Healthy rural hearts: The feasibility of a telehealth nutrition randomised controlled trial for rural people at risk of cardiovascular disease.

INTRODUCTION: Improving dietary patterns using medical nutrition therapy delivered via telehealth could make an effective contribution to reducing cardiovascular disease burden in rural Australia. However, it is important that medical nutrition therapy programmes are developed in collaboration with rural stakeholders, to increase feasibility for the rural context and the likelihood of successful implementation. The aim of this study was to evaluate the preliminary feasibility outcomes of integration (implementation), practicality, acceptability, demand, and preliminary effectiveness at the 3-month timepoint of the Healthy Rural Hearts randomised control trial. METHODS: Feasibility measures were collected from participants in the Healthy Rural Hearts medical nutrition therapy trial. Study participants were patients from eligible primary care practices who had been assessed by their general practitioner as being at moderate to high risk of developing cardiovascular disease in the next five years. The sample in this analysis includes those who had completed the first 3-months of the study. Feasibility outcomes were measured over the first 3-months of the trial intervention. A process evaluation survey was used to collect measures relating to intervention implementation, practicality, acceptability, and demand. Completion rates of the Australian Eating Survey Heart version, Personalised Nutrition Questionnaire, pathology tests and telehealth medical nutrition therapy consultations delivered by Accredited Practising Dietitians were also used to measure intervention practicality. Preliminary effectiveness was evaluated by comparing the intervention group's dietary change, measured using Australian Eating Survey Heart with data from the control group. RESULTS: A total of 105 participants (75 intervention, 30 control participants) were eligible for inclusion in analysis. Attendance rates at the first 3-months of dietitian consultations ranged from 94.7% to 89.3% between the first and 3-month consultations, and most participants were able to complete the Australian Eating Survey Heart and Personalised Nutrition Questionnaire prior to their initial consultation [Australian Eating Survey Heart (n = 57, 76%) and Personalised Nutrition Questionnaire (n = 61, 81.3%)] and the Australian Eating Survey Heart prior to their 3-month consultation (n = 52, 69.3%). Of the participants who completed a pathology test at the 3-month time-point (n = 54, 72%), less than half were able to do so prior to their dietitian consultation (n = 35, 46.7%). Of the 75 intervention participants, 28 (37.3%) completed the process evaluation survey. Intervention participants ranked acceptability of the Healthy Rural Hearts intervention highly (mean rank out of 10 = 9.5, SD 1.9), but provided mixed responses on whether they would access the intervention outside of the study (mean rank out of 10 = 6.0, SD 3.5). There were statistically significant increases in percentage total energy intake derived from nutrient-dense core foods compared to the control group (p ≤ 0.05). DISCUSSION: The positive findings related to acceptability and implementation outcomes suggest that the Healthy Rural Hearts intervention was acceptable, practical, and able to be implemented within this population living in rural NSW. This, combined with the small to medium effect size in the proportion of total energy derived from nutrient-dense core foods compared to the control group indicates that long-term intervention effectiveness on other cardiovascular disease outcomes is important to evaluate in the future.

Sustaining an Aboriginal wellbeing program: Informing health promotion practice and policy.

ISSUE ADDRESSED: Aboriginal and Torres Strait Islander Peoples' holistic concepts of wellbeing are inadequately represented in the health promotion discourse. The aim of this article was to explore what sustains an Aboriginal wellbeing program, to inform critical reflection and reorientation to empower Aboriginal wellbeing approaches in health promotion practice and policy. METHODS: Aboriginal and non-Indigenous researchers collaboratively designed a critically framed, strengths-based research approach with Aboriginal Community Controlled Health Service staff and wellbeing program participants. Data from Individual Yarning (n = 15) with program participants and staff inspired co-researchers to co-develop interpretations over two half-day Collaborative Yarning sessions (n = 9). RESULTS: Co-researchers depicted five lifeworld qualities that sustain an Aboriginal wellbeing program: love, connection, respect, culture and belonging. The lifeworld qualities are relational, communicative and involve the dynamics of identity, power and self-determination. CONCLUSIONS: The five qualities support a lifeworld approach to an Aboriginal wellbeing program, opening communicative and relational opportunities to mediate culturally responsive interactions. The qualities mediated interactions between people in the lifeworld including program participants and coordinators, and systems representatives including health service providers. A lifeworld approach provides a way to empower Aboriginal self-determination and leadership through embedment of cultural determinants of health in wellbeing programs. SO WHAT?: Health service providers and policy makers can use lifeworld approaches to guide critical reflection and reorient practice and policy related to Aboriginal health. The lifeworld qualities that encompass this approach in wellbeing programs are communicative and relational, centred on local community voices and co-produced with community for Aboriginal identity, empowerment and self-determination.

