results
In total, 52 GPs consented to take part in the study, and 40 (77%) completed the study. Most GPs made a diagnosis of colorectal cancer treatment side effects/symptoms of recurrence that was consistent with the experts’ opinions. However, correct diagnosis was dependent on the type of case viewed. Compared with radiation proctitis, GPs were more likely to recognize peripheral neuropathy (odds ratio, OR, 4.43, 95% CI 1.41-13.96, P=.011) and erectile dysfunction (OR 9.70, 95% CI 2.48-38.03, P=.001), but less likely to identify chemotherapy-induced fatigue (OR 0.19, 95% CI 0.08-0.44). GPs who had more hours of direct patient care (OR 0.38, 95% CI 0.17-0.84, P=.02), were experienced (OR 9.78, 95% CI 1.18-8.84, P=.02), and consulted more patients per week (OR 2.48, 95% CI 1.16-5.30, P=.02) suggested a management plan that was consistent with the expert opinion.
Conclusions
In this pilot study, years of experience and direct patient contact hours had a significant and positive impact on the management of patients. This study also showed promising results indicating that management of the common side effects of colorectal cancer treatment can be delegated to general practice. Such an intervention could support the application of shared models of care. However, a larger study, including the management of side effects in real patients, needs to be conducted before this can be safely recommended.
doi:10.2196/jmir.4942
PMCID: PMC4642383  PMID: 26541077
colorectal cancer; general practice; Internet survey; side effects; video vignettes
8.  Belongingness in Early Secondary School: Key Factors that Primary and Secondary Schools Need to Consider 
PLoS ONE  2015;10(9):e0136053.
It is unknown if, and how, students redefine their sense of school belongingness after negotiating the transition to secondary school. The current study used longitudinal data from 266 students with, and without, disabilities who negotiated the transition from 52 primary schools to 152 secondary schools. The study presents the 13 most significant personal student and contextual factors associated with belongingness in the first year of secondary school. Student perception of school belongingness was found to be stable across the transition. No variability in school belongingness due to gender, disability or household-socio-economic status (SES) was noted. Primary school belongingness accounted for 22% of the variability in secondary school belongingness. Several personal student factors (competence, coping skills) and school factors (low-level classroom task-goal orientation), which influenced belongingness in primary school, continued to influence belongingness in secondary school. In secondary school, effort-goal orientation of the student and perception of their school’s tolerance to disability were each associated with perception of school belongingness. Family factors did not influence belongingness in secondary school. Findings of the current study highlight the need for primary schools to foster belongingness among their students at an early age, and transfer students’ belongingness profiles as part of the hand-over documentation. Most of the factors that influenced school belongingness before and after the transition to secondary are amenable to change.
doi:10.1371/journal.pone.0136053
PMCID: PMC4570666  PMID: 26372554
9.  Protocol for a randomised controlled trial of an outreach support program for family carers of older people discharged from hospital 
BMC Geriatrics  2015;15:70.
Background
Presentations to hospital of older people receiving family care at home incur substantial costs for patients, families, and the health care system, yet there can be positive carer outcomes when systematically assessing/addressing their support needs, and reductions in older people’s returns to hospital attributed to appropriate discharge planning. This study will trial the Further Enabling Care at Home program, a 2-week telephone outreach initiative for family carers of older people returning home from hospital. Hypotheses are that the program will (a) better prepare families to sustain their caregiving role and (b) reduce patients' re-presentations/readmissions to hospital, and/or their length of stay; also that reduced health system costs attributable to the program will outweigh costs of its implementation.
