Patient and Partner Perspectives of Pregnancy-Related Counseling and Information Needs in Women With Kidney Disease: An Australian National Survey.

Introduction: The experiences and information needs for reproductive health counseling in women with chronic kidney disease (CKD) are poorly defined, despite the known importance of pregnancy planning in this higher-risk cohort. Methods: Australian adult women with CKD and their partners or family members completed a consumer codesigned survey about experiences of and preferences for pregnancy-related counseling, support, and education. Data were analyzed descriptively and with qualitative content analysis of free-text responses. Results: Responses were received from 102 women (CKD, n = 60; dialysis, n = 11; transplant, n = 26; unsure, n = 5 ) and 17 partners/family members. Pregnancy-related discussions were initiated mostly by women themselves (60.0%) compared to nephrologists (26.7%), and only after conception in 14.7%. Women found pregnancy-related discussions satisfactory (68.0%) and useful (50.7%) but also stressful (66.7%), with only 54.7% feeling in control of decision-making. Information deficits and quality, preformed decisions, clinician-patient disconnect, and burden of decision-making contributed to usefulness and outcomes of pregnancy-related counseling. Women received insufficient information about contraception (not provided in 35.2% of cases), medication safety (40.9%), fetal complications (33.8%) and emotional and psychological impact of pregnancy (73.2%). Women preferred counseling from nephrologists (86.4%), face-to-face settings (79.6%), websites (72.7%), handouts (61.4%), and online support groups (46.6%). High-quality, multiformat information by content experts, peer support, and psychological support were also strongly desired. Conclusion: This study highlights that preconception counseling and information needs of women with CKD are currently not being met. Frameworks and tools to assist patients and clinicians, particularly nephrologists, to initiate and conduct sensitive, useful, and informed shared decision-making (SDM) about pregnancy are urgently needed.

Clinical yarning education: development and pilot evaluation of an education program to improve clinical communication in Aboriginal health care - participant, and health manager perspectives.

BACKGROUND: Effective communication between health care clinicians and Aboriginal patients is critical to delivering high quality, accessible, culturally secure health care. Despite this, ineffective communication is a well-documented barrier, and few studies have reported interventions to improve communication. Clinical Yarning is a patient centred communication framework for Aboriginal health care. Building on this framework, this study reports the development and evaluation of a Clinical Yarning education program. METHODS: A Clinical Yarning education program was developed, underpinned by the principles of cultural security and adult learning, informed by a behavioural skills approach. The program was delivered in five health/education settings in one rural Western Australian region. Mixed-methods evaluation included a retrospective pre/post questionnaire to ascertain changes in participants' knowledge, confidence, competence and their perceptions about communication in Aboriginal health care, and the program. Qualitative semi-structured interviews were undertaken with health service managers who oversaw each health care setting and who had not participated in the education program, to explore perceptions about the program and implementation considerations. RESULTS: Twenty-eight health care clinicians and six students completed training and the evaluation survey. There were significant improvements in self-rated communication skills, ability, confidence, knowledge, and perceived importance of communication training from pre to post-program. Participants strongly recommended the program to others, and most commonly valued the simulation/interactive learning activities. Health service managers acknowledged the limitations in most existing cultural training, and felt Clinical Yarning addressed a need; both the concept of Clinical Yarning and the education program provided were valued. Considerations identified for future implementation included: building multilevel partnerships within health services, offering alternate training options such as eLearning or train-the-trainer approaches, and integrating into existing development programs. Workforce transiency and availability were a barrier, particularly in remote areas. CONCLUSIONS: This study offers preliminary support for the Clinical Yarning education program and provides a foundation for further development of this training approach. A future priority is implementation research to investigate the impact of the Clinical Yarning education program on health care and patient outcomes.

Understanding the Impact and Tackling the Burden of Osteoarthritis for Aboriginal and Torres Strait Islander People.

