Measuring treatment burden in people with Type 2 Diabetes Mellitus (T2DM): a mixed-methods systematic review.

BACKGROUND: Measuring treatment burden is important for the effective management of Type 2 Diabetes Mellitus (T2DM) care. The purpose of this systematic review was to identify the most robust approach for measuring treatment burden in people with T2DM based on existing evidence. METHODS: Articles from seven databases were retrieved. Qualitative, quantitative, and mixed-methods studies examining treatment burden in adults with T2DM and/or reporting relevant experiences were included. A convergent segregated approach with a mixed-methods design of systematic review was employed, creating a measurement framework in a narrative review for consistent critical appraisal. The quality of included studies was assessed using the Joanna Briggs Institute tool. The measurement properties of the instruments were evaluated using the Consensus based Standards for selection of Health Measurement Instruments (COSMIN) checklist. RESULTS: A total of 21,584 records were screened, and 26 articles were included, comprising 11 quantitative, 11 qualitative, and 4 mixed-methods studies. A thematic analysis of qualitative data extracted from the included articles summarised a measurement framework encompassing seven core and six associated measurements. The core measurements, including financial, medication, administrative, lifestyle, healthcare, time/travel, and medical information burdens, directly reflect the constructs pertinent to the treatment burden of T2DM. In contrast, the associated measurement themes do not directly reflect the burdens or are less substantiated by current evidence. The results of the COSMIN checklist evaluation demonstrated that the Patient Experience with Treatment and Self-management (PETS), Treatment Burden Questionnaire (TBQ), and Multimorbidity Treatment Burden Questionnaire (MTBQ) have robust instrument development processes. These three instruments, with the highest total counts combining the number of themes covered and "positive" ratings in COSMIN evaluation, were in the top tertile stratification, demonstrating superior applicability for measuring T2DM treatment burden. CONCLUSIONS: This systematic review provides evidence for the currently superior option of measuring treatment burden in people with T2DM. It also revealed that most current research was conducted in well-resourced institutions, potentially overlooking variability in under-resourced settings.

Exploring treatment burden in people with type 2 diabetes mellitus: a thematic analysis in china's primary care settings.

BACKGROUND: Understanding treatment burden is a critical element to the effective management of Type 2 Diabetes Mellitus (T2DM). The current study aims to address the knowledge gap surrounding treatment burden of T2DM from the patient's perspective in China's primary care settings. METHODS: A narrative review informed the creation of an a priori coding structure to identify aspects of T2DM treatment burden. Focus groups were conducted, employing a maximum variation sampling strategy to select participants from diverse sociodemographic backgrounds across urban, suburban, rural, and remote areas in China. Participants included adults with T2DM care in primary care settings for over a year and a Treatment Burden Questionnaire score of 25 or higher. Deductive thematic analysis, guided by the coding structure, facilitated a comprehensive exploration and further development of the conceptual framework of T2DM treatment burden. RESULTS: Four focus groups, each comprising five participants from diverse areas, were conducted. Utilising the Cumulative Complexity Model and Normalisation Process Theory as theoretical underpinnings, the thematic analysis refined the conceptual framework based on the coding structure from the narrative review. Five key themes were refined, encompassing medical information, medication, administration, healthcare system, and lifestyle. Additionally, the financial and time/travel themes merged into a new theme termed "personal resources", illustrating their overlapping within the framework. Participants in these focus groups highlighted challenges in managing medical information, an aspect often underrepresented in prior treatment burden research. The thematic analysis culminated in a finalised conceptual framework, offering a comprehensive understanding of the treatment burden experiences of people with T2DM in China's primary care settings. This framework includes six key constructs, delineating T2DM treatment burden and associated factors, such as antecedents and consequences. CONCLUSIONS: This study provides insights into the treatment burden of T2DM. A conceptual framework was finalised to deepen the understanding of the multifaceted constructs and the nature of treatment burden in people with T2DM. Furthermore, it emphasises the need to tailor T2DM treatment to individual capacities, considering their personal resource allocation and treatment utilisation.

What makes a space safe? Consumers' perspectives on a mental health safe space.