Methods/Design
In this randomised controlled trial, family carers of older patients aged 70+ discharged from a Medical Assessment Unit in a Western Australian tertiary hospital, plus the patients themselves, will be recruited at discharge (N = 180 dyads). Carers will be randomly assigned (block allocation, assessors blinded) to receive usual care (control) or the new program (intervention). The primary outcome is the carer’s self-reported preparedness for caregiving (Preparedness for Caregiving Scale administered within 4 days of discharge, 2–3 weeks post-discharge, 6 weeks post-discharge). To detect a clinically meaningful change of two points with 80 % power, 126 carers need to complete the study. Patients’ returns to hospital and subsequent length of stay will be ascertained for a minimum of 3 months after the index admission. Regression analyses will be used to determine differences in carer and patient outcomes over time associated with the group (intervention or control). Data will be analysed using an Intention to Treat approach. A qualitative exploration will examine patients’ and their family carers’ experiences of the new program (interviews) and explore the hospital staff’s perceptions (focus groups). Process evaluation will identify barriers to, and facilitators of, program implementation. A comprehensive economic evaluation will determine cost consequences.
Discussion
This study investigates a novel approach to identifying and addressing family carers’ needs following discharge from hospital of the older person receiving care. If successful, the program has potential to be incorporated into routine post-discharge support.
Trial registration
Australian and New Zealand Clinical Trial Registry: ACTRN12614001174673.
doi:10.1186/s12877-015-0065-5
PMCID: PMC4479237  PMID: 26108207
10.  Should Schools Expect Poor Physical and Mental Health, Social Adjustment, and Participation Outcomes in Students with Disability? 
PLoS ONE  2015;10(5):e0126630.
The literature on whether students with disabilities have worse physical and mental health, social adjustment, and participation outcomes when compared to their peers without disabilities is largely inconclusive. While the majority of case control studies showed significantly worse outcomes for students with disabilities; the proportion of variance accounted for is rarely reported. The current study used a population cross-sectional approach to determine the classification ability of commonly used screening and outcome measures in determining the disability status. Furthermore, the study aimed to identify the variables, if any, that best predicted the presence of disability. Results of univariate discriminant function analyses suggest that across the board, the sensitivity of the outcome/screening tools to correctly identify students with a disability was 31.9% higher than the related Positive Predictive Value (PPV). The lower PPV and Positive Likelihood Ratio (LR+) scores suggest that the included measures had limited discriminant ability (17.6% to 40.3%) in accurately identifying students at-risk for further assessment. Results of multivariate analyses suggested that poor health and hyperactivity increased the odds of having a disability about two to three times, while poor close perceived friendship and academic competences predicted disability with roughly the same magnitude. Overall, the findings of the current study highlight the need for researchers and clinicians to familiarize themselves with the psychometric properties of measures, and be cautious in matching the function of the measures with their research and clinical needs.
doi:10.1371/journal.pone.0126630
PMCID: PMC4429077  PMID: 25965845
11.  The Personal and Contextual Contributors to School Belongingness among Primary School Students 
PLoS ONE  2015;10(4):e0123353.
School belongingness has gained currency among educators and school health professionals as an important determinant of adolescent health. The current cross-sectional study presents the 15 most significant personal and contextual factors that collectively explain 66.4% (two-thirds) of the variability in 12-year old students’ perceptions of belongingness in primary school. The study is part of a larger longitudinal study investigating the factors associated with student adjustment in the transition from primary to secondary school. The study found that girls and students with disabilities had higher school belongingness scores than boys, and their typically developing counterparts respectively; and explained 2.5% of the variability in school belongingness. The majority (47.1% out of 66.4%) of the variability in school belongingness was explained by student personal factors, such as social acceptance, physical appearance competence, coping skills, and social affiliation motivation; followed by parental expectations (3% out of 66.4%), and school-based factors (13.9% out of 66.4%) such as, classroom involvement, task-goal structure, autonomy provision, cultural pluralism, and absence of bullying. Each of the identified contributors of primary school belongingness can be shaped through interventions, system changes, or policy reforms.
doi:10.1371/journal.pone.0123353
PMCID: PMC4398482  PMID: 25876074
12.  Metabolomic Method: UPLC-q-ToF Polar and Non-Polar Metabolites in the Healthy Rat Cerebellum Using an In-Vial Dual Extraction 
PLoS ONE  2015;10(4):e0122883.