OBJECTIVE: The aim of this study was to understand and describe the lived experience of Aboriginal and Torres Strait Islander people with osteoarthritis. METHODS: Qualitative study guided by cultural security, which ensures that research is conducted in a way that will not compromise the cultural values, beliefs, and expectations of Aboriginal and Torres Strait Islander people. Participants were purposively sampled through the networks of project staff. Research yarns (a cultural form of conversation used as a data gathering tool) were conducted with 25 Aboriginal and Torres Strait Islander adults with self-reported osteoarthritis in Western Australia and Victoria, Australia. Data were analyzed using a framework approach and presented through composite storytelling (hypothetical stories representing an amalgam of participants' experiences). RESULTS: Two composite stories were constructed to reflect themes relating to beliefs and knowledge, impact, coping, and health care experiences. Common beliefs held by participants were that osteoarthritis is caused by previous physically active lifestyles. Many participants feared for their future, increasing disability and needing a wheelchair. Pain associated with osteoarthritis impacted daily activities, sleep, work, family, and social life and cultural activities. Multidimensional impacts were often experienced within complex health or life circumstances and associated with increased anxiety and depression. Most participants reported negative health care experiences, characterized by poor patient-provider communication. CONCLUSION: Our findings highlight that osteoarthritis is a multidimensional issue for Aboriginal and Torres Strait Islander people that permeates all aspects of life and highlights the need for integrated, multidisciplinary care that is culturally informed and individualized to patient need.

Insulin-like Growth Factor Binding Protein 3 Increases Mouse Preimplantation Embryo Cleavage Rate by Activation of IGF1R and EGFR Independent of IGF1 Signalling.

The viability of embryos cultured in vitro is poor compared to those that develop in vivo. The lack of maternally derived growth factors in vitro may contribute to this problem. Insulin-like growth factor binding protein 3 (IGFBP3) is one such growth factor that has been identified in the maternal reproductive system. This study examined the role of autocrine and exogenous IGFBP3 in mouse preimplantation embryos. Embryos expressed IGFBP3 across all stages of preimplantation development, and addition of exogenous IGFBP3 to embryo culture media increased the rate of development to the 2-, 4-, 5-, and 8-cell stages. Addition of inhibitors of the IGF1 and EGF receptors prevented this IGFBP3-mediated improvement in developmental rate, but the effect was not cumulative, indicating that both receptors are transactivated downstream of IGFBP3 as part of the same signalling pathway. Acute exposure to IGFBP3 increased phosphorylation of Akt and rps6 in 4-8 cell embryos, suggesting activation of the PI3-kinase/Akt pathway downstream of the IGF1 and EGFR receptors to promote cell proliferation and survival. In conclusion, addition of IGFBP3 to embryo culture media increases early cleavage rates independent of IGF1 signalling and therefore, IGFBP3 addition to IVF culture media should be considered.

Using the Healthy Community Assessment Tool: Applicability and Adaptation in the Midwest of Western Australia.

Population-based studies have associated poor living conditions with the persistent disparity in the health of Aboriginal and non-Aboriginal Australians. This project assesses the applicability of the Health Community Assessment Tool and its role in improving the environment of a small community in the Midwest of Western Australia (WA). The action research cycles started with the initial reflection on the suitability of the HCAT version 2 for the local community context and whether it was fit-for-purpose. The researcher provided 'critical companionship', while the participants of the study were invited to be co-researchers (the Assessors) who critically examined the HCAT and assess the community. The relevant domains to the serviced town (an outer regional community) were pest control and animal management; healthy housing; food supply; community vibrancy, pride and safety; reducing environmental tobacco smoke; and promoting physical activity. The Assessors found the HCAT descriptors mostly aligned with their community context but found some of the items difficult to apply. Based on participant's suggestions, some of the original scoring scales were reformatted. School attendance and illicit drug use were identified as a key outcome indicator for youth but were missing from the HCAT. The HCAT domains applied helped streamlining core business of agencies in the local community. The face validity of HCAT items were confirmed in this research with minor adjustments to reflect local context. Youth engagement to education is of high community concern and the development of an item would create similar interagency collaborative dialogues.

Unmet Needs of Aboriginal Australians With Musculoskeletal Pain: A Mixed-Method Systematic Review.

