Proximal and distal influences on dietary change among a diverse group with prediabetes participating in a pragmatic, primary care nurse-led intervention: a qualitative study.

OBJECTIVE: To understand motivators, facilitators and challenges to dietary change amongst a diverse sample of New Zealanders with prediabetes participating in a primary care nurse-led individualised dietary intervention. DESIGN: A qualitative study involving semi-structured, face-to-face interviews with a stratified sample of adults with prediabetes and BMI ≥ 25 kg/m2, purposefully selected from a larger 2-year primary care-based prediabetes dietary intervention study. Thematic analysis was undertaken. A socio-ecological model guided interpretation. SETTING: Hawke's Bay, Aotearoa/New Zealand, April 2018-March 2020. PARTICIPANTS: Fifty-eight people aged 28-69 years, with similar numbers of men and women, indigenous Maori and non-Maori, and those who had and had not regressed to normoglycaemia at 6 months. RESULTS: Motivators for wanting to make dietary changes were determination not to progress to diabetes; wanting to be healthy and contribute to others and encouragement by others. Facilitators for adopting and maintaining changes were a strong desire to be healthy; personal determination and feeling supported. Challenges were compromised control over life and environmental factors; feeling unsupported by others; social occasions; financial constraints and living with other health conditions. Developing their own strategies to overcome challenges was empowering, enabling a sense of control. These factors were similar across demographic and glycaemic outcome groups. CONCLUSIONS: Influences on dietary change involved personal, interpersonal, organisational, environmental and policy factors. Although findings appeared similar across groups, dietary interventions need to address the specific ways motivators, facilitators and challenges manifest for individuals and social groups and be tailored accordingly within the context of the wider obesogenic and socio-economic environment.

Understanding the experiences, perspectives and values of indigenous women around smoking cessation in pregnancy: systematic review and thematic synthesis of qualitative studies.

BACKGROUND: The prevalence of smoking during pregnancy among indigenous women approaches 50% and is associated with sudden infant death, pregnancy loss, preterm delivery, low birth weight, and anatomical deformity. This study aims to synthesise qualitative studies by reporting experiences, perceptions, and values of smoking cessation among pregnant indigenous women to inform potential interventions. METHOD: A highly-sensitive search of MEDLINE, Embase, PsychINFO, and CINAHL, in conjunction with analysis of Google Scholar and reference lists of related studies was conducted in March 2018. We utilised two methods (thematic synthesis and an indigenous Maori analytical framework) in parallel to analyse data. Completeness of reporting in studies was evaluated using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) framework. RESULTS: We included seven studies from Australia and New Zealand involving 250 indigenous women. Three themes were identified. Realising well-being and creating agency included giving the best start to baby, pride in being a healthy mum, female role models, and family support. Understanding the drivers for smoking included the impact of stress and chaos that hindered prioritisation of self-care, the social acceptability of smoking, guilt and feeling judged, and inadequate information about the risks of smoking. Indigenous women strongly preferred culturally responsive approaches to smoking cessation, placing value on programs designed specifically for and by indigenous people, that were accessible, and provided an alternative to smoking. CONCLUSION: Future interventions and smoking cessation programmes might be more effective and acceptable to indigenous women and families when they harness self-agency and the desire for a healthy baby, recognise the high value of indigenous peer involvement, and embed a social focus in place of smoking as a way to maintain community support and relationships. Development and evaluation of smoking cessation programs for pregnant indigenous women and families is warranted.

Experiences, perspectives and values of Indigenous peoples regarding kidney transplantation: systematic review and thematic synthesis of qualitative studies.

