Maternal acceptability of a dietary intervention designed to lower children's intake of saturated fat and cholesterol: the Dietary Intervention Study in Children (DISC)

Indian Model of Integrated Healthcare (IMIH): a conceptual framework for a coordinated referral system in resource-constrained settings

INTRODUCTION

With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings.

METHODS

A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance.

RESULTS

Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level.

CONCLUSION

IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation.

Factors influencing the implementation of chronic care models: A systematic literature review

Background

The increasing prevalence of chronic disease faced by both developed and developing countries is of considerable concern to a number of international organisations. Many of the interventions to address this concern within primary healthcare settings are based on the chronic care model (CCM). The implementation of complex interventions such as CCMs requires careful consideration and planning. Success depends on a number of factors at the healthcare provider, team, organisation and system levels.

Methods

The aim of this systematic review was to systematically examine the scientific literature in order to understand the facilitators and barriers to implementing CCMs within a primary healthcare setting. This review focused on both quantitative and qualitative studies which included patients with chronic disease (cardiovascular disease, chronic kidney disease, chronic respiratory disease, type 2 diabetes mellitus, depression and HIV/AIDS) receiving care in primary healthcare settings, as well as primary healthcare providers such as doctors, nurses and administrators. Papers were limited to those published in English between 1998 and 2013.

Results

The search returned 3492 articles. The majority of these studies were subsequently excluded based on their title or abstract because they clearly did not meet the inclusion criteria for this review. A total of 226 full text articles were obtained and a further 188 were excluded as they did not meet the criteria. Thirty eight published peer-reviewed articles were ultimately included in this review. Five primary themes emerged. In addition to ensuring appropriate resources to support implementation and sustainability, the acceptability of the intervention for both patients and healthcare providers contributed to the success of the intervention. There was also a need to prepare healthcare providers for the implementation of a CCM, and to support patients as the way in which they receive care changes.

Conclusion

This systematic review demonstrated the importance of considering human factors including the influence that different stakeholders have on the success or otherwise of the implementing a CCM.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0319-5) contains supplementary material, which is available to authorized users.

Impact of location and availability of behavioral health services for children

Literature suggests advantages for co-locating behavioral health care in primary care. We compared the impact of location of services on attendance at behavioral health appointments when access to care was assured for externalizing behavior problems with referral as usual. Two primary care pediatric practices had an evidence-based parenting program co-located in the practice for parents of children aged 2-12 years and two practices had the program available using an enhanced-referral procedure for locations external to the practices. The program was available at the regional children's hospital (referral as usual). During an 8-month period, the rate of attendance at first appointments was significantly higher in the co-located than the enhanced referral condition (.38 and .12 % of patient visits, respectively; χ(2) = 13.32; p < .0003; OR = 3.10; 95 % CI: 1.63, 5.89). These outcomes, while low, were better than the near 0 rate of attendance to referral as usual. Availability of behavioral health services in both conditions increased rates of attended appointments. However, the low rates of attendance indicate increasing availability of services, alone, is not sufficient to decrease the unmet need of children with behavioral problems. Factors other than availability must be addressed in order to improve outcomes for children.

The Efficacy and Acceptability of the Triple P-Positive Parenting Program With Japanese Parents

This study examined the efficacy of the Group Triple P-Positive Parenting Program with a Japanese population to evaluate the feasibility and acceptability of the program and the parenting skills taught in a crosscultural context. The study involved 50 Japanese parents living in Australia and used a randomised group comparison design with two conditions, Triple P group and a waitlist control group. The results revealed significant reductions in parent reported child behaviour problems, parental overreactivity and laxness, and parental conflict as well as increasing parental competence. The acceptability of the program was found to be high. Intervention effects and program acceptability in a Japanese context as well as limitations and future research are discussed.

Four therapeutic diets: adherence and acceptability

Many health conditions are treated, at least in part, by therapeutic diets. Although the success of any intervention depends on its acceptability to the patient, the acceptability of therapeutic diets and factors that influence it have been largely neglected in nutrition research. A working definition of acceptability is proposed and an examination and summary are provided of available data on the acceptability of common diet regimens used for medical conditions. The goal is to suggest ways to improve the success of therapeutic diets. The proposed working definition of "acceptability" refers to the user's judgment of the advantages and disadvantages of a therapeutic diet-in relation to palatability, costs, and effects on eating behaviour and health-that influence the likelihood of adherence. Very low-calorie, reduced-fat omnivorous, vegetarian and vegan, and low-carbohydrate diets all achieve acceptability among the majority of users in studies of up to one year, in terms of attrition and adherence rates and results of questionnaires assessing eating behaviours. Longer studies are fewer, but they suggest that vegetarian, vegan, and reduced-fat diets are acceptable, as indicated by sustained changes in nutrient intake. Few studies of this length have been published for very low-calorie or low-carbohydrate diets. Long-term studies of adherence and acceptability of these and other therapeutic diets are warranted.

Pediatric hyperlipidemia: child and adolescent disease understandings and perceptions about dietary adherence

PURPOSE

Pediatric hyperlipidemia increases cardiovascular disease risk. The cornerstone of treatment is a restrictive, lipid-lowering diet. Child disease understandings and perceptions of dietary adherence were explored, a secondary aim of the Endothelial Assessment of Risk from Lipids in Youth trial.

DESIGN AND METHODS

Focus groups and individual interviews were conducted with participants, ages 9-20 years (n = 50). Data were thematically analyzed.

FINDINGS

Adherence is influenced by individual characteristics (developmental level, knowledge), in the context of social interactions (family modeling, peer relationships, school).

PRACTICAL IMPLICATIONS

Dietary practices are developed within social interactions. Interventions promoting adherence must consider children within their social contexts.