Development of a Scoring Tool for Australian Rural Food Retail Environments.

Current tools scoring the healthiness of food retail outlets do not reflect outlets found in rural locations. This study aimed to adapt pre-existing Australian scoring tools to represent non-metropolitan areas. Rural nutrition experts were identified, and a modified Delphi technique was used to adapt two pre-existing, food-scoring tools in five iterative stages. Stages included identifying all relevant outlets, providing a description and score for each, ensuring consistency between outlet scores and pre-existing, metro-centric tools, and providing instructions for correct use. Six rural nutrition experts were identified and engaged in the modified Delphi technique. The final tool consisted of 12 categories of food outlets and listed 35 individual outlets. Consistent with pre-existing Australian tools, scores ranged from +10 to -10 and included descriptions reflective of rural retail outlets. Scores were based on whether the majority of foods offered within the outlet were consistent with foods recommended in national health guidelines. The developed tool was designed to accommodate the diverse nature of food retail outlets found in non-metropolitan areas. This study assists in explaining the link between the food environment and health in populations living rurally.

Delivery of telehealth nutrition and physical activity interventions to adults living in rural areas: a scoping review.

BACKGROUND: Lifestyle behaviours related to smoking, alcohol, nutrition, and physical activity are leading risk factors for the development of chronic disease. For people in rural areas, access to individualised lifestyle services targeting behaviour change may be improved by using telehealth. However, the scope of literature investigating telehealth lifestyle behaviour change interventions for rural populations is unknown, making it difficult to ascertain whether telehealth interventions require adaptation for rural context via a systematic review. This scoping review aimed to address this gap, by mapping existing literature describing telehealth lifestyle interventions delivered to rural populations to determine if there is scope for systematic review of intervention effectiveness in this research topic. METHODS: The PRISMA extension for scoping review checklist guided the processes of this scoping review. A search of eight electronic databases reported in English language until June 2023 was conducted. Eligible studies included adults (18 years and over), who lived in rural areas of high-income countries and undertook at least one synchronous (video or phone consultation) telehealth intervention that addressed either addictive (smoking or alcohol), or non-addictive lifestyle behaviours (nutrition or physical activity). Studies targeting addictive and non-addictive behaviours were separated after full text screening to account for the involvement of addictive substances in smoking and alcohol studies that may impact behaviour change interventions described. Studies targeting nutrition and/or physical activity interventions are presented here. RESULTS: The search strategy identified 17179 citations across eight databases, with 7440 unique citations once duplicates were removed. Full texts for 492 citations were retrieved and screened for inclusion with 85 publications reporting on 73 studies eligible for data extraction and analysis. Of this, addictive behaviours were comprised of 15 publications from 13 studies. Non-addictive behaviours included 70 publications from 58 studies and are reported here. Most interventions were delivered within the United States of America (n = 43, 74.1%). The most common study design reported was Randomised Control Trial (n = 27, 46.6%). Included studies involved synchronous telehealth interventions targeting nutrition (11, 18.9%), physical activity (5, 8.6%) or nutrition and physical activity (41, 70.7%) and were delivered predominately via videoconference (n = 17, 29.3%). CONCLUSIONS: Despite differences in intervention characteristics, the number of randomised control trials published suggests sufficient scope for future systematic reviews to determine intervention effectiveness related to nutrition and physical activity telehealth interventions for rural populations. TRIAL REGISTRATION: The scoping review protocol was not pre-registered.