Unbiased metabolomic analysis of biological samples is a powerful and increasingly commonly utilised tool, especially for the analysis of bio-fluids to identify candidate biomarkers. To date however only a small number of metabolomic studies have been applied to studying the metabolite composition of tissue samples, this is due, in part to a number of technical challenges including scarcity of material and difficulty in extracting metabolites. The aim of this study was to develop a method for maximising the biological information obtained from small tissue samples by optimising sample preparation, LC-MS analysis and metabolite identification. Here we describe an in-vial dual extraction (IVDE) method, with reversed phase and hydrophilic liquid interaction chromatography (HILIC) which reproducibly measured over 4,000 metabolite features from as little as 3mg of brain tissue. The aqueous phase was analysed in positive and negative modes following HILIC separation in which 2,838 metabolite features were consistently measured including amino acids, sugars and purine bases. The non-aqueous phase was also analysed in positive and negative modes following reversed phase separation gradients respectively from which 1,183 metabolite features were consistently measured representing metabolites such as phosphatidylcholines, sphingolipids and triacylglycerides. The described metabolomics method includes a database for 200 metabolites, retention time, mass and relative intensity, and presents the basal metabolite composition for brain tissue in the healthy rat cerebellum.
doi:10.1371/journal.pone.0122883
PMCID: PMC4390242  PMID: 25853858
13.  Clinical Setting Influences Off-Label and Unlicensed Prescribing in a Paediatric Teaching Hospital 
PLoS ONE  2015;10(3):e0120630.
Purpose
To estimate the prevalence of off-label and unlicensed prescribing during 2008 at a major paediatric teaching hospital in Western Australia.
Methods
A 12-month retrospective study was conducted at Princess Margaret Hospital using medication chart records randomly selected from 145,550 patient encounters from the Emergency Department, Inpatient Wards and Outpatient Clinics. Patient and prescribing data were collected. Drugs were classified as off-label or unlicensed based on Australian registration data. A hierarchical system of age, indication, route of administration and dosage was used. Drugs were classified according to the Anatomical Therapeutic Chemical Code.
Results
A total of 1,037 paediatric patients were selected where 2,654 prescriptions for 330 different drugs were prescribed to 699 patients (67.4%). Most off-label drugs (n = 295; 43.3%) were from the nervous system; a majority of unlicensed drugs were systemic hormonal preparations excluding sex hormones (n = 22, 32.4%). Inpatients were prescribed more off-label drugs than outpatients or Emergency Department patients (p < 0.0001). Most off-label prescribing occurred in infants and children (31.7% and 35.9% respectively) and the highest percentage of unlicensed prescribing (7.2%) occurred in infants (p < 0.0001). There were 25.7% of off-label and 2.6% of unlicensed medications prescribed across all three settings. Common reasons for off-label prescribing were dosage (47.4%) and age (43.2%).
Conclusion
This study confirmed off-label and unlicensed use of drugs remains common. Further, that prevalence of both is influenced by the clinical setting, which has implications in regards to medication misadventure, and the need to have systems in place to minimise medication errors. Further, there remains a need for changes in the regulatory system in Australia to ensure that manufacturers incorporate, as it becomes available, evidence regarding efficacy and safety of their drugs in children in the official product information.
doi:10.1371/journal.pone.0120630
PMCID: PMC4355417  PMID: 25756896
14.  Parenteral Medication Prescriptions, Dispensing and Administration Habits in Mongolia 
PLoS ONE  2014;9(12):e115384.