Comparison of attitudes towards breakfast by Turkish fourth graders living in Turkey and Germany

The purpose of this article is to identify and compare Turkish fourth graders attitudes towards breakfast living in Turkey and Germany. A sample group of 882 Turkish students enrolled in fourth grade in Hamburg (Germany, N=422) and Konya (Turkey, N=460) were surveyed. Independent t-tests, chi(2) test and Pearson product-moment correlations were used. More students living in Turkey had breakfast and had enough time before going to school (P<0.01). Students living in Turkey reported that eating breakfast affected them positively (P<0.01). Students living in Germany reported that eating breakfast made them feel tired (P<0.01). The consumption of breakfast cereal (P<0.05) and fruit juice (P<0.01) that had not been consumed widely in Turkey increased in Germany. Students who eat breakfast also eat lunch (r=0.296 and -0.236, P<0.01, students living in Turkey and Turkish students living in Germany, respectively). Nutrition education programs in primary schools may change Student's attitudes about breakfast and offering a breakfast programme in schools may greatly improve breakfast consumption rates.

Associations between perceived parent behaviors and middle school student fruit and vegetable consumption

OBJECTIVE

To examine whether (1) student perceptions of parent behaviors explain variations in fruit and vegetable consumption, (2) self-efficacy mediates this relationship, and (3) perceived home fruit and vegetable availability moderates this relationship.

DESIGN

A cross-sectional survey.

SETTING

Classrooms in 3 middle schools in 2 northeast Georgia counties.

PARTICIPANTS

366 middle school students. The response and participation rates were 59% and 56%, respectively.

VARIABLES MEASURED

Perceived authoritative parenting, perceived parent control, perceived parent modeling, perceived parent support, self-efficacy, perceived fruit and vegetable availability, and fruit and vegetable consumption.

ANALYSIS

Hierarchical multiple regression; P <.05.

RESULTS

Perceived parent modeling, perceived parent support, self-efficacy, and perceived fruit and vegetable availability were significant predictors of fruit and vegetable consumption. The relationship between perceived parent support and fruit and vegetable consumption was mediated by self-efficacy. The relationship between fruit and vegetable consumption and both perceived parent modeling and support was moderated by perceived fruit and vegetable availability.

CONCLUSIONS AND IMPLICATIONS

Parents appear to moderately influence middle school student fruit and vegetable consumption. Educators might focus on improving home fruit and vegetable availability and student self-efficacy, as well as parent support and modeling. The level of availability might indicate where efforts should focus for enhancing parent behaviors.

Results of an adjunct dietary intervention program in the Women's Health Initiative

OBJECTIVE

The purpose of this study was to develop, implement, and evaluate the efficacy of an intensive intervention program (IIP) based on motivational interviewing to motivate participants within the dietary study of the Women's Health Initiative (WHI) to meet the study's nutritional goals.

SUBJECTS/DESIGN

WHI dietary intervention participants (n=175) from 3 clinical centers were randomly assigned to either intervention or control status. Participants assigned to IIP intervention received 3 individual motivational interviewing contacts from a dietitian, plus the usual WHI Dietary Intervention. Participants randomly assigned to IIP control received the usual WHI dietary modification (DM) Intervention. Percent of energy from fat was estimated at study baseline and at follow-up (1 year later) using the WHI Food Frequency Questionnaire.

RESULTS

The change in percent energy from fat between IIP baseline and IIP 1-year follow-up was -1.2% for IIP intervention participants and +1.4% for IIP control participants, giving an overall difference of 2.6% (P<.001). Participants having the highest IIP baseline fat intake (>30% energy) showed the largest overall change in percent energy from fat between IIP baseline and IIP follow-up.

CONCLUSIONS

The results of this study indicate that a protocol based on motivational interviewing and delivered through contacts with trained dietitians is an efficacious way to further lower dietary fat intake among participants exposed to ongoing intervention. These data will be useful in future intervention situations when there is a need to increase motivation to change.

Longitudinal study of nutrient and food intakes of white preschool children aged 24 to 60 months

OBJECTIVE

To determine nutrient and food intakes of 72 white preschool children primarily from families of middle and upper socioeconomic status and to compare children's nutrient intakes with current recommendations.

DESIGN

Six in-home interviews were conducted with mothers when children were 24 to 60 months old; at each time mothers provided 3 days of dietary information on the child. Children and mothers independently provided information on the child's favorite and least favorite foods at 42 and 54 months.

SUBJECTS

Preschool children (24 to 60 months old) participating in a longitudinal study.

STATISTICAL ANALYSES

Mean nutrient intakes were compared with the most recent Recommended Dietary Allowances/Adequate Intakes. Differences over time were tested with repeated-measures analysis of variance; gender differences were determined with t tests. Food frequencies (i.e., percentage of children consuming specific foods) were determined from dietary recalls and food records. Dietary variety was assessed with the Variety Index for Toddlers or the Variety Index for Children.

RESULTS

Means were consistently less than the RDA/AI for energy, zinc, folate, and vitamins D and E. Energy, carbohydrate, and fat intakes were highest (P < or = .01) at 60 months. Boys consumed more (P < or = .05) protein (10 g), calcium (197 mg), magnesium (35 mg), and pantothenic acid (0.8 mg) at 60 months than did girls. Foods most commonly eaten were fruit drink, carbonated beverages, 2% milk, and french fries. The vegetable group consistently had the lowest variety scores; vegetables also dominated least favorite foods lists.

APPLICATIONS

Parents need to be encouraged to include more sources of zinc, folate, vitamin E, and vitamin D in children's diets. Parents should also encourage their children to eat more vegetables, zinc- and folate-fortified cereals, lean red meats, seafood, vegetable oils, and low-fat milk.