Mitigating Contaminant-Driven Risks for the Safe Expansion of the Agricultural-Sanitation Circular Economy in an Urbanizing World

The widespread adoption of an agricultural circular economy requires the recovery of resources such as water, organic matter, and nutrients from livestock manure and sanitation. While this approach offers many benefits, we argue this is not without potential risks to human and environmental health that largely stem from the presence of contaminants in the recycled resources (e.g., pharmaceuticals, pathogens). We discuss context specific challenges and solutions across the three themes: (1) contaminant monitoring; (2) collection transport and treatment; and (3) regulation and policy. We advocate for the redesign of sanitary and agricultural management practices to enable safe resource reuse in a proportionate and effective way. In populous urban regions with access to sanitation provision, processes can be optimized using emergent technologies to maximize removal of contaminant from excreta prior to reuse. Comparatively, in regions with limited existing capacity for conveyance of excreta to centralized treatment facilities, we suggest efforts should focus on creation of collection facilities (e.g., pit latrines) and decentralized treatment options such as composting systems. Overall, circular economy approaches to sanitation and resource management offer a potential solution to a pressing challenge; however, to ensure this is done in a safe manner, contaminant risks must be mitigated.

"IT's too much to do alone": A mixed-methods exploration of patient experiences implementing emergency department management plans for chronic pain

OBJECTIVES

To explore the experiences of socio-culturally diverse community members attempting to manage their chronic pain and enact evidence-based management plans following an index Emergency Department (ED) visit.

METHODS

A convergent parallel mixed-methods design with qualitative interviews and descriptive analysis was undertaken in two public hospitals in a multicultural region in Sydney, Australia. Consecutive adults were recruited from culturally and linguistically diverse (CALD: n = 45) or Australian-born (n = 45) backgrounds, who presented to the ED for a chronic neuromusculoskeletal pain condition. Consenting participants were prescribed an individualised chronic pain management plan following examination by a physiotherapist, who collected standardised measures of pain and health literacy. Six months later, participants underwent a structured phone survey regarding their pain status and whether they had actioned management plans. Participants were invited to participate in a semi-structured interview.

RESULTS

Six-month data were available for 82 of 90 participants who attended the ED and consented to the baseline assessment (40 CALD and 42 Australian-born). Participants were 52% females, predominately middle-aged (mean age 54.7 years), with an overall mean symptom duration of 10 years (SD 9.0). At 6 months, there were nine representations by six CALD participants and 23 by nine Australian-born participants. Overall, 52% reported unchanged pain, 24% were worse and 23% improved, with similar action plan progress for CALD (58%) and Australian-born (53%) participants. Pain features and health literacy were similar, irrespective of progress with pain management plans. From 41 participants who consented to phone interviews, three themes emerged to explain their progress with recommendations: 'illness model', 'urgency' and 'control orientation'.

CONCLUSIONS

Patients presenting to the ED with chronic pain might be more likely to action discharge recommendations if primary care providers identify patient-specific and contextual barriers to implementation.

Experiences of Boosting Inpatient Exercise After HipFracture Surgery Using An Alternative Workforce - A Qualitative Study

BACKGROUND

Thrice-daily physiotherapy immediately following surgical repair of hip fracture has been shown to be safe and to reduce total hospital length of stay. However, implementing this is challenging with respect to health service funding and staffing. A novel approach may be to utilize an alternative workforce (allied health staff and student physiotherapists) to deliver two of the three daily treatments. However, how patients and staff may view such an approach is unknown. Thus, the aim of this qualitative study was to explore the views of inpatients with surgical repair of a hip fracture, their carers, health care professionals, and physiotherapy students about the implementation and acceptability of thrice-daily physiotherapy, with two sessions delivered by the alternative workforce (the BOOST study).

METHODS

Semi-structured interviews and focus groups with patients, carers, health professionals and physiotherapy students. All interviews were digitally recorded and transcribed via verbatim. The transcripts were coded, and the data analysed via inductive thematic analysis.

RESULTS

A total of 37 interviews (32 one-to-one interviews and five focus group interviews) were analysed. Five main themes were identified: (1) individual perceptions of the intervention: inpatients/carer/staff/student, (2) implementation within the service and organisational context, (3) implementation strategies that were effective, (4) improvements to implementation strategies/barriers to implementation/unsuccessful strategies and (5) future directions of BOOST.