High levels of injection prescribing were reported in Mongolia. Understanding the factors influencing the injection prescribing is essential to reduce their inappropriate use. The study evaluated the views, experiences and attitudes of community members associated with the prescribing of injections in Mongolia. A structured questionnaire focusing on respondents' characteristics, experiences and views about injections was developed and administered face-to-face to community members in Ulaanbaatar, Mongolia. Standard descriptive statistics were used to summarize demographic data and responses to the questionnaires. Dependant variables were compared using Kruskal-Wallis Tests for independence. Statistical analyses were performed using SPSS Version 21.0. Six hundred participants were approached and the response rate was 79% (n = 474). Almost half of the respondents were aged between 31 and 50 (n = 228, 48.1%) and 40.9% of respondents were male (n = 194). Most respondents were from Ulaanbaatar city (n = 407, 85.7%). All respondents had received injections in the past and 268 (56.5%) had received injection in the past year. The most common reason for having an injection in the past year was reported as treatment of a disease (n = 163, 60.8%), or for administration of vitamins (n = 70, 26.1%). Injections were prescribed by a doctor (n = 353, 74.9%), dispensed by a pharmacist (n = 283, 59.7%) and administered by a nurse (n = 277, 54.9%). Only 16% of all respondents had the expectation of receiving injections when they visited a doctor (n = 77). An important perception regarding injections was that they hastened the recovery process (n = 269, 56.8%). When asked their opinion about therapeutic injections, 40% of all respondents agreed that injections were a better medicine (n = 190) than oral medications, with older respondents strongly agreeing (p<0.001). Based on this total sample, approximately 1891 injections per 1000 patients were administered. The excessive injection use seems to be promoted by inappropriate prescribing, dispensing and administration of medication by doctors and others.
doi:10.1371/journal.pone.0115384
PMCID: PMC4274029  PMID: 25531766
15.  Management of behavioural change in patients presenting with a diagnosis of dementia: a video vignette study with Australian general practitioners 
BMJ Open  2014;4(9):e006054.
Objective
To test the impact of feedback on the proposed management of standardised patients presenting with behavioural change with a diagnosis of dementia in Australian primary care.
Materials and methods
A video vignette study was performed with Australian general practitioners (GPs) in 2013. Participants viewed six pairs of matched videos depicting people presenting changed behaviour in the context of a dementia diagnosis in two phases. In both phases GPs indicated their diagnosis and management. After phase 1, GPs were offered feedback on management strategies for the patients depicted. Analyses focused on identification of change in management between the two phases of the study. Factors impacting on the intention to coordinate care for such patients were tested in a questionnaire based on the Theory of Planned Behaviour.
Results
Forty-five GPs completed the study. There was significant improvement in the proposed management of three of the six scenarios after the intervention. Older GPs were more likely to refer appropriately (OR=1.11 (1.01 to 1.23), p=0.04.). Overall referral to support agencies was more likely after the intervention (OR=2.52 (1.53 to 4.14), p<0.001). Older GPs were less likely to intend to coordinate care for such patients (OR=0.89 (0.81 to 0.98) p=0.02). Participants who felt confident about their ability to coordinate care were more likely to do so (OR=3.79 (1.08 to 13.32) p=0.04).
Conclusions
The intervention described in this study promoted multidisciplinary management of patients with behavioural problems with a diagnosis of dementia. Increasing practitioner confidence in their ability to coordinate care may increase the proportion of GPs who will respond to patients and carers in this context. Older GPs may benefit in particular.
doi:10.1136/bmjopen-2014-006054
PMCID: PMC4179570  PMID: 25256189
PRIMARY CARE
16.  An evaluation of patients’ adherence with hypoglycemic medications among Papua New Guineans with type 2 diabetes: influencing factors 
Purpose
The aims of this study were to evaluate the extent of adherence to hypoglycemic medications, assess the relationship between adherence and glycemic control, and evaluate factors affecting adherence.
Research design and methods
This was a cross-sectional study of patients with established type 2 diabetes attending the Port Moresby General Hospital Diabetes Clinic. Face-to-face interviews were conducted using a questionnaire designed for the study and data were collected concerning the 3 months prior to interview. The questionnaire covered demographic details, lifestyle, biochemical and physical measurements, and medication management. Glycemic control was investigated among patients adhering to their medications (not missing doses) to different degrees (100%, 95%, 90%, and 80%).