The provision of community-based space for people experiencing a mental health crisis is regarded as a favourable alternative to the emergency department. However, the only non-emergency department safe spaces in Western Australia are located within hospitals or hospital grounds. This qualitative study asked mental health consumers in Western Australia with experience of presentation at the emergency department during a mental health crisis to describe what a safe space would look and feel like. Data were collected through focus groups and thematically analysed. The findings present the voices of mental health consumers through the framework of health geography and the therapeutic landscape. These participants articulated important physical and social features of a therapeutic safe space and their symbolism as inclusive, accessible places where they would experience a sense of agency and belonging. Participants also expressed a need for trained peer support within the space to complement the skilled professional mental health team. Participants' experiences of the emergency department during mental health crises were described as contrary to their recovery needs. The research reinforces the need for an alternative to the emergency department for adults who experience mental health crises and provides consumer-led evidence to inform the design and development of a recovery-focused safe space.

Enabling social care services for older adults during periods of long-term social isolation: Service provider perspectives.

OBJECTIVE: To investigate how small, local organisations were impacted by and responded to COVID-19 in their delivery of social care services to older adults (70 years and older). Lessons learnt and future implications are discussed. METHODS: Six representatives from four social care services (five females and one male) participated in individual semistructured interviews. Responses were analysed thematically. RESULTS: The key themes identified were service providers' experience, perceived needs of older adults and adapting services. Service providers positioned themselves as front-line essential workers for their older adult clients, resulting in some emotional toll and distress for the service providers. They provided information, wellness checks and at-home assistance to keep their older adult clients connected. CONCLUSIONS: Service providers feel more prepared for future restrictions but flag the potential of training and supporting older adults to use technology to stay connected, as well as the need for more readily available funding to allow services to adapt quickly during times of crisis.

Calling an ambulance for non-emergency medical situations: Results of a cross-sectional online survey from an Australian nationally representative sample.

OBJECTIVE: To investigate the Australian general public's perception of appropriate medical scenarios that warrants a call to an emergency ambulance. METHODS: An online survey asked participants to identify the likely medical treatment pathway they would take for 17 hypothetical medical scenarios. The number and type of non-emergency scenarios (n = 8) participants incorrectly suggested were appropriate to place a call for an emergency ambulance were calculated. Participants included Australian residents (aged >18 years) who had never worked as an Australian registered medical doctor, nurse or paramedic. RESULTS: From a sample of 5264 participants, 40% suggested calling an emergency ambulance for a woman in routine labour was appropriate. Other medical scenarios which were most suggested by participants to warrant an emergency ambulance call was 'Lego in ear canal' (11%), 'Older person bruising' (8%) and 'Flu' (7%). Women, people aged 56+ years, those without a university qualification, with lower household income and with lower emotional wellbeing were more likely to suggest calling an emergency ambulance was appropriate for non-emergency scenarios. CONCLUSIONS: Although emergency healthcare system (EHS) capacity not increasing at the same rate as demand is the biggest contributor to EHS burden, non-urgent medical situations for which other low-acuity healthcare pathways may be appropriate does play a small role in adding to the overburdening of the EHS. This present study outlines a series of complaints and demographic characteristics that would benefit from targeted educational interventions that may aid in alleviating ambulance service attendances to low-acuity callouts.

Communication surrounding initiation and withdrawal of non-invasive ventilation in adults with motor neurone disease.

BACKGROUND: Motor neurone disease causes respiratory weakness that can lead to death. While non-invasive ventilation relieves symptoms, there are complex issues to consider prior to commencement. AIM: To identify what is known and understood about the clinician communication of non-invasive ventilation by people with motor neurone disease. METHOD: The Joanna Briggs Institute approach to systematic reviews was followed for literature retrieval and selection. DATA SOURCES: Research literature published between 1990-2019 in English from the Medline, CINAHL, ProQuest Research Library and the Cochrane Library of Systematic Reviews databases were used. RESULTS: A total of two themes emerged: communication challenges doctors face when discussing non-invasive ventilation withdrawal, and the importance of well-timed, effective communication by clinicians-specifically the influence clinicians have on family decision-making. CONCLUSIONS: Guidance on communications around palliative care, non-invasive ventilation introduction and withdrawal exist, however implementation is often not straightforward. Research into the communication surrounding non-invasive ventilation from those living with motor neuron disease, their families and clinicians is required to inform guideline implementation and practice.