BACKGROUND: Kidney transplantation is considered best practice treatment for end stage kidney disease (ESKD), however Indigenous patients are substantially less likely to receive either a deceased or live donor kidney transplant than non-Indigenous patients. We describe Indigenous peoples' experiences and perspectives including traditional values around kidney transplantation to inform international transplant programs. METHODS: We conducted a systematic review of qualitative studies involving Indigenous adults who have experience with or perceptions of kidney transplantation. We searched MEDLINE, Embase, PsychINFO, and CINAHL, in conjunction with analysis of Google Scholar and reference lists of related studies till July 2019. We utilised thematic synthesis to analyse data. Completeness of reporting in studies was evaluated using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) framework. RESULTS: Eight studies involving 225 Indigenous participants were included. Five themes were identified: strong desire for transplantation (seeking normality and freedom from dialysis, wanting to reduce burden of disease within community); lack of partnership in shared decision-making (receiving inadequate information, ineffective communication); barriers to live kidney donation (difficulty asking, apprehension about impact on donor, avoiding additional financial burden and fear of complications); cultural considerations (influence of traditional values and beliefs, reconciling traditional values with pragmatic need); and experiencing lack of cultural competence in clinical care (struggling with prejudice and ignorance, mistrust of clinicians and health system). CONCLUSION: Indigenous participants had a strong desire for a kidney transplant and recognised the need for more readily available kidney transplants for others in their communities with ESKD. However, they faced prejudice and a lack of cultural competence by health workers as well as wider barriers to transplantation in systems that did not support effective and culturally appropriate delivery of information and care. Traditional cultural values also influenced decisions regarding kidney transplantation but such values were moderated when considering transplantation. Transplantation programs need to identify and mitigate barriers, such as the financial burden, promote cultural safety and incorporate traditional values into the promotion of transplantation in order to address inequitable transplantation rates. REGISTRATION: Not applicable.

Transcendent professionalism: keeping promises and living the questions.

Wynia and colleagues propose a definition of professionalism as a belief system by which to shape health care rather than a list of values and behaviors. The belief that professionalism is the best way to organize and deliver health care constitutes a promise to society. The notion that the medical profession as a whole as well as its individual members should be held accountable to standards of competence, ethical values, and interpersonal attributes developed, declared, and enforced by the profession itself is also a promise to society. The author argues that good promises offer a stabilizing influence over the inherent uncertainty in human relationships and may provide the ground for a lasting trustworthy relationship between the medical profession and society; however, the professionalism belief system itself is vulnerable if the promise is breached. The modern world has challenged the professionalism model of organizing health care, and individual practitioners as well as their professional organizations are seeking clarity about what professionalism means given current realities. This commentary reflects on these circumstances and provides some recommendations for developing a construct of professionalism.

Ngati and healthy: translating diabetes prevention evidence into community action.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) is a major health issue in New Zealand Maori. Clinical trials have demonstrated potential for the prevention of T2DM, but whether community public health programmes aiming to prevent diabetes are effective is untested. OBJECTIVE: To describe the planning and design of an intervention aiming to translate T2DM prevention clinical trial evidence into a community-wide population health intervention in a high risk predominantly Maori community. APPROACH: Community concerns about the diabetes burden were heard by the local diabetes nurse, herself a tribal member, and discussed with a locally raised academic. Project planning ensued. The intervention and its evaluation were designed using a participatory community development model. The planned intervention had three components: community-wide health promotion initiatives conveying healthy lifestyle messages, community education and monitoring for identified high-risk individuals and their extended families, and a structural strategy aimed at adapting local environments to support lifestyle changes. The evaluation plan involved interrupted time series surveys coupled with formative and process evaluations rather than a randomised control trial design. DISCUSSION: Consulting communities, validating community concerns and prioritising cultural and ethical issues were key steps. Time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team were united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of our ethically and culturally appropriate non-randomised control trial evaluation design. The pre-intervention survey demonstrated high rates of diabetes (13%), insulin resistance (33%) and risk factors, and provided evidence for positive, as opposed to negative, lifestyle intervention messages. CONCLUSION: Community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, but require a high level of commitment from the health sector and buy-in from the community. Adequate commitment, leadership, planning and resources are essential.

Sudden unexpected infant death in Auckland: a retrospective case review.

AIM: To review autopsy reports of all SUDI deaths in the Auckland region, New Zealand, from October 2000 to December 2009. METHODS: Information on all SUDI cases from 2000 to 2009 was extracted from autopsy and police reports from the National Forensic Pathology Service at Auckland Hospital. RESULTS: Of the 332 post-mortems in this period, 221 were classified as SUDI. Of these, 83% were Maori or Pacific infants. The median age at death was 11 weeks and 11% occurred in 7- to 28-day-olds. At the time of death, 64% overall were bedsharing; this was more common in 7-28 day olds (92%). Bedsharing infants were significantly younger at death than non-bedsharing infants (p=0.008). Where sleep position was known, 57% were placed in non-supine at the last sleep. There was no evidence of diagnostic shift and the prevalence of bedsharing did not change over the decade. CONCLUSIONS: Bedsharing was associated with a high proportion of SUDI cases, especially in the youngest infants, and non-supine sleep positions were common. There is a need to enhance SUDI prevention messages and consider innovative ways of promoting safe sleeping environment and supine sleep position in Maori and Pacific communities.