OBJECTIVE: Musculoskeletal pain (MSP) conditions are the biggest cause of disability, and internationally, indigenous peoples experience a higher burden. There are conflicting reports about Aboriginal Australians and MSP. We conducted a systematic review to describe the prevalence, associated factors, impacts, care access, health care experiences, and factors associated with MSP among Aboriginal Australians. METHODS: We used a systematic search of quantitative and qualitative scientific and grey literature (PROSPERO# CRD42016038342). Articles were appraised using the Mixed Methods Appraisal Tool. Due to study heterogeneity, a narrative synthesis was conducted. RESULTS: Of 536 articles identified, 18 were included (14 quantitative, 4 qualitative), of high (n = 11), medium (n = 2), and low (n = 5) quality. Prevalence of MSP in Aboriginal populations was similar to or slightly higher than the non-Aboriginal population (prevalence rate ratio 1.1 for back pain, 1.2-1.5 for osteoarthritis [OA], and 1.0-2.0 for rheumatoid arthritis). Aboriginal people accessed primary care for knee or hip OA at approximately half the rate of non-Aboriginal people, and were less than half as likely to have knee or hip replacement surgery. Communication difficulties with health practitioners were the main reason why Aboriginal people with MSP choose not to access care. No articles reported interventions. CONCLUSION: Findings provide preliminary evidence of an increased MSP burden among Aboriginal Australians, and particularly for OA, a mismatch between the disease burden and access to health care. To increase accessibility, health services should initially focus on improving Aboriginal patients' experiences of care, in particular by improving patient-practitioner communication. Implications for care and research are outlined.

Addressing Disparities in Low Back Pain Care by Developing Culturally Appropriate Information for Aboriginal Australians: "My Back on Track, My Future".

OBJECTIVES: Addressing disparities in low back pain care (LBP) is an important yet largely unaddressed issue. One avenue to addressing disparities, recommended by clinical guidelines, is to ensure that LBP information is culturally appropriate. Our objectives were, first, to develop LBP information that was culturally appropriate for Aboriginal Australians living in a rural area and, second, to compare this to traditional information. METHODS: The overall information development process was guided by a "cultural security" framework and included partnerships between Aboriginal/non-Aboriginal investigators, a synthesis of research evidence, and participation of a project steering group consisting of local Aboriginal people. LBP information (entitled My Back on Track, My Future [MBOT]) was developed as five short audio-visual scenarios, filmed using Aboriginal community actors. A qualitative randomized crossover design compared MBOT with an evidence-based standard (the Back Book [BB]). Twenty Aboriginal adults participated. Qualitatively we ascertained which information participants' preferred and why, perceptions about each resource, and LBP management. RESULTS: Thirteen participants preferred MBOT, four the BB, two both, and one neither. Participants valued seeing "Aboriginal faces," language that was understandable, the visual format, and seeing Aboriginal people undertaking positive changes in MBOT. In contrast, many participants found the language and format of the BB a barrier. Participants who preferred the BB were more comfortable with written information and appreciated the detailed content. CONCLUSIONS: The MBOT information was more preferred and addressed important barriers to care, providing support for use in practice. Similar processes are needed to develop pain information for other cultural groups, particularly those underserved by existing approaches to care.

Improving access to primary care for Aboriginal babies in Western Australia: study protocol for a randomized controlled trial.

BACKGROUND: Despite a decade of substantial investments in programs to improve access to primary care for Aboriginal mothers and infants, more than 50% of Western Australian Aboriginal babies are still not receiving primary and preventative care in the early months of life. Western Australian hospitals now input birth data into the Western Australian electronic clinical management system within 48 hours of birth. However, difficulties have arisen in ensuring that the appropriate primary care providers receive birth notification and clinical information by the time babies are discharged from the hospital. No consistent process exists to ensure that choices about primary care are discussed with Aboriginal families. METHODS/DESIGN: We will undertake a population-based, stepped wedge, cluster randomized controlled trial of an enhanced model of early infant primary care. The intervention is targeted support and care coordination for Aboriginal families with new babies starting as soon as possible during the antenatal period or after birth. Dedicated health professionals and research staff will consult with families about the families' healthcare needs, provide information about healthcare in the first 3 months of life, offer assistance with birth and Medicare forms, consult with families about their choice for primary care provider, offer to notify the chosen primary care provider about the baby's health needs, and offer assistance with healthcare coordination at the time of discharge from the hospital. We will evaluate this model of care using a rigorous stepped wedge approach. Our primary outcome measure is a reduced hospitalization rate in infants younger than 3 months of age. Secondary outcome measures include completed Aboriginal and Torres Strait Islander child health screening assessments, immunization coverage, and satisfaction of the families about early infant primary care. We will also assess the cost effectiveness of the model of care. DISCUSSION: This study will be conducted over a 4-year period in partnership with birthing hospitals and primary care providers including Western Australian Aboriginal Community Controlled Health Services and the new Primary Health Networks. The results of our trial will be used to develop improved primary care models and to improve health outcomes for all Aboriginal infants. These are vital steps toward more equitable health service delivery for the Aboriginal and Torres Strait Islander children in Australia. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Registration number: ACTRN12615000976583 Date registered: 17 September 2015.