Ability of the Australian general public to identify common emergency medical situations: Results of an online survey of a nationally representative sample.

OBJECTIVE: To investigate the Australian general public's ability to identify common medical emergencies as requiring an emergency response. METHODS: An online survey asked participants to identify likely medical treatment pathways they would take for 17 hypothetical medical scenarios (eight emergency and nine non-emergency). The number and type of emergency scenarios participants correctly suggested warranted an emergency medical response was examined. Participants included Australian residents (aged>18 years; n = 5264) who had never worked as an Australian registered medical doctor, nurse or paramedic. RESULTS: Most emergencies were predominately correctly classified as requiring emergency responses (e.g. Severe chest pain, 95% correct). However, non-emergency medical responses were often chosen for some emergency scenarios, such as a child suffering from a scalp haematoma (67%), potential meningococcal disease (57%), a box jellyfish sting (40%), a paracetamol overdose (37%), and mild chest pain (26%). Participants identifying as Aboriginal or Torres Strait Islander suggested a non-emergency response to emergency scenarios 29% more often compared with non-indigenous participants. CONCLUSIONS: Educational interventions targeting specific medical symptoms may work to alleviate delayed emergency medical intervention. This research highlights a particular need for improving symptom identification and healthcare system confidence amongst Aboriginal and Torres Strait Islander populations.

Lived Experience of Emergency Health Care Utilization during the COVID-19 Pandemic: A Qualitative Study.

INTRODUCTION: As the understanding of health care worker lived experience during coronavirus disease 2019 (COVID-19) grows, the experiences of those utilizing emergency health care services (EHS) during the pandemic are yet to be fully appreciated. STUDY OBJECTIVE: The objective of this research was to explore lived experience of EHS utilization in Victoria, Australia during the COVID-19 pandemic from March 2020 through March 2021. METHODS: An explorative qualitative design underpinned by a phenomenological approach was applied. Data were collected through semi-structured, in-depth interviews, which were transcribed verbatim and analyzed using Colaizzi's approach. RESULTS: Qualitative data were collected from 67 participants aged from 32 to 78-years-of-age (average age of 52). Just over one-half of the research participants were male (54%) and three-quarters lived in metropolitan regions (75%). Four key themes emerged from data analysis: (1) Concerns regarding exposure and infection delayed EHS utilization among participants with chronic health conditions; (2) Participants with acute health conditions expressed concern regarding the impact of COVID-19 on their care, but continued to access services as required; (3) Participants caring for people with sensory and developmental disabilities identified unique communication needs during interactions with EHS during the COVID-19 pandemic; communicating with emergency health care workers wearing personal protective equipment (PPE) was identified as a key challenge, with face masks reported as especially problematic for people who are deaf or hard-of-hearing; and (4) Children and older people also experienced communication challenges associated with PPE, and the need for connection with emergency health care workers was important for positive lived experience during interactions with EHS throughout the pandemic. CONCLUSION: This research provides an important insight into the lived experience of EHS utilization during the COVID-19 pandemic, a perspective currently lacking in the published peer-reviewed literature.

Venous access devices for the delivery of long-term chemotherapy: the CAVA three-arm RCT.