Rural nutrition and dietetics research-Future directions.

AIM: The aim of this study was to summarise key evidence from recent Australian rural nutrition research and provide recommendations for future nutrition and dietetics research with rural communities. CONTEXT: Clear evidence demonstrates that diet plays a role in the health gap between rural and metropolitan Australia. Despite the opportunity to address the health of rural Australians through better nutrition, alarmingly low investment in nutrition and dietetics research has occurred historically, and over the past decade. APPROACH: A review of the evidence was undertaken by rural nutrition and dietetics leaders to provide a commentary piece to inform future rural nutrition research efforts. CONCLUSION: Establishing strong, collaborative place-based nutrition and dietetics research teams are necessary to combat the significant gaps in the scientific knowledge of solutions to improve nutrition in rural Australia. Further, dieticians and nutritionists who live in and understand the rural contexts are yet to be fully harnessed in research, and better engaging with these professionals will have the best chance of successfully addressing the nutrition-related disease disparity between rural and metropolitan Australia.

Developing a telehealth medical nutrition therapy (MNT) service for adults living in rural Australia at risk of cardiovascular disease: An intervention development study.

BACKGROUND: Receiving medical nutrition therapy (MNT) from an accredited practising dietitian (APD) can reduce diet-related cardiovascular disease (CVD) risk factors. However, people living in rural areas of Australia experience barriers to accessing dietitians because of their remote location. Telehealth has the potential to improve dietetic access in rural areas; however, there is limited research into the development and delivery of telehealth MNT interventions specific to these areas. The present study describes the development of the Healthy Rural Hearts (HealthyRHearts) telehealth MNT intervention, which was developed as a part of the HealthyRHearts randomised control trial, set in primary care practices in rural areas of the Hunter New England and Central Coast Primary Health Network. The aim of HealthyRHearts is to improve diet-related risk factors for CVD in rural adults at moderate to high CVD risk using a telehealth MNT intervention delivered by an APD. METHODS: The study describes the development of the HealthyRHearts telehealth MNT intervention, using the 14-item GUIDance for rEporting of intervention Development (GUIDED) checklist and the Template for Intervention Description and Replication (TIDieR) framework to guide description. RESULTS: HealthyRHearts is a complex intervention that aims to translate a telehealth MNT intervention for CVD prevention into rural and remote primary care settings. The intervention is designed to be implemented across multiple sites of varying characteristics and needs, with the ability to accommodate individual complexities within the rural context and target population. Participants are adults aged 45-75 years who are assessed as moderate to high risk of CVD by their general practitioner (GP). Consenting participants are referred to the intervention by their GPs and receive five telehealth MNT consultations with an APD over 6-months. APDs are trained in the intervention protocol including intervention materials, resources and behaviour change counselling strategies. CONCLUSION: Using the GUIDED and TIDieR frameworks to guide description of the HealthyRHearts intervention development process facilitates detailed description of decision-making pathways for each element of the intervention design. The comprehensive description of the intervention development process for HealthyRHearts is intended to facilitate replication, iteration and optimisation of the intervention for rural contexts.

Dietary patterns in rural and metropolitan Australia: a cross-sectional study exploring dietary patterns, inflammation and association with cardiovascular disease risk factors.