Institutional attributes associated with innovation and improvement: results of a multisite study.

BACKGROUND: To date, no studies have explored why some teaching hospitals and health systems appear to offer a more fertile environment for innovation and improvement in the learning environment. As a consequence, little is known about the role of organizational attributes and culture in fostering innovation and improvements in settings where residents learn and participate in care, though these have been studied extensively in the general literature on organizations. AIMS: The goals of our study entailed (1) gathering ground-level observations on processes and common attributes; (2) disseminating this information for adoption and adaptation; and (3) exploring whether the current accreditation model may present barriers to institution- and program-level innovation. METHODS: We conducted a qualitative study of 4 institutions, successful in innovation and improvement in their learning environment, and sought to replicate the findings with a second group of 5 institutions. RESULTS: THREE THEMES EMERGED FROM THE INTERVIEWS AND SITE VISITS OF THE PARTICIPANTS IN THE ALPHA PHASE: (1) a structure and culture that promote integration and inclusion; (2) a recognition of the value of resident education to the institution; and (3) a learning organization rooted in the extensive use of data and ongoing change, improvement, and innovation. CONCLUSIONS: Some of the concepts identified in our small sample of "innovative" institutions could be relatively easily adopted or adapted by others that seek to enhance innovation and improvement in the learning environment. In contrast, the structural factors that characterized 3 of the 4 alpha participants, particularly the organization and compensation of faculty, may not be generalizable to many other institutions.

Two-year results from a community-wide diabetes prevention intervention in a high risk indigenous community: the Ngati and Healthy project.

We describe changes in markers and prevalence of glucose metabolism disorders following a 2-year community-wide intervention aimed at reducing insulin resistance (IR) prevalence in a high risk community. Surveys were undertaken before and 2 years after implementation of a community developed and led diabetes prevention program. Proportions and means were calculated and compared by sex and age groups: 25-49 years and 50+ years. A process evaluation contributed to interpretation of results. Response rates were around 50% and demographic characteristics similar in both surveys. Overall, IR prevalence decreased markedly from 35.5% to 25.4% (p=0.003). Most changes were observed amongst 25-49 years old women for whom there was a significant change in prevalences of IR and glucose metabolism disorders (p=0.015), largely due to reduced IR prevalence (38.2-25.6%). In 2006, 60.3% achieved minimum recommended exercise levels and 65.4% ate wholegrain bread compared with 45.1% (p=0.002) and 42.2% (p=0.044), respectively, in 2003. Participation in a community diabetes prevention intervention appeared to reduce IR prevalence after 2 years in those with the highest level of participation and most marked lifestyle changes.

Perspectives on continuing education in the health professions: improving health care through lifelong learning.

In November 2007, the Josiah Macy, Jr. Foundation convened a conference to address a number of complex issues concerning continuing education (CE) in the health professions. Participants concluded that CE, as currently practiced, does not focus adequately on improving clinician performance and patient care, is too dependent on lectures and too removed from the daily practice of clinicians, does not encourage or emphasize newer technologies and point-of-care learning, is poorly integrated across disciplines, and is inappropriately financed. Recommendations concerning educational methods, metrics, responsibilities, research in CE, financing, and oversight are reviewed. The relationship between the goals of improving clinician performance and patient care, while maintaining high standards of accountability and transparency, are reviewed.

Competencies: from deconstruction to reconstruction and back again, lessons learned.

I address the potential impact of the Association of Schools of Public Health's development of a competency model for the graduate Master of Public Health. I reflect on the model in relation to the Accreditation Council for Graduate Medical Education's adoption of a competency-based model for medical education. Six lessons learned by the Accreditation Council for Graduate Medical Education that the Association of Schools of Public Health might consider in moving forward are how learning outcomes can be enhanced by using competency models, the effect of competency development processes in "creating a common language" among educators, the benefits and challenges of numerous competencies within a model, the usefulness of the Dreyfus model for progressive competency development, the need for multiple assessment tools used over time, and the value of learning portfolios.

Preparing the personal physician for practice (P(4)): redesigning family medicine residencies: new wine, new wineskins, learning, unlearning, and a journey to authenticity.