Results
Of a total of 356 participants who were prescribed hypoglycemic medications, 59.6% omitted some of their doses. Age appeared to have a significant impact on adherence at some levels of adherence, with those aged >60 years being more likely to be adherent (logistic regression). Those who were 95%–99% and those who were <80% adherent had a statistically significant risk of a high glycated hemoglobin of >10% (85.5 mmol/mol). Multiple factors were identified as contributors to nonadherence, with patient-based issues (86.0%) and the health care system (21.7%) being the most common.
Conclusion
This study showed a significant level of nonadherence among patients with type 2 diabetes in Papua New Guinea. Nonadherence to medication appeared to be associated with poor glycemic control and was due to a variety of reasons. Future interventions aimed at improving adherence will need to take these into account.
doi:10.2147/PPA.S66655
PMCID: PMC4172082  PMID: 25258517
adherence; type 2 diabetes; A1C; Papua New Guinea; age; sex; contributing factors
17.  The Cost of Autism Spectrum Disorders 
PLoS ONE  2014;9(9):e106552.
Objective
A diagnosis of an autism spectrum disorders is usually associated with substantial lifetime costs to an individual, their family and the community. However, there remains an elusive factor in any cost-benefit analysis of ASD diagnosis, namely the cost of not obtaining a diagnosis. Given the infeasibility of estimating the costs of a population that, by its nature, is inaccessible, the current study compares expenses between families whose children received a formal ASD diagnosis immediately upon suspecting developmental atypicality and seeking advice, with families that experienced a delay between first suspicion and formal diagnosis.
Design
A register based questionnaire study covering all families with a child with ASD in Western Australia.
Participants
Families with one or more children diagnosed with an ASD, totalling 521 children diagnosed with an ASD; 317 records were able to be included in the final analysis.
Results
The median family cost of ASD was estimated to be AUD $34,900 per annum with almost 90% of the sum ($29,200) due to loss of income from employment. For each additional symptom reported, approximately $1,400 cost for the family per annum was added. While there was little direct influence on costs associated with a delay in the diagnosis, the delay was associated with a modest increase in the number of ASD symptoms, indirectly impacting the cost of ASD.
Conclusions
A delay in diagnosis was associated with an indirect increased financial burden to families. Early and appropriate access to early intervention is known to improve a child's long-term outcomes and reduce lifetime costs to the individual, family and society. Consequently, a per symptom dollar value may assist in allocation of individualised funding amounts for interventions rather than a nominal amount allocated to all children below a certain age, regardless of symptom presentation, as is the case in Western Australia.
doi:10.1371/journal.pone.0106552
PMCID: PMC4156354  PMID: 25191755
18.  School Belongingness and Mental Health Functioning across the Primary-Secondary Transition in a Mainstream Sample: Multi-Group Cross-Lagged Analyses 
PLoS ONE  2014;9(6):e99576.
The relationship between school belongingness and mental health functioning before and after the primary-secondary school transition has not been previously investigated in students with and without disabilities. This study used a prospective longitudinal design to test the bi-directional relationships between these constructs, by surveying 266 students with and without disabilities and their parents, 6-months before and after the transition to secondary school. Cross-lagged multi-group analyses found student perception of belongingness in the final year of primary school to contribute to change in their mental health functioning a year later. The beneficial longitudinal effects of school belongingness on subsequent mental health functioning were evident in all student subgroups; even after accounting for prior mental health scores and the cross-time stability in mental health functioning and school belongingness scores. Findings of the current study substantiate the role of school contextual influences on early adolescent mental health functioning. They highlight the importance for primary and secondary schools to assess students’ school belongingness and mental health functioning and transfer these records as part of the transition process, so that appropriate scaffolds are in place to support those in need. Longer term longitudinal studies are needed to increase the understanding of the temporal sequencing between school belongingness and mental health functioning of all mainstream students.
doi:10.1371/journal.pone.0099576
PMCID: PMC4072543  PMID: 24967580
19.  The Impact of Personal Background and School Contextual Factors on Academic Competence and Mental Health Functioning across the Primary-Secondary School Transition 
PLoS ONE  2014;9(3):e89874.