OBJECTIVES: This study sought first to empirically define dietary patterns and to apply the novel Dietary Inflammation Score (DIS) in data from rural and metropolitan populations in Australia, and second to investigate associations with cardiovascular disease (CVD) risk factors. DESIGN: Cross-sectional study. SETTING: Rural and metropolitan Australia. PARTICIPANTS: Adults over the age of 18 years living in rural or metropolitan Australia who participated in the Australian Health survey. PRIMARY OUTCOMES: A posteriori dietary patterns for participants separated into rural and metropolitan populations using principal component analysis. SECONDARY OUTCOMES: association of each dietary pattern and DIS with CVD risk factors was explored using logistic regression. RESULTS: The sample included 713 rural and 1185 metropolitan participants. The rural sample was significantly older (mean age 52.7 compared with 48.6 years) and had a higher prevalence of CVD risk factors. Two primary dietary patterns were derived from each population (four in total), and dietary patterns were different between the rural and metropolitan areas. None of the identified patterns were associated with CVD risk factors in metropolitan or rural areas, aside diet pattern 2 being strongly associated with from self-reported ischaemic heart disease (OR 13.90 95% CI 2.29 to 84.3) in rural areas. There were no significant differences between the DIS and CVD risk factors across the two populations, except for a higher DIS being associated with overweight/obesity in rural areas. CONCLUSION: Exploration of dietary patterns between rural and metropolitan Australia shows differences between the two populations, possibly reflective of distinct cultures, socioeconomic factors, geography, food access and/or food environments in the different areas. Our study provides evidence that action targeting healthier dietary intakes needs to be tailored to rurality in the Australian context.

HealthyRHearts - reducing cholesterol in rural adults via telehealth-based medical nutrition therapy: protocol for a cluster randomised controlled trial.

BACKGROUND: Few randomised controlled trials specifically focus on prevention in rural populations. Cardiovascular disease (CVD) contributes to approximately one quarter of deaths in Australia. Nutrition is a key component affecting many risk factors associated with CVD, including hypercholesterolaemia. However, access to medical nutrition therapy (MNT) is limited for people living in rural areas, potentially exacerbating inequities related to health outcomes. Telehealth services present an opportunity to improve MNT access and address healthcare disparities for rural populations. The present study aims to evaluate feasibility, acceptability, and cost-effectiveness of a telehealth MNT CVD intervention program in lowering CVD risk over 12-months in regional and rural primary health care settings. METHODS/DESIGN: A cluster randomised controlled trial set in rural and regional general practices in NSW, Australia, and their consenting patients (n = 300 participants). Practices will be randomised to either control (usual care from their General Practitioner (GP) + low level individualised dietetic feedback) or intervention groups (usual care from their GP + low level individualised dietetic feedback + telehealth MNT intervention). Telehealth consultations will be delivered by an Accredited Practising Dietitian (APD), with each intervention participant scheduled to receive five consultations over a 6-month period. System-generated generic personalised nutrition feedback reports are provided based on completion of the Australian Eating Survey - Heart version (AES-Heart), a food frequency questionnaire. Eligible participants must be assessed by their GP as at moderate (≥ 10%) to high (> 15%) risk of a CVD event within the next five years using the CVD Check calculator and reside in a regional or rural area within the Hunter New England Central Coast Primary Health Network (HNECC PHN) to be eligible for inclusion. Outcome measures are assessed at baseline, 3, 6 and 12 months. The primary outcome is reduction in total serum cholesterol. Evaluation of the intervention feasibility, acceptability and cost-effective will incorporate quantitative, economic and qualitative methodologies. DISCUSSION: Research outcomes will provide knowledge on effectiveness of MNT provision in reducing serum cholesterol, and feasibility, acceptability, and cost-effectiveness of delivering MNT via telehealth to address CVD risk in rural regions. Results will inform translation to health policy and practice for improving access to clinical care in rural Australia. TRIAL REGISTRATION: This trial is registered at anzctr.org.au under the acronym HealthyRHearts (Healthy Rural Hearts), registration number ACTRN12621001495819.

Omega-3 Fatty Acids during Pregnancy in Indigenous Australian Women of the Gomeroi Gaaynggal Cohort.