CONCLUSIONS

The qualitative data revealed that higher frequency physiotherapy was well-received by inpatients and that staff/students involved in providing care perceived it as a safe, acceptable and valuable practice. Implementation of higher daily frequency of physiotherapy using an alternative workforce may feasibly be adopted for inpatients following hip fracture surgery.

TRIAL REGISTRATION

This study was approved by the Human Research Ethics Committee (HREC) of the Western Sydney Local Health District (2020/ETH02718). Mutual recognition of approval was subsequently obtained from Northern Sydney Local Health District HREC.

What do parents think about child's routine height and weight measures? A qualitative study

BACKGROUND

Routine height and weight screening of children accessing health services in South Western Sydney Local Health District (SWSLHD) was implemented to address childhood obesity. This qualitative study aims to explore the views of parents/carers regarding the role of healthcare professionals (HCPs) in measuring their child and raising the issue of weight when accessing health services.

METHODS

A qualitative study using semi-structured interviews was performed. Parents/carers of children who had their height and weight measured at a SWSLHD facility were invited to participate. Purposive sampling was used to select parents/carers of children from different body mass index (BMI) categories and different health settings. Interviews were digitally audio-recorded and transcribed verbatim. The de-identified data were coded and analysed thematically using NVivo.

RESULTS

A total of 24 semi-structured interviews were conducted. Of these, 14 were of parents/carers of children who were outside the healthy weight range. Three main themes were identified: parental perception of their child's weight, parental expectations, and parental challenges. We found that many parents/carers were unaware of their child's weight status and often underestimated it. Many were open to receiving advice and resources as long as it was addressed professionally and respectfully.

CONCLUSIONS

Contrary to the views of some health professionals, parents/carers want to know their child's weight status. They valued the information and advice provided by well-trained clinicians who are confident to raise the issue of weight with parents/carers.

A snapshot of primary care physiotherapy management of knee osteoarthritis in an Australian setting: does it align with evidence-based guidelines?

BACKGROUND

Systematic implementation of evidence-based, clinical practice guidelines for management of knee osteoarthritis (OA) in primary care physiotherapy in Australia is embryonic. Clinical practice guidelines have been implemented in the public healthcare sector at a State-level for physiotherapists in the form of multidisciplinary programs, but the reach of physiotherapy-led OA management programs is grossly inadequate in the private sector.

OBJECTIVE

To provide a snapshot of the management of people with knee OA in private physiotherapy practice in an Australian setting. Primarily the aim was to determine the alignment between the treatment provided and guideline-based management. Secondary aims included the capture of both patient-reported improvement after 3-months and patient satisfaction with treatment. Whether patient-reported outcome measures (PROMS) were routinely used was also ascertained.

METHODS

A prospective, observational study enrolling adults >=45 years with knee OA across nine primary care physiotherapy practices. Knee injury OA Outcome Score (KOOS) and Routine Assessment Patient Index 3 (RAPID3) were collected (baseline; 3 months) by researchers along with satisfaction with treatment. Treatment details and use of PROMS were obtained from physiotherapy record audit and patient interview. The treatment provided was compared to the minimum core elements of management stipulated in OA management guidelines.

RESULTS

Twenty-six adults (58% female, mean age 60 (9) years, 54% overweight or obese) participated. 100% were prescribed ≥1 appropriate exercise(s); 42% received OA education; 12% received weight management advice. Mean improvement (95%CI) in KOOS Pain was 9.8 (3.4 to 16.1) and RAPID3 was -3.4 (-5.5 to -1.3). Satisfaction with treatment was high (8.3/10). No PROMs were used for assessment or monitoring.

CONCLUSION

Primary care physiotherapy treatment of knee OA did not meet minimum criteria per clinical practice guidelines. However, participant improvement at three months reached minimally important change thresholds for patient-reported measures and satisfaction was high. The data provide useful insights about areas that are deficient, thus, should inform future implementation strategies designed to improve care delivery and the uptake of routine measurement of patient-reported outcomes.

Acceptability and barriers of a GP-physiotherapist partnership in the diagnosis and management of COPD in primary care: A qualitative study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is commonly diagnosed and managed in primary care but there is evidence that this has been suboptimal, with low confidence expressed in providing interventions requiring behaviour change. The aim of this study was to determine the acceptability of a general practitioner (GP)-physiotherapist partnership in the diagnosis and management of COPD in primary care and to explore the experiences of participants during the implementation of the model.