Students negotiate the transition to secondary school in different ways. While some thrive on the opportunity, others are challenged. A prospective longitudinal design was used to determine the contribution of personal background and school contextual factors on academic competence (AC) and mental health functioning (MHF) of 266 students, 6-months before and after the transition to secondary school. Data from 197 typically developing students and 69 students with a disability were analysed using hierarchical linear regression modelling. Both in primary and secondary school, students with a disability and from socially disadvantaged backgrounds gained poorer scores for AC and MHF than their typically developing and more affluent counterparts. Students who attended independent and mid-range sized primary schools had the highest concurrent AC. Those from independent primary schools had the lowest MHF. The primary school organisational model significantly influenced post-transition AC scores; with students from Kindergarten - Year 7 schools reporting the lowest scores, while those from the Kindergarten - Year 12 structure without middle school having the highest scores. Attending a school which used the Kindergarten - Year 12 with middle school structure was associated with a reduction in AC scores across the transition. Personal background factors accounted for the majority of the variability in post-transition AC and MHF. The contribution of school contextual factors was relatively minor. There is a potential opportunity for schools to provide support to disadvantaged students before the transition to secondary school, as they continue to be at a disadvantage after the transition.
doi:10.1371/journal.pone.0089874
PMCID: PMC3946588  PMID: 24608366
20.  The use of herbal medicines during breastfeeding: a population-based survey in Western Australia 
Background
Main concerns for lactating women about medications include the safety of their breastfed infants and the potential effects of medication on quantity and quality of breast milk. While medicine treatments include conventional and complementary medicines, most studies to date have focused on evaluating the safety aspect of conventional medicines. Despite increasing popularity of herbal medicines, there are currently limited data available on the pattern of use and safety of these medicines during breastfeeding. This study aimed to identify the pattern of use of herbal medicines during breastfeeding in Perth, Western Australia, and to identify aspects which require further clinical research.
Methods
This study was conducted using a self-administered questionnaire validated through two pilot studies. Participants were 18 years or older, breastfeeding or had breastfed in the past 12 months. Participants were recruited from various community and health centres, and through advertising in newspapers. Simple descriptive statistics were used to summarise the demographic profile and attitudes of respondents, using the SPSS statistical software.
Results
A total of 304 questionnaires from eligible participants were returned (27.2% response rate) and analysed. Amongst the respondents, 59.9% took at least one herb for medicinal purposes during breastfeeding, whilst 24.3% reported the use of at least one herb to increase breast milk supply. Most commonly used herbs were fenugreek (18.4%), ginger (11.8%), dong quai (7.9%), chamomile (7.2%), garlic (6.6%) and blessed thistle (5.9%). The majority of participants (70.1%) believed that there was a lack of information resources, whilst 43.4% perceived herbal medicines to be safer than conventional medicines. Only 28.6% of users notified their doctor of their decision to use herbal medicine(s) during breastfeeding; 71.6% had previously refused or avoided conventional medicine treatments due to concerns regarding safety of their breastfed infants.
Conclusions
The use of herbal medicines is common amongst breastfeeding women, while information supporting their safety and efficacy is lacking. This study has demonstrated the need for further research into commonly used herbal medicines. Evidence-based information should be available to breastfeeding women who wish to consider use of all medicines, including complementary medicines, to avoid unnecessary cessation of breastfeeding or compromising of pharmacotherapy.
doi:10.1186/1472-6882-13-317
PMCID: PMC3835544  PMID: 24219150
Herbal medicines; Breastfeeding; Lactation; Breastfeeding women; Survey; Prevalence
21.  An evaluation of prescribing practices for community-acquired pneumonia (CAP) in Mongolia 
Background
Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality in all age groups worldwide. It may be classified as mild/moderate or severe, the latter usually requiring hospitalisation. Although, there are many studies reported in relation to CAP, there is relatively little known about the treatment of CAP and its antibiotic use in Mongolia. The study aim was to evaluate prescribing practices for the treatment of mild/moderate CAP in Mongolia with respect to national prescribing guidelines.