Higher dietary intakes of Omega-3 long-chain polyunsaturated fatty acids (n-3 LC-PUFAs) have been linked to lower rates of preterm birth and preeclampsia. The aim of this analysis was to describe dietary intake and fractions of red blood cell (RBC) membrane LC-PUFAs during pregnancy in a cohort of Indigenous Australian women. Maternal dietary intake was assessed using two validated dietary assessment tools and quantified using the AUSNUT (Australian Food and Nutrient) 2011-2013 database. Analysis from a 3-month food frequency questionnaire indicated that 83% of this cohort met national n-3 LC-PUFA recommendations, with 59% meeting alpha-linolenic acid (ALA) recommendations. No nutritional supplements used by the women contained n-3 LC-PUFAs. Over 90% of women had no detectable level of ALA in their RBC membranes, and the median Omega-3 Index was 5.5%. This analysis appears to illustrate a decline in concentrations of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) across gestation in women who had preterm birth. However, there was no visible trend in LC-PUFA fractions in women who experienced hypertension during pregnancy. Further research is needed to better understand the link between dietary intake of n-3 LC-PUFA-rich foods and the role of fatty acids in preterm birth and preeclampsia.

Effectiveness and reporting of nutrition interventions in cardiac rehabilitation programmes: a systematic review.

AIMS: Dietary modification is essential for the secondary prevention of cardiovascular disease. However, there are limited published evidence syntheses to guide practice in the cardiac rehabilitation (CR) setting. This systematic review's objective was to assess effectiveness and reporting of nutrition interventions to optimize dietary intake in adults attending CR. METHODS AND RESULTS: Randomized controlled trials (RCTs) of nutrition interventions within CR were eligible for inclusion and had to have measured change in dietary intake. MEDLINE, Embase, Emcare, PsycINFO, CINAHL, Scopus, and The Cochrane Library were searched from 2000 to June 2020, limited to publications in English. Evidence from included RCTs was synthesized descriptively. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. This review is registered on PROSPERO; CRD42020188723. Of 13 048 unique articles identified, 11 were eligible. Randomized controlled trials were conducted in 10 different countries, included 1542 participants, and evaluated 29 distinct dietary intake outcomes. Five studies reported statistically significant changes in diet across 13 outcomes. Most nutrition interventions were not reported in a manner that allowed replication in clinical practice or future research. CONCLUSION: There is a gap in research testing high-quality nutrition interventions in CR settings. Findings should be interpreted in the light of limitations, given the overall body of evidence was heterogenous across outcomes and study quality; 6 of 11 studies were conducted more than 10 years old. Future research should investigate strategies to optimize and maintain nutrition improvements for patients attending CR. REGISTRATION: PROSPERO; CRD42020188723.

Experiences of co-designing research about a rural Aboriginal well-being program: Informing practice and policy.

OBJECTIVE: The objective of this study was to explore data and Aboriginal and non-Aboriginal researchers' experiences and reflexivity in co-designing research about a rural Aboriginal well-being program to inform practice and policy. SETTING: Gumbaynggirr, Birpai, Kamilaroi and Awabakal countries located in regional and rural New South Wales, Australia. PARTICIPANTS: Rural and regionally located research team who co-designed processes to challenge the status quo about a critically framed, rural-based Aboriginal well-being research project. DESIGN: Researchers drew on data from a research project in an interpretive cycle of collaborative Yarning. Data included 90 published articles, 12 Yarning transcripts and 26 reflective journal text sets, as well as researcher experiences and reflexivity. RESULTS: The Duguula Gayirray (Yarning together), Yandaarray (walking together) and Duguula Nguraljili (sharing together) co-design practice model was developed to represent key actions in the context of an Aboriginal well-being program in a rural context. Actions were supported by seven interpersonal ways of being and were underpinned by respectful relationships between community and researchers. DISCUSSION: Duguula Gayirray, Yandaarray and Duguula Nguraljili are critical to co-design practice and are grounded in respectful relationships. Our experiences led us to critique our perceptions of power sharing, equitable partnerships and collaborative knowledges towards opportunity for collective research co-design. CONCLUSION: Duguula Gayirray, Yandaarray and Duguula Nguraljili transformed our understanding of achieving liberation from dominant western research in the context of a rurally located Australian Aboriginal well-being program. This study contributes to progression of Aboriginal health research practice and policy recommendations, enabling real cultural change in health care with rurally located Aboriginal communities.