BACKGROUND: Venous access devices are used for patients receiving long-term chemotherapy. These include centrally inserted tunnelled catheters or Hickman-type devices (Hickman), peripherally inserted central catheters (PICCs) and centrally inserted totally implantable venous access devices (PORTs). OBJECTIVES: To evaluate the clinical effectiveness, safety, cost-effectiveness and acceptability of these devices for the central delivery of chemotherapy. DESIGN: An open, multicentre, randomised controlled trial to inform three comparisons: (1) peripherally inserted central catheters versus Hickman, (2) PORTs versus Hickman and (3) PORTs versus peripherally inserted central catheters. Pre-trial and post-trial qualitative research and economic evaluation were also conducted. SETTING: This took place in 18 UK oncology centres. PARTICIPANTS: Adult patients (aged ≥ 18 years) receiving chemotherapy (≥ 12 weeks) for either a solid or a haematological malignancy were randomised via minimisation. INTERVENTIONS: Hickman, peripherally inserted central catheters and PORTs. PRIMARY OUTCOME: A composite of infection (laboratory confirmed, suspected catheter related and exit site infection), mechanical failure, venous thrombosis, pulmonary embolism, inability to aspirate blood and other complications in the intention-to-treat population. RESULTS: Overall, 1061 participants were recruited to inform three comparisons. First, for the comparison of peripherally inserted central catheters (n = 212) with Hickman (n = 212), it could not be concluded that peripherally inserted central catheters were significantly non-inferior to Hickman in terms of complication rate (odds ratio 1.15, 95% confidence interval 0.78 to 1.71). The use of peripherally inserted central catheters compared with Hickman was associated with a substantially lower cost (-£1553) and a small decrement in quality-adjusted life-years gained (-0.009). Second, for the comparison of PORTs (n = 253) with Hickman (n = 303), PORTs were found to be statistically significantly superior to Hickman in terms of complication rate (odds ratio 0.54, 95% confidence interval 0.37 to 0.77). PORTs were found to dominate Hickman with lower costs (-£45) and greater quality-adjusted life-years gained (0.004). This was alongside a lower complications rate (difference of 14%); the incremental cost per complication averted was £1.36. Third, for the comparison of PORTs (n = 147) with peripherally inserted central catheters (n = 199), PORTs were found to be statistically significantly superior to peripherally inserted central catheters in terms of complication rate (odds ratio 0.52, 95% confidence interval 0.33 to 0.83). PORTs were associated with an incremental cost of £2706 when compared with peripherally inserted central catheters and a decrement in quality-adjusted life-years gained (-0.018) PORTs are dominated by peripherally inserted central catheters: alongside a lower complications rate (difference of 15%), the incremental cost per complication averted was £104. The qualitative work showed that attitudes towards all three devices were positive, with patients viewing their central venous access device as part of their treatment and recovery. PORTs were perceived to offer unique psychological benefits, including a greater sense of freedom and less intrusion in the context of personal relationships. The main limitation was the lack of adequate power (54%) in the non-inferiority comparison between peripherally inserted central catheters and Hickman. CONCLUSIONS: In the delivery of long-term chemotherapy, peripherally inserted central catheters should be considered a cost-effective option when compared with Hickman. There were significant clinical benefits when comparing PORTs with Hickman and with peripherally inserted central catheters. The health economic benefits were less clear from the perspective of incremental cost per quality-adjusted life-years gained. However, dependent on the willingness to pay, PORTs may be considered to be cost-effective from the perspective of complications averted. FUTURE WORK: The deliverability of a PORTs service merits further study to understand the barriers to and methods of improving the service. TRIAL REGISTRATION: This trial is registered as ISRCTN44504648. FUNDING: This project was funded by the National Institute for Health Research (NHIR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 47. See the NIHR Journals Library website for further project information.

For patients who need long-term chemotherapy delivered through a vein, there are currently three options: (1) a Hickman-type device, which is a flexible tube (central line) inserted underneath the skin on the chest into a large vein; (2) a peripherally inserted central catheter, which is a long line tube inserted into a vein in the arm and passed through a large vein in the chest; and (3) a totally implantable device, which is a small chamber (accessed externally by a needle) that sits underneath the skin, usually in the chest, and goes into a large vein. The Cancer And Venous Access (CAVA) trial compared these devices in > 1000 patients and looked at complications, quality of life, acceptability and value for money. We found that totally implantable devices halved the risk of complications compared with the other two options (which had similar complication rates to each other). We found that patients' quality of life was similar for all three devices, although a quality-of-life measure specific to these devices showed some emotional and psychological benefits in favour of totally implantable devices. All three devices work, although the totally implantable devices are associated with fewer complications and are less intrusive for patients. In the CAVA trial, we found that totally implantable devices are the most costly device to use, followed by the Hickman-type device, with the peripherally inserted central device being the cheapest. This is partly because of the tendency for totally implantable devices to remain in patients for a longer period of time than the other two options. The costs could potentially be reduced by training nurse-led teams to insert totally implantable devices, as already happens with the other two devices. Totally implantable devices can be considered value for money depending on how people value avoiding complications and the quality-of-life benefits for patients.