Methods
Written prescriptions with a written diagnosis of CAP included were collected prospectively and sequentially for ten weeks from a purposefully selected sample of community pharmacies in rural and urban areas of Mongolia. The data collected included the patient’s age, gender, medication details, frequency and number of doses prescribed. Evaluation was with respect to the Mongolian Standard Treatment Guidelines (2005, 2008). Statistical differences between groups were tested using the Chi-squared and Fisher’s exact tests.
Results
Prescriptions were collected from 22 pharmacies and represented the prescribing practices of 118 doctors. The study enrolled 394 (193 adults and 201 children) patients, with a median age for children of 2.0 years (range: 0.03-12) and adults of 33.0 years (range: 13–92).
The most commonly prescribed drugs were aminopenicillins, vitamins, and mucolytics, with the median number of drugs being three per prescription. Inappropriate drug selection was similar for adults (57.7%) and children (56.6%), and the major reason for an overall frequency of inappropriate prescribing for adults was 89.0% and for children 78.0%. Doctors in urban areas prescribed more inappropriate drugs than those in rural areas for both children and adults, p = .0014. The proportion of prescribed injections was 28.4% for adults and 9.0% for children, and for adults was significantly higher in urban areas. The prescribing standard for non-hospitalized patients in Mongolia states that injections should not be prescribed.
Conclusions
The high level of inappropriate prescribing for mild/moderate CAP highlights the need to develop comprehensive and reliable procedures nationwide to improve prescribing practices in Mongolia.
doi:10.1186/1472-6963-13-379
PMCID: PMC4016517  PMID: 24088338
22.  The Case for Using the Repeatability Coefficient When Calculating Test–Retest Reliability 
PLoS ONE  2013;8(9):e73990.
The use of standardised tools is an essential component of evidence-based practice. Reliance on standardised tools places demands on clinicians to understand their properties, strengths, and weaknesses, in order to interpret results and make clinical decisions. This paper makes a case for clinicians to consider measurement error (ME) indices Coefficient of Repeatability (CR) or the Smallest Real Difference (SRD) over relative reliability coefficients like the Pearson’s (r) and the Intraclass Correlation Coefficient (ICC), while selecting tools to measure change and inferring change as true. The authors present statistical methods that are part of the current approach to evaluate test–retest reliability of assessment tools and outcome measurements. Selected examples from a previous test–retest study are used to elucidate the added advantages of knowledge of the ME of an assessment tool in clinical decision making. The CR is computed in the same units as the assessment tool and sets the boundary of the minimal detectable true change that can be measured by the tool.
doi:10.1371/journal.pone.0073990
PMCID: PMC3767825  PMID: 24040139
23.  Internal Consistency, Test–Retest Reliability and Measurement Error of the Self-Report Version of the Social Skills Rating System in a Sample of Australian Adolescents 
PLoS ONE  2013;8(9):e73924.
The social skills rating system (SSRS) is used to assess social skills and competence in children and adolescents. While its characteristics based on United States samples (US) are published, corresponding Australian figures are unavailable. Using a 4-week retest design, we examined the internal consistency, retest reliability and measurement error (ME) of the SSRS secondary student form (SSF) in a sample of Year 7 students (N = 187), from five randomly selected public schools in Perth, western Australia. Internal consistency (IC) of the total scale and most subscale scores (except empathy) on the frequency rating scale was adequate to permit independent use. On the importance rating scale, most IC estimates for girls fell below the benchmark. Test–retest estimates of the total scale and subscales were insufficient to permit reliable use. ME of the total scale score (frequency rating) for boys was equivalent to the US estimate, while that for girls was lower than the US error. ME of the total scale score (importance rating) was larger than the error using the frequency rating scale. The study finding supports the idea of using multiple informants (e.g. teacher and parent reports), not just student as recommended in the manual. Future research needs to substantiate the clinical meaningfulness of the MEs calculated in this study by corroborating them against the respective Minimum Clinically Important Difference (MCID).