Communication regarding the deactivation of implantable cardioverter-defibrillators: A scoping review and narrative summary of current interventions.

OBJECTIVES: Communication about deactivation of implantable cardioverter-defibrillator (ICD) therapy at end-of-life (EoL) is a recognised issue within clinical practice. The aim of this scoping review was to explore and map the current literature in this field, with a focus on papers which implemented interventional studies. METHODS: Systematic searches of six major databases were conducted. Citations were included by four researchers according to selection criteria. Key demographic data and prespecified themes in relation to communication of ICD deactivation at EoL were extracted. RESULTS: The search found 6197 texts of which 63 were included: 39 quantitative, 14 qualitative and 10 mixed-methods. Surveys were predominantly used to gather data (n = 34), followed by interviews (n = 18) and retrospective reviews of patient records (n = 18). CONCLUSIONS: Several key gaps in the literature warrant further research. These include who is responsible for initiating ICD deactivation discussions, how clinicians should initiate and conduct these discussions, when ICD deactivations should be occurring, and family perspectives. Adequately explored themes include patient and clinician knowledge and attitudes regarding ICD deactivation at EoL. PRACTICAL IMPLICATIONS: Facilities treating patients with ICDs at EoL should consider ongoing quality improvement projects aimed at clinician education and protocol changes to improve communication surrounding EoL ICD deactivation.

Identifying features of quality in rural placements for health students: scoping review.

OBJECTIVES: To explore and synthesise the evidence relating to features of quality in rural health student placements. DESIGN: Scoping review. DATA SOURCES: MEDLINE, CINAHL, Embase, ProQuest, Informit, Scopus, ERIC and several grey literature data sources (1 January 2005 to 13 October 2020). STUDY SELECTION: The review included peer-reviewed and grey literature from Organisation for Economic Co-operation and Development listed countries that focused on quality of health student placements in regional, rural and remote areas. DATA EXTRACTION: Data were extracted regarding the methodological and design characteristics of each data source, and the features suggested to contribute to student placement quality under five categories based on a work-integrated learning framework. RESULTS: Of 2866 resulting papers, 101 were included for data charting and content analysis. The literature was dominated by medicine and nursing student placement research. No literature explicitly defined quality in rural health student placements, although proxy indicators for quality such as satisfaction, positive experiences, overall effectiveness and perceived value were identified. Content analysis resulted in four overarching domains pertaining to features of rural health student placement quality: (1) learning and teaching in a rural context, (2) rural student placement characteristics, (3) key relationships and (4) required infrastructure. CONCLUSION: The findings suggest that quality in rural health student placements hinges on contextually specific features. Further research is required to explore these findings and ways in which these features can be measured during rural health student placements.

Characterizing the Health of Older Rural Australians Attending Rural Events: Implications for Future Health Promotion Opportunities.

This paper describes the health of older Australians (>65 years) attending rural events to inform health promotion interventions for rural populations. This cross-sectional study collected survey data and objective health measures between 2017 and 2020 at two events held in rural New South Wales, Australia. Participants included in the analysis were adults > 65 years of age. Data included demographic and health information, anthropometric measures (height, weight, waist circumference), and dietary and physical activity data. A total of 256 people > 65 years participated. Our sample, which was mostly male (59.0%), contained people aged between 66 and 75 years (72.3%). Participants lived in either a large rural (34.0%) or small rural town (22.3%), with low levels of education (60.9% did not complete high school). Dietary quality was rated as below average. All but 17.2% of the participants reported having a health condition. The risk of a health condition was associated with increasing age, lower education, and higher waist circumference, but not remoteness. Rural events may provide an opportunity to access, engage with, and understand the health of older rural Australians, especially males. They may offer ideal contexts for health and nutrition promotion opportunities in rural areas where access to health professionals is limited.