The quality of diagnosis and triage advice provided by free online symptom checkers and apps in Australia.

OBJECTIVES: To investigate the quality of diagnostic and triage advice provided by free website and mobile application symptom checkers (SCs) accessible in Australia. DESIGN: 36 SCs providing medical diagnosis or triage advice were tested with 48 medical condition vignettes (1170 diagnosis vignette tests, 688 triage vignette tests). MAIN OUTCOME MEASURES: Correct diagnosis advice (provided in first, the top three or top ten diagnosis results); correct triage advice (appropriate triage category recommended). RESULTS: The 27 diagnostic SCs listed the correct diagnosis first in 421 of 1170 SC vignette tests (36%; 95% CI, 31-42%), among the top three results in 606 tests (52%; 95% CI, 47-59%), and among the top ten results in 681 tests (58%; 95% CI, 53-65%). SCs using artificial intelligence algorithms listed the correct diagnosis first in 46% of tests (95% CI, 40-57%), compared with 32% (95% CI, 26-38%) for other SCs. The mean rate of first correct results for individual SCs ranged between 12% and 61%. The 19 triage SCs provided correct advice for 338 of 688 vignette tests (49%; 95% CI, 44-54%). Appropriate triage advice was more frequent for emergency care (63%; 95% CI, 52-71%) and urgent care vignette tests (56%; 95% CI, 52-75%) than for non-urgent care (30%; 95% CI, 11-39%) and self-care tests (40%; 95% CI, 26-49%). CONCLUSION: The quality of diagnostic advice varied between SCs, and triage advice was generally risk-averse, often recommending more urgent care than appropriate.

A clinical trial of nurse practitioner care in residential aged care facilities.

BACKGROUND: Optimising quality of life and reducing hospitalisation for people living in residential aged care facilities (RACF) are important health policy goals. METHODS: A cluster controlled clinical trial of nurse practitioner care in RACF. Six facilities were included: three randomly allocated to intervention where nurse practitioners working with general practitioners and using a best practice guide were responsible for care, and three control. Participants were followed up for a minimum of 12 months unless dead or transferred to another facility. RESULTS: We enrolled two hundred patients (101 intervention and 99 control) with a mean (SD) follow up of 604 (276) days. There were 98 ED visits by intervention participants, resulting in 56 hospitalisations, compared with 121 ED visits and 70 hospitalisations for controls (risk reduction = 8%, 95% CI = -1% -17%, p = 0.10). For the pre-specified secondary outcomes of transfers within the first 12 months of enrolment, the number of residents making at least one visit (46 in each study arm) and rate of ED attendance (0.66 visits per intervention resident versus 0.70 visits per control resident) was not affected by the intervention. After adjusting for dependency and comorbidity, the intervention group had non-significantly lower transfers (OR 0.7, 95% CI 0.3-1.5, p = 0.34). There was a reduction in the rate of decline in the quality of life of intervention compared to control residents. CONCLUSIONS: Nurse practitioner care coordination resulted in no statistically significant change in rates of ED transfer or health care utilisation, but better maintained resident quality of life.

Validation of standard operating procedures in a multicenter retrospective study to identify -omics biomarkers for chronic low back pain.