The family medicine community has come together in the Future of Family Medicine Project in an attempt to be clear about its work and values and to address the frustrations of both its own practitioners and the public. A new model has been proposed, offering several attractive features for both patients and practitioners. The project has generated momentum around the notion that it is really possible to redesign family medicine residency programs. This article reviews assumptions about the redesign and 10 interventions in 3 categories. The categories are both familiar and new, and knowledge, skills, and attitudes are reframed. The interventions include learning portfolios, a curriculum that goes beyond rotations, becoming explicit about locally useful knowledge, getting discretion and discipline right, linking evaluations to system improvement, attention to the science of clinical practice, simulation, validating resident feelings, educating to mastery, and attention to group and individual formation.

Patient safety curriculum for surgical residency programs: results of a national consensus conference.

BACKGROUND: The American College of Surgeons (ACS) and the Accreditation Council for Graduate Medical Education (ACGME) are committed to promoting patient safety through education. In view of the critical role of residents in the delivery of safe patient care, the ACS and ACGME sponsored jointly a national consensus conference to initiate the development of a curriculum on patient safety that may be used across all surgical residency programs. CONCLUSIONS: National leaders in surgery with expertise in surgical care and surgical education, patient safety experts, medical educators, key stakeholders from national organizations, and surgical residents were invited to participate in the conference. Attendees considered patient safety issues within the context of the 6 core competencies defined by the ACGME and American Board of Medical Specialties (ABMS). Discussions resulted in the development of a curriculum matrix that includes listings of patient safety topics, teaching and learning strategies, and assessment methods. Guidelines for implementation and dissemination are also provided. The curriculum content underscores the need to create an organizational culture of safety and focuses on both individuals and systems. Individual residency programs may prioritize the curriculum content based on their specific needs. The ACS and ACGME will pursue development of educational modules to address the curriculum content, disseminate helpful information, and assist in implementation of new educational interventions. This effort has the potential to positively impact residency education in surgery, help surgical program directors address the core competencies, and enhance patient safety.

Insulin resistance and impaired glucose metabolism in a predominantly Maori community.

We sought to identify lifestyle behaviours which influence risk of impaired glucose metabolism, IGM (newly diagnosed type 2 diabetes, impaired glucose tolerance [IGT] or impaired fasting glycemia [IFG]) or insulin resistance (IR) in a predominantly Maori community, and applied the McAuley formula to determine whether it predicts high risk individuals amongst this community. Three hundred and seventy one participants completed a lifestyle and dietary behaviour questionnaire and oral glucose tolerance test. Clinical variables, microalbuminuria, fasting glucose, insulin and lipids were measured. Diabetes, IFG and IGT were defined according to WHO criteria. IR was defined using the McAuley formula. Those with IGM and those with IR showed similar risk factor attributes. Odds ratios (95% CI) for development of IGM and IR were 0.43 (0.21-0.88) and 0.51 (0.33-0.80), respectively, for regular physical activity, and 0.55 (0.26-1.15) and 0.59 (0.37-0.96), respectively, for two or more dietary behaviours characterized by a high intake of fibre. Regular physical activity and a diet characterized by a high intake of dietary fibre were found to reduce risk of newly diagnosed IGM or IR. The McAuley formula appears to predict high-risk individuals in a predominantly Maori population as it does in European populations.

In search of coherence: a view from the Accreditation Council for Graduate Medical Education.

The Conjoint Committee on Continuing Medical Education has developed a position paper, a set of recommendations, and next steps in the reform of continuing medical education (CME). The Accreditation Council for Graduate Medical Education (ACGME) sets standards for and accredits residency programs in graduate medical education and is not directly involved with CME. This article offers a perspective about the Conjoint Committee's recommendations from the executive director of the ACGME. It is a personal rather than an organizational perspective. Each of the 7 recommendations of the Conjoint Committee offers some opportunity for the ACGME and identifies issues that confront medical educators and accreditors at earlier stages of the formation of physicians. The Conjoint Committee's report also exposes the painful reality that organized medicine is almost hopelessly fragmented at a time when it is important to work together. Earlier efforts to produce a more coherent system of professional oversight have failed, but several emerging realities now may make possible what was not before. These include a common language for the competencies needed to practice medicine, common metrics of competence, technologic advances in learning portfolios, conceptual advances about the use of data on physician competence, and an inexorable focus on improvement of patient care. The possibility of patient-centered rather than profession-centered oversight is emerging. The most profound consequence of the Conjoint Committee's work may be a new organizational model, based on readily available data, that enhances trust. If so, a radical transformation of the accreditation of medical education will follow.