METHODS

Semi-structured interviews were conducted with physiotherapists (n = 3), GPs (n = 2), practice nurses (PNs) (n = 2) and patients (n = 12) who had participated in the InNovaTivE Gp-physiotheRapist pArTnErship for copD (INTEGRATED) trial. We sought to explore participants' views about their experiences and perceived benefits, barriers and facilitators to the implementation of this model of care. Interviews were transcribed, coded and thematically analysed. Synthesis of the data was guided by the Theoretical Domains Framework for clinician interviews and the health belief model for patient interviews.

RESULTS

All clinicians felt that this integrated model helped to optimise care for patients with COPD by facilitating evidence-based practice. GPs and PNs valued the physiotherapist's knowledge and skills relating to diagnosis and management, which was reported to complement their own management and improve patient outcomes. Patients reported a sense of empowerment following their appointments and acknowledged improved self-management skills. However, physiotherapists reported many patients were already engaging in positive health behaviours. Responses were mixed on the effectiveness of the model in facilitating teamwork between clinicians with different perspectives concerning management, communication pathways and logistical issues, such as time and room availability, being cited as barriers.

CONCLUSIONS

An experienced cardiorespiratory physiotherapist embedded into a small number of primary care practices to work in partnership with GPs for COPD diagnosis and management was acceptable and viewed as beneficial for patients. Barriers relating to logistics and resources remain, which must be addressed to optimise implementation.

PATIENT OR PUBLIC CONTRIBUTION

Patient input was obtained from qualitative feedback from a prior study conducted by two authors and was used to refine the model of care to determine the added value of a physiotherapist integrated into the primary care team. This feedback was also used to refine the interview guides utilised in this study determine the acceptability of this model of care. We had health service involvement from the rehabilitation service of the local health district who were directly involved in determining study aims and establishing the project around the priorities for their chronic disease integration service. For example, this project aimed to engage with a less severe patient population in primary care who would benefit from pulmonary rehabilitation. The findings from this study will be used to further tailor the model of care to the needs of the public and patients.

TRIAL REGISTRATION

ACTRN12619001127190.

A collaborative primary health care model for children and young people in rural Australia: explorations of cross-sectoral leader action

BACKGROUND

Cross-sectoral collaborations are considered necessary to address detrimental health, social, educational and economic outcomes that impact marginalised and disadvantaged populations. There is a strong relationship between the health of children and their educational attainment; good health promotes positive learning. This paper reports cross-sectoral executive and senior management level systems changes required to enable the design of a collaborative primary healthcare service model for children and young people in rural Australia.

METHODS

A descriptive qualitative design was used. Data were collected from executive and senior managers from three organisations (Education, Health and a University Department of Rural Health [n =6]) through individual semi-structured interviews. Data were analysed using an inductive, thematic approach. The study draws on Lewin's Model of Change.

RESULTS

Three overarching themes were generated from the data: an embedded challenge and experimental solutions; building a shared language and understanding; and the role of relationships and trust. Despite the unique geographical and social context of the study area, strategies emerged from the data on how a solution to an embedded challenge, through design of a primary healthcare model, was established and how the strategies described could be transferred and scaled to other rural and remote communities.

CONCLUSION

Contextual differences make each rural and remote area unique. In this study, strategies that are described in the managing change literature were evident. The authors conclude that drawing on strong management of change principles could mean that a service model designed for one remote community might be transferrable to other communities.

Creaky knees: Is there a reason for concern? A qualitative study of the perspectives of people with knee crepitus

OBJECTIVE

Crepitus is a feature of osteoarthritis that may affect one's participation in exercise. An informed understanding is required of the perceptions that people have of their knee crepitus and how it affects their exercise behaviours. This study aims to investigate the role that crepitus may play in beliefs about exercise and knee health.

METHODS

Focus group and individual interviews were conducted online with participants who had knee crepitus. The transcripts were thematically analysed through an inductive approach.

RESULTS

Five main themes were identified from 24 participants: (1) individual variation of, (2) occurrence of, (3) meaning of knee crepitus, (4) attitudes and exercise behaviours regarding crepitus, and (5) knowledge deficits and needs concerning crepitus during exercise. The variety of crepitus sounds described occurred with a range of exercises or after inactivity. For those already with osteoarthritis or other symptoms, crepitus was of less concern than symptoms such as pain. Most participants had not ceased exercise but may have modified movement due to crepitus and associated symptoms; some had increased intentional strength training to try alleviating it. Participants agreed that more understanding about the processes causing crepitus and what exercise was safe for knee health would be beneficial.