Chronic low back pain (CLBP) is one of the most common medical conditions, ranking as the greatest contributor to global disability and accounting for huge societal costs based on the Global Burden of Disease 2010 study. Large genetic and -omics studies provide a promising avenue for the screening, development and validation of biomarkers useful for personalized diagnosis and treatment (precision medicine). Multicentre studies are needed for such an effort, and a standardized and homogeneous approach is vital for recruitment of large numbers of participants among different centres (clinical and laboratories) to obtain robust and reproducible results. To date, no validated standard operating procedures (SOPs) for genetic/-omics studies in chronic pain have been developed. In this study, we validated an SOP model that will be used in the multicentre (5 centres) retrospective "PainOmics" study, funded by the European Community in the 7th Framework Programme, which aims to develop new biomarkers for CLBP through three different -omics approaches: genomics, glycomics and activomics. The SOPs describe the specific procedures for (1) blood collection, (2) sample processing and storage, (3) shipping details and (4) cross-check testing and validation before assays that all the centres involved in the study have to follow. Multivariate analysis revealed the absolute specificity and homogeneity of the samples collected by the five centres for all genetics, glycomics and activomics analyses. The SOPs used in our multicenter study have been validated. Hence, they could represent an innovative tool for the correct management and collection of reliable samples in other large-omics-based multicenter studies.

Comparison of the HUI3 and the EQ-5D-3L in a nursing home setting.

BACKGROUND: Accurately assessing changes in the quality of life of older people living permanently in nursing homes is important. The multi-attribute utility instrument most commonly used and recommended to assess health-related quality of life in the nursing home population is the three-level EuroQol EQ-5D-3L. To date, there have been no studies using the Health Utilities Index Mark III (HUI3). The purpose of this study was to compare the level of agreement and sensitivity to change of the EQ-5D-3L and HUI3 in a nursing home population. METHODS: EQ-5D-3L and HUI3 scores were measured as part of a cluster randomised controlled trial of nurse led care coordination in a nursing home population in Perth, Western Australia at baseline and 6-month follow up. RESULTS: Both measures were completed for 199 residents at baseline and 177 at 6-month follow-up. Mean baseline utility scores for EQ-5D-3L (0.45; 95% CI 0.41-0.49) and HUI3 (0.15; 95% CI 0.10-0.20) were significantly different (Wilcoxon signed rank test, p<0.01) and agreement was poor to moderate between absolute scores from each instrument (intra-class correlation coefficient = 0.63). The EQ-5D-3L appeared more sensitive to change over the 6-month period. CONCLUSION: Our findings show that the EQ-5D-3L and HUI3 estimate different utility scores among nursing home residents. These differences should be taken into account, particularly when considering the implications of the cost-effectiveness of particular interventions and we conclude that the HUI3 is no better suited to measuring health-related quality of life in a nursing home population when compared to the EQ-5D-3L.

'Omics' biomarkers associated with chronic low back pain: protocol of a retrospective longitudinal study.

INTRODUCTION: Chronic low back pain (CLBP) produces considerable direct costs as well as indirect burdens for society, industry and health systems. CLBP is characterised by heterogeneity, inclusion of several pain syndromes, different underlying molecular pathologies and interaction with psychosocial factors that leads to a range of clinical manifestations. There is still much to understand in the underlying pathological processes and the non-psychosocial factors which account for differences in outcomes. Biomarkers that may be objectively used for diagnosis and personalised, targeted and cost-effective treatment are still lacking. Therefore, any data that may be obtained at the '-omics' level (glycomics, Activomics and genome-wide association studies-GWAS) may be helpful to use as dynamic biomarkers for elucidating CLBP pathogenesis and may ultimately provide prognostic information too. By means of a retrospective, observational, case-cohort, multicentre study, we aim to investigate new promising biomarkers potentially able to solve some of the issues related to CLBP. METHODS AND ANALYSIS: The study follows a two-phase, 1:2 case-control model. A total of 12 000 individuals (4000 cases and 8000 controls) will be enrolled; clinical data will be registered, with particular attention to pain characteristics and outcomes of pain treatments. Blood samples will be collected to perform -omics studies. The primary objective is to recognise genetic variants associated with CLBP; secondary objectives are to study glycomics and Activomics profiles associated with CLBP. ETHICS AND DISSEMINATION: The study is part of the PainOMICS project funded by European Community in the Seventh Framework Programme. The study has been approved from competent ethical bodies and copies of approvals were provided to the European Commission before starting the study. Results of the study will be reviewed by the Scientific Board and Ethical Committee of the PainOMICS Consortium. The scientific results will be disseminated through peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02037789; Pre-results.