Rural healthcare delivery and maternal and infant outcomes for diabetes in pregnancy: A systematic review.

AIM: The aim of this systematic review was to examine the literature regarding rural healthcare delivery for women with any type of diabetes in pregnancy, and subsequent maternal and infant outcomes. METHODS: Eight databases were searched in September 2020, including Medline, EMCare, CINAHL, EMBASE, Maternity and Infant Care, Cochrane, Rural and Remote Health and Aboriginal and Torres Strait Islander Health bibliography. Studies from high-income countries in rural, regional or remote areas with interventions conducted during the antenatal period were included. Intervention details were reported using the template for intervention description and replication template. Two reviewers independently assessed for risk of bias using the RoB2 and ROBINS I tools. RESULTS: Three articles met the inclusion criteria: two conducted in Australia and one in the United States. A multidisciplinary approach was reported in two of the included studies, which were modified specifically for their respective rural settings. All three studies reported rates of caesarean section, birthweight (grams) and gestational age at birth as maternal and infant outcomes. One study was considered at moderate risk of bias, and two studies were at serious risk of bias. CONCLUSION: There is a significant gap in research relating to healthcare delivery for women with diabetes in pregnancy in rural areas. This lack of research is concerning given that 19% of individuals in high-income countries reside rurally. Further research is required to understand the implications of healthcare delivery models for diabetes in pregnancy in rural areas.

Current Nutrition Practice in Cardiac Rehabilitation Programs.

PURPOSE: This study sought to determine current practice regarding nutrition care within cardiac rehabilitation (CR) programs, including perceived barriers and facilitators to providing nutrition care in this setting. METHODS: A cross-sectional survey was conducted in October and November 2019. Potential participants were program coordinators, identified through the Australian Cardiovascular Health and Rehabilitation Association program directory and invited to participate via e-mail. RESULTS: Forty-nine respondents (response rate: 13%) are included in this analysis. Programs provided group (n = 42, 86%) and/or individual (n = 25, 51%) nutrition education, and most were supported by a dietitian (63%). However, the availability of dietitians and nutrition care provided at CR was variable. For example, individual education was consistently provided at 13 programs and usually by health professionals other than dietitians. Eight programs (16%) used a formal behavior change framework for nutrition care. Generally, respondents were positive about the role of nutrition; CR coordinators perceived nutrition as a valuable component of the program, and that they had good nutrition knowledge. An identified barrier was the financial resources available to support the provision of nutrition care. CONCLUSIONS: To ensure that patients receive the benefits of evidence-based nutrition care, program staff may require additional support, particularly regarding the use of evidence-based behavior change techniques. Key facilitators that may be leveraged to achieve this include the high value and priority that CR program coordinators place on nutrition care.

A Comparison of Diet Quality in a Sample of Rural and Urban Australian Adults.

The diet quality of rural Australians is under researched. Characterising disparities in diet quality between rural and urban populations may inform targeted interventions in at- risk groups. A cross-sectional study aimed to determine the relationship between diet quality, rurality and sociodemographic characteristics in a sample of Australian adults. Participants were recruited at rural and regional events between 2017 and 2020, in New South Wales, Australia. Diet quality was measured using the Healthy Eating Quiz or Australian Eating Survey to generate an Australian Recommended Food Score (ARFS). ARFS was compared by rurality and sociodemographic characteristics using multivariate regression. Participants (n = 247; 53% female) had a mean ± SD ARFS of 34.5 ± 9.0. There was no significant effect of rurality on ARFS (ß-coefficient = -0.4; 95%CI -3.0, 2.3). Compared to participants aged 18-30 years, higher ARFS was evident for those aged 31-50 (ß = 5.4; 95%CI 0.3, 10.4), 51-70 (ß = 4.4; 95%CI 0.3, 8.5) and >71 years (ß = 6.5; 95% CI 1.6-11.4). Compared to those living alone, participants living with a partner (ß = 5.2; 95%CI 2.0, 8.4) and families with children (ß = 5.6; 95%CI 1.4, 9.8) had significantly higher ARFS. ARFS was significantly lower with each additional self-reported chronic health condition (ß = -1.4; 95%CI -2.3, -0.4). Our results indicate that diet quality as defined by the ARFS was classified as 'getting there' and that age, living arrangements and chronic health conditions, but not rurality, influenced diet quality in a sample of Australian adults.