doi:10.1371/journal.pone.0073924
PMCID: PMC3767833  PMID: 24040116
24.  A Policy-into-Practice Intervention to Increase the Uptake of Evidence-Based Management of Low Back Pain in Primary Care: A Prospective Cohort Study 
PLoS ONE  2012;7(5):e38037.
Background
Persistent non-specific low back pain (nsLBP) is poorly understood by the general community, by educators, researchers and health professionals, making effective care problematic. This study evaluated the effectiveness of a policy-into-practice intervention developed for primary care physicians (PCPs).
Methods
To encourage PCPs to adopt practical evidence-based approaches and facilitate time-efficient, integrated management of patients with nsLBP, we developed an interdisciplinary evidence-based, practical pain education program (gPEP) based on a contemporary biopsychosocial framework. One hundred and twenty six PCPs from primary care settings in Western Australia were recruited. PCPs participated in a 6.5-hour gPEP. Self-report measures recorded at baseline and at 2 months post-intervention included PCPs' attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS), evidence-based clinical practices (knowledge and skills regarding nsLBP management: 5-point Likert scale with 1 =  nil and 5 =  excellent) and practice behaviours (recommendations based on a patient vignette; 5-point Likert scale).
Results
Ninety one PCPs participated (attendance rate of 72%; post-intervention response rate 88%). PCP-responders adopted more positive, guideline-consistent beliefs, evidenced by clinically significant HC-PAIRS score differences (mean change  = −5.6±8.2, p<0.0001; 95% confidence interval: −7.6 to −3.6) and significant positive shifts on all measures of clinical knowledge and skills (p<0.0001 for all questions). Self management strategies were recommended more frequently post-intervention. The majority of responders who were guideline-inconsistent for work and bed rest recommendations (82% and 62% respectively) at pre-intervention, gave guideline-consistent responses at post-intervention.
Conclusion
An interprofessional pain education program set within a framework that aligns health policy and practice, encourages PCPs to adopt more self-reported evidence-based attitudes, beliefs and clinical behaviours in their management of patients with nsLBP. However, further research is required to determine cost effectiveness of this approach when compared with other modes of educational delivery and to examine PCP behaviours in actual clinical practice.
doi:10.1371/journal.pone.0038037
PMCID: PMC3360643  PMID: 22662264
25.  Looking through the Same Eyes? Do Teachers' Participation Ratings Match with Ratings of Students with Autism Spectrum Conditions in Mainstream Schools? 
Autism Research and Treatment  2012;2012:656981.
To create an inclusive classroom and act accordingly, teachers' understanding of the experiences of participation of students with autism spectrum conditions (ASCs) is crucial. This understanding may depend on the teachers' professional experiences, support and personal interests. The aim of the present questionnaire study was to investigate how well the teachers' ratings of their students with ASCs' perception of participation matched with the students' own ratings. Furthermore, possible correlations between the accuracy of teachers' ratings and the teachers' self-reported professional experience, support (including support-staff), and personal interest were investigated. Teachers' ratings were also used to examine how their understandings correlated with classroom actions. The agreements between teachers' and students' ratings were moderate to high, and the ability to attune to the students' perception of participation was not affected by the presence of a support-staff. The teachers' personal interest in teaching students with ASC correlated with their accuracy, suggesting that this is a factor to consider when planning for successful placements in mainstream schools. Teachers' understandings of the students with ASCs' perception of being bullied or unpopular correlated with implementation of activities to improve the attitudes of classmates, but not with actions to enhance social relations for the students with ASC.
doi:10.1155/2012/656981
PMCID: PMC3420386  PMID: 22934176

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