Reducing depression during the menopausal transition with health coaching: Results from the healthy menopausal transition randomised controlled trial.

OBJECTIVE: To determine if health coaching (HC) decreases the incidence of depression, reduces the severity of symptoms, and increases quality of life during the menopausal transition (MT). RESEARCH DESIGN AND METHODS: Parallel, single-blinded, randomised controlled trial of 6 sessions of phone-delivered HC compared with usual care. Participants were 351 community-dwelling women free of major depression going through the MT, of whom 180 were assigned the intervention and 171 usual care. The primary outcome of interest was the incidence of clinically significant depressive symptoms over 52 weeks. Other study measures included the Hospital Anxiety and Depression Scale, quality of life (SF-12), the Menopause Rating Scale (MRS), diet, body mass index, alcohol use, smoking and physical activity. We considered that women with Patient Health Questionnaire (PHQ-9) scores between 5 and 14 (inclusive) had sub-threshold depressive symptoms. RESULTS: Nine women developed clinically significant symptoms of depression during the study-2 had been assigned HC (odds ratio, OR=0.26, 95%CI=0.05, 1.29; p=0.099). Intention-to-treat showed that, compared with usual care, the intervention led to a greater decline in depressive scores, most markedly for participants with sub-threshold depressive symptoms. Similar, but less pronounced, benefits were noticed for anxiety scores and the mental component summary of the SF-12. The intervention led to a decline in MRS scores by week 26 and subtle improvements in body mass, consumption of vegetables and smoking. CONCLUSIONS: HC addressing relevant risk factors for depression during the MT improves mental health measures. Our findings indicate that women with sub-threshold depressive symptoms may benefit the most from such interventions, and suggest that HC could play a useful role in minimizing mental health disturbance for women going through the MT.

Engaging Australian Aboriginal narratives to challenge attitudes and create empathy in health care: a methodological perspective.

BACKGROUND: Unconscious bias and negative attitudes towards minority groups have detrimental effects on the way health care is, or is not, provided to these groups. Recognition of racist attitudes and behaviours as well as understanding clients' experiences of health and health care are pivotal to developing better health care strategies to positively impact on the quality and safety of care provided to Indigenous people. Indigenous research demands inclusive research processes and the use of culturally appropriate methodologies. This paper presents a methodological account of collecting narratives which accurately and respectfully reflect Aboriginal Australians' experiences with health care in Western Australia. The purpose of these narratives is to provide health students and professionals with an opportunity to 'walk-in the shoes' of Aboriginal people where face-to-face interaction is not feasible. METHODS: With the incorporation of Indigenous peoples' voices being an important link in cultural safety, the project was led by an Indigenous Reference group, who encouraged active participation of Aboriginal people in all areas of the project. Using a phenomenological approach and guided by the Indigenous Reference group, yarning data collection was implemented to collect stories focusing on Aboriginal people's experiences with health care services. An open-access, on-line website was established to host education resources developed from these "yarns". RESULTS: Yarning provided a rich source of information on personal experiences and encouraged the story provider to recognise their facilitative role in the research process. While the methodology used in this project was lengthy and labour-intensive it afforded a respectful manner for story collection and highlighted several innate flaws when Western methods are applied to an Indigenous context. CONCLUSION: Engagement of an Indigenous Reference Group was pivotal to designing an appropriate methodology that incorporated the voices of Aboriginal people in a multimedia resource of Aboriginal narratives. However further research is warranted to understand how the resources are being used and integrated into curricula, and their impact on students and health care outcomes.

Depressive symptoms in midlife: the role of reproductive stage.