'Yarn with me': applying clinical yarning to improve clinician-patient communication in Aboriginal health care.

Although successful communication is at the heart of the clinical consultation, communication between Aboriginal patients and practitioners such as doctors, nurses and allied health professionals, continues to be problematic and is arguably the biggest barrier to the delivery of successful health care to Aboriginal people. This paper presents an overarching framework for practitioners to help them reorientate their communication with Aboriginal patients using 'clinical yarning'. Clinical yarning is a patient-centred approach that marries Aboriginal cultural communication preferences with biomedical understandings of health and disease. Clinical yarning consists of three interrelated areas: the social yarn, in which the practitioner aims to find common ground and develop the interpersonal relationship; the diagnostic yarn, in which the practitioner facilitates the patient's health story while interpreting it through a biomedical or scientific lens; and the management yarn, that employs stories and metaphors as tools for patients to help them understand a health issue so a collaborative management approach can be adopted. There is cultural and research evidence that supports this approach. Clinical yarning has the potential to improve outcomes for patients and practitioners.

Insulin-like growth factor 1 increases apical fibronectin in blastocysts to increase blastocyst attachment to endometrial epithelial cells in vitro.

STUDY QUESTION: Does insulin-like growth factor 1 (IGF1) increase adhesion competency of blastocysts to increase attachment to uterine epithelial cells in vitro? SUMMARY ANSWER: IGF1 increases apical fibronectin on blastocysts to increase attachment and invasion in an in vitro model of implantation. WHAT IS KNOWN ALREADY: Fibronectin integrin interactions are important in attachment of blastocysts to uterine epithelial cells at implantation. STUDY DESIGN, SIZE, DURATION: Mouse blastocysts (hatched or near completion of hatching) were cultured in serum starved (SS) medium with varying treatments for 24, 48 or 72 h. Treatments included 10 ng/ml IGF1 in the presence or absence of the PI3 kinase inhibitor LY294002, an IGF1 receptor (IGF1R) neutralizing antibody or fibronectin. Effects of treatments on blastocysts were measured by attachment of blastocysts to Ishikawa cells, blastocyst outgrowth and fibronectin and focal adhesion kinase (FAK) localization and expression. Blastocysts were randomly allocated into control and treatment groups and experiments were repeated a minimum of three times with varying numbers of blastocysts used in each experiment. FAK and integrin protein expression on Ishikawa cells was quantified in the presence or absence of IGF1. PARTICIPANTS/MATERIALS, SETTING, METHODS: Fibronectin expression and localization in blastocysts was studied using immunofluorescence and confocal microscopy. Global surface expression of integrin αvß3, ß3 and ß1 was measured in Ishikawa cells using flow cytometry. Expression levels of phosphorylated FAK and total FAK were measured in Ishikawa cells and blastocysts by western blot and image J analysis. Blastocyst outgrowth was quantified using image J analysis. MAIN RESULTS AND THE ROLE OF CHANCE: The presence of IGF1 significantly increased mouse blastocyst attachment to Ishikawa cells compared with SS conditions (P < 0.01). IGF1 treatment resulted in distinct apical fibronectin staining on blastocysts, which was reduced by the PI3 kinase inhibitor LY294002. This coincided with a significant increase in blastocyst outgrowth in the presence of IGF1 (P < 0.01) or fibronectin (P < 0.001), which was abolished by LY294002 (P < 0.001). Apical expression of integrin αvß3, ß3 and ß1 in Ishikawa cells was unaltered by IGF1. However, IGF1 increased phosphorylated FAK (P < 0.05) and total FAK expression in Ishikawa cells. FAK signalling is linked to integrin activation and can affect the integrins' ability to bind and recognize extracellular matrix proteins such as fibronectin. Treatment of blastocysts with IGF1 before co-culture with Ishikawa cells increased their attachment (P < 0.05). This effect was abolished in the presence of LY294002 (P < 0.001) or an IGF1R neutralizing antibody (P < 0.05). LIMITATIONS, REASONS FOR CAUTION: This study uses an in vitro model of attachment that uses mouse blastocysts and human endometrial cells. This involves a species crossover and although this use has been well documented as a model for attachment (as human embryo numbers are limited) the results should be interpreted carefully. WIDER IMPLICATIONS OF THE FINDINGS: This study presents mechanisms by which IGF1 improves attachment of blastocysts to Ishikawa cells and documents for the first time how IGF1 can increase adhesion competency in blastocysts. Failure of the blastocyst to implant is the major cause of human assisted reproductive technology (ART) failure. As growth factors are absent during embryo culture, their addition to embryo culture medium is a potential avenue to improve IVF success. In particular, IGF1 could prove to be a potential treatment for blastocysts before transfer to the uterus in an ART setting.