CONCLUSION

Crepitus does not appear to be a major cause of concern for people who experience it. However, it is a factor that influences exercise behaviours as is pain. If health professionals could guide people with concerns about their crepitus, they may be more confident in exercising to benefit their joint health.

Knee osteoarthritis patient perspectives of their care in an australian private physiotherapy setting: a qualitative exploratory interview study

PURPOSE

This study aimed to understand perceptions that knee osteoarthritis patients have regarding their experiences of guideline-based recommendations within their care received from physiotherapists in private practice.

METHODS

A qualitative semi-structured interview study nested within a larger trial auditing care provided by physiotherapists. Recruited adults ≥ 45 years with knee osteoarthritis across nine primary care physiotherapy practices. Interview questions were anchored around the core elements recommended in guidelines for the management of knee osteoarthritis and patient perceptions of these were analysed using both content and thematic qualitative analysis approaches. Patient satisfaction with care received was asked at the time of interview.

RESULTS

Twenty-six patients volunteered for the study (mean 60 years, 58% female). Analysis identified that physiotherapists focused on treating symptoms through quadriceps strengthening exercises, which patients found to be effective, though focussed less on other aspects of evidenced-based care. Patient's perceived treatment to be effective in relieving pain and enabling them to stay active and they appreciated the positive role that their physiotherapist provided in alleviating their concerns. Overall, patients were satisfied with their physiotherapy care but would have liked more specific osteoarthritis education and longer-term management.

CONCLUSION

The description of the physiotherapy-related care received by people with knee osteoarthritis aligns with guideline recommendations, though mainly for strength-related exercise prescription. Despite some perceived shortfalls in care, patients do appear to be satisfied. However, improvements in patient outcomes may be possible if more elements of guideline-base care are regularly provided, including enhancing osteoarthritis education and fostering behaviour change.

TRIAL REGISTRATION

ACTRN12620000188932.

The effects of an innovative GP-physiotherapist partnership in improving COPD management in primary care

BACKGROUND

Evidence suggests that management of people with Chronic Obstructive Pulmonary Disease (COPD) in primary care has been suboptimal, in particular, with low referral rates to pulmonary rehabilitation (PR). The aim of this study was to evaluate the effectiveness of a GP-physiotherapist partnership in optimising management of COPD in primary care.

METHODS

A pragmatic, pilot, before and after study was conducted in four general practices in Australia. A senior cardiorespiratory physiotherapist was partnered with each general practice. Adults with a history of smoking and/or COPD, aged ≥ 40 years with ≥ 2 practice visits in the previous year were recruited following spirometric confirmation of COPD. Intervention was provided by the physiotherapist at the general practice and included PR referral, physical activity and smoking cessation advice, provision of a pedometer and review of inhaler technique. Intervention occurred at baseline, one month and three months. Main outcomes included PR referral and attendance. Secondary clinical outcomes included changes in COPD Assessment Test (CAT) score, dyspnoea, health activation and pedometer step count. Process outcomes included count of initiation of smoking cessation interventions and review of inhaler technique.

RESULTS

A total of 148 participants attended a baseline appointment where pre/post bronchodilator spirometry was performed. 31 participants with airflow obstruction on post-bronchodilator spirometry (mean age 75yrs (SD 9.3), mean FEV₁% pred = 75% (SD 18.6), 61% female) received the intervention. At three months, 78% (21/27) were referred to PR and 38% (8/21) had attended PR. No significant improvements were seen in CAT scores, dyspnoea or health activation. There was no significant change in average daily step count at three months compared to baseline (mean difference (95% CI) -266 steps (-956 to 423), p = 0.43). Where indicated, all participants had smoking cessation interventions initiated and inhaler technique reviewed.

CONCLUSION

The results of this study suggest that this model was able to increase referrals to PR from primary care and was successful in implementing some aspects of COPD management, however, was insufficient to improve symptom scores and physical activity levels in people with COPD.

TRIAL REGISTRATION

ANZCTR, ACTRN12619001127190. Registered 12 August 2019 - Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx .

Mobile Health Pulmonary Rehabilitation Compared to a Center-Based Program for Cost-Effectiveness and Effects on Exercise Capacity, Health Status, and Quality of Life in People with Chronic Obstructive Pulmonary Disease: A Protocol for a Randomized Controlled Trial

OBJECTIVE

A comprehensive digitalized program is a novel way to improve access to pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