Starting from scratch: Developing and sustaining a rural research team lessons from a nutrition and dietetics case study.

OBJECTIVE: To describe the development of and key factors for sustaining a rural-based research team focussed on nutrition and dietetics. DESIGN: A longitudinal embedded case study approach with data sourced from publicly available records and observations. Case study sub-units were developed into 3 phases with analysis using theoretical propositions and pattern matching. Quantitative data were descriptively analysed. SETTING: University of Newcastle Department of Rural Health across 4 rural sites. PARTICIPANTS: Publicly available data sources from existing team members. MAIN OUTCOME MEASURES: Staffing levels, research supervision, internal and external grant outcomes and peer-reviewed journal publications. RESULT: Academic staffing has increased by 4 full-time equivalent positions over 18 years, with 6 current higher-degree research students. Key factors identified in the development of a discipline-specific research workforce included staff higher degree by research completions, longevity of staff in research-active roles, immersive rural placements with a research component and collaborations with nationally competitive researchers. Rural pilot research projects, community connections, understanding of the local context and research networks were fundamental to establishing a viable team. CONCLUSION: Systematically investing in research that is embedded in local communities will ensure sustainability and relevance, capacity building of existing staff and an ability to problem solve at the local level. Sustained and focussed investment is needed if the current rural research workforce is to develop towards a capacity that meets current demand.

The Effectiveness of Randomized Controlled Trials to Improve Dietary Intake in the Context of Cardiovascular Disease Prevention and Management in Rural Communities: A Systematic Review.

BACKGROUND: Dietary intake is an important modifiable risk factor for cardiovascular disease. However, to our knowledge, there are no systematic reviews of nutrition interventions in the context of cardiovascular disease prevention and management within rural communities. This is important to investigate, given the unique geographic, social, and contextual factors associated with rurality. OBJECTIVE: Our primary objective was to systematically assess evidence on the effectiveness of randomized controlled trials to improve dietary intake in the context of cardiovascular disease prevention and management in rural communities. METHODS: Nine electronic databases were searched from inception to June 2020, including MEDLINE, The Cochrane Library, Embase, Emcare, PsycINFO, Scopus, Rural and Remote Health, CINAHL, and AMED. Randomized controlled trials that reported results of interventions with adult, rural populations and measured change in dietary intake compared to usual care, alternative intervention, or no intervention controls were included. Included randomized controlled trials were also assessed according to the TIDieR (Template for Intervention Description and Reporting) checklist and RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. RESULTS: Thirteen articles reporting results of randomized controlled trials were identified. Included articles reported a range of nutrition interventions and measured 18 dietary intake outcomes. Most studies (n = 10) demonstrated effectiveness in altering at least 1 dietary intake outcome, including fruit and/or vegetable (n = 9), fiber (n = 2), Dietary Risk Assessment score (n = 2), energy, dairy, carotene, vitamin C and sodium (all n = 1). However, there was wide variation in the reporting of intervention components (according to the TIDieR checklist) and impact (according to RE-AIM framework), resulting in difficulty interpreting the "real-world" implications of these results. CONCLUSIONS: Through this systematic review, we found limited evidence of improvement in dietary intakes due to nutrition interventions in the context of cardiovascular disease prevention and management in rural communities. Fruit and/or vegetable intakes were the most frequently reported dietary intake outcomes, and most likely to be improved across the included studies. Included studies were generally not well reported, which may hinder replication by clinicians and consolidation of the evidence base by other researchers. Given the substantial burden of cardiovascular disease experienced by those living in rural areas of developed countries, additional high-quality nutrition research that acknowledges the complexities of rural health is required.