Exploring Australian Aboriginal women's experiences of menopause: a descriptive study.

BACKGROUND: Despite extensive literature demonstrating differing experiences in menopause around the world, documentation of the experience of menopause in Australian Aboriginal women is scarce, and thus their menopausal experience is relatively unknown. This study aimed to understand Australian Aboriginal women's understanding and experience of menopause and its impact on their lives. METHODS: The study was an exploratory qualitative study. Twenty-five Aboriginal women were recruited from a regional centre in the Mid-West region of Western Australia using opportunistic and snowballing sampling. Interviews and focus group discussions were undertaken from February 2011 to February 2012 using open-ended questioning with a yarning technique. Thematic analysis was undertaken of the transcribed interviews. RESULTS: A number of themes were revealed. These related to the language used, meanings and attitudes to menopause, symptoms experienced, the role of men, a lack of understanding, coping mechanisms and the attribution of menopausal changes to something else. The term "change of life" was more widely recognised and signified the process of ageing, and an associated gain of respect in the local community. A fear of menopausal symptoms or uncertainty about their origin was also common. Overall, many women reported insufficient understanding and a lack of available information to assist them and their family to understand the transition. CONCLUSION: There are similarities between Aboriginal and non-Aboriginal experiences of menopause, including similar symptom profiles. The current language used within mainstream health settings may not be appropriate to this population if it fails to recognise the importance of language and reflect the attributed meaning of menopause. The fear of symptoms and uncertainty of their relationship to menopause demonstrated a need for more information which has not adequately been supplied to Australian Aboriginal women through current services. While this study is with a select population of Aboriginal Australian women, it reveals the importance of acknowledging differences, particularly in use of language to convey ideas and support Aboriginal women experiencing menopause.

'I could never have learned this in a lecture': transformative learning in rural health education.

Health indicators for rural populations in Australia continue to lag behind those of urban populations and particularly for Indigenous populations who make up a large proportion of people living in rural and remote Australia. Preparation of health practitioners who are adequately prepared to face the 'messy swamps' of rural health practice is a growing challenge. This paper examines the process of learning among health science students from several health disciplines from five Western Australian universities during 'Country Week': a one-week intensive experiential interprofessional education program in rural Western Australia. The paper weaves together strands of transformative theory of learning with findings from staff and student reflections from Country Week to explore how facilitated learning in situ can work to produce practitioners better prepared for rural health practice.

Insulin-like growth factor 1 acts as an autocrine factor to improve early embryogenesis in vitro.

Consideration of embryo-derived growth factors, such as IGF1, is important when culturing an embryo in an in vitro fertilization (IVF) setting, or when studying the effect of growth factors on embryo development in vitro. Addition of IGF1 to the culture medium has been reported to cause a range of developmental responses in preimplantation mouse embryos. This variability may be due to culture of embryos in suboptimal culture media and at different culture densities/volumes. This study examined the role of exogenous and autocrine IGF1 on mouse preimplantation development in vitro, by treatment of embryos with an IGF1R neutralising antibody (IGF1R nAb) under low density (1 embryo/100 microl) or high density (1 embryo/1 microl) culture conditions. At low density, IGF1R nAb reduced development to the blastocyst stage, hatching, and total cell numbers in blastocysts and increased the number of apoptotic cells in blastocysts, suggesting that autocrine IGF1 signalling is occurring, even at low density. This signalling is independent of IGF1 present in the zona pellucida, since culturing embryos in the absence of their zona pellucida had no effect on blastocyst development. Addition of 10 ng/ml IGF1 increased blastocyst development at low density, but decreased hatching at high density. Similarly, high levels of exogenous IGF1 at low density decreased hatching. IGF1 appears to play a role in cell survival and treatment of blastocysts with IGF1 increased Akt phosphorylation. The IGF1R antagonist picropodophyllin was also used in this study, but was found to have non-specific effects on the mitotic spindle. In conclusion, IGF1 is an important growth factor for the improvement of preimplantation development; however, for optimal development the total amount of IGF1 present must be tightly controlled.