OBJECTIVE: The aim of the study was to determine the prevalence of depression among community-dwelling women in the premenopause, menopausal transition (MT), and postmenopause stage. We also sought to clarify the direct and indirect contribution of menopausal status on the risk of depression. METHODS: Cross-sectional survey of 1,612 women aged 45 to 55 years living in the Perth metropolitan region, who were recruited using a random sample of the electoral roll (voting is compulsory in Australia), was conducted. Women with clinically significant symptoms of depression had Patient Health Questionnaire (PHQ-9) scores of at least 10, and those with major depression, reported symptoms consistent with Diagnostic and Statistical Manual of Mental Disorders, 5th ed (DSM-5), criteria. We used past and current gynecological and reproductive data to classify women as premenopausal, undergoing the MT, and postmenopausal. Other study measures included age, place of birth, education, marital status, drinking habit, number of children, medical illnesses, and history of premenstrual syndrome, postnatal depression, and past depression or anxiety. We investigated the direct and indirect effect of reproductive status with mediation/modulation analysis. RESULTS: Among the women included in the survey, 8.2%, 11.5%, and 13.0% of women in premenopause, MT, and postmenopause had PHQ-9 at least 10, whereas major depression was present in 2.2%, 3.4%, and 3.6% of them. Reproductive status did not affect the prevalence of major depression, but more postmenopausal than premenopausal women had PHQ-9 score equal to or greater than 10 (P = 0.013). Compared with premenopausal women, MT was associated with a direct odds ratio (OR) 1.35 (95% confidence interval [CI] = 0.90, 2.01) and indirect OR 1.08 (95% CI = 0.92, 1.26) for PHQ-9 at least 10. Similarly, the direct and indirect effect of the postmenopause on the odds of PHQ-9 at least 10 was OR 1.31 (95% CI = 0.87, 1.98) and OR 1.29 (95% CI = 1.10, 1.52). CONCLUSIONS: The slight, but not significant, excess of depressive symptoms during MT and early postmenopause cannot be attributed to a direct effect of reproductive status.

Long-term effect of respiratory training for chronic obstructive pulmonary disease patients at an outpatient clinic: a randomised controlled trial.

OBJECTIVE: To assess the effect of respiratory training (RT) on lung function, activity tolerance and acute exacerbation frequency with chronic obstructive pulmonary disease (COPD). DESIGN: A randomised controlled trial. SETTING: Outpatient clinic and home of the COPD patients, Zhengzhou City, China. SUBJECTS: Sixty participants with COPD were randomised into two groups: an intervention group (n = 30) which received the RT in self-management and a control group (n = 30) that received an education program during the study. INTERVENTION: Pulmonary function, activity tolerance and frequency of acute exacerbation of these COPD patients were evaluated before and after the program. The intervention and control programs were delivered at monthly outpatient clinic visits over a period of 12 months. The pulmonary rehabilitation (PR) program was conducted by a physiotherapist (who delivered RT to the participant over a minimum of 1 h per visit) for the intervention group, whereas the control group received routine health education provided by physiotherapists. The intervention group patients were then instructed to perform exercises at home as taught in the RT at least 5 days per week at home. RESULTS: After 12 months of RT, the lung function and the activity tolerance of the COPD patients in the intervention group were significantly improved and the exacerbation frequency was also decreased. CONCLUSION: Long-term RT can improve lung function and activity tolerance while decreasing the frequency of acute exacerbation for COPD patients.

Improving health Professional's knowledge of hepatitis B using cartoon based learning tools: a retrospective analysis of pre and post tests.

BACKGROUND: Hepatitis B serology is complex and a lack of knowledge in interpretation contributes to the inadequate levels of screening and referral for highly effective hepatitis antiviral treatments. This knowledge gap needs to be addressed so that current and future healthcare professionals are more confident in the detection and assessment of hepatitis B to improve the uptake of treatment and reduce long-term complications from the disease. Cartoons have been used effectively as a teaching tool in other settings and were considered as a potentially useful teaching aid in explaining hepatitis B serology. This study examines the impact of cartoons in improving healthcare professionals' knowledge. METHODS: A cartoon based learning tool designed to simplify the complexities of hepatitis B serology was developed as part of an online learning program for medical practitioners, nurses and students in these professions. A retrospective analysis was carried out of pre and post online test results. RESULTS: An average improvement of 96% of correct answers to case study questions in hepatitis B serology was found across all ten questions following the use of an online cartoon based learning tool. CONCLUSION: The data indicates a significant improvement of participants' knowledge of hepatitis B serology from pre-test to post-test immediately following an online cartoon based learning tool. However, further research is required to measure its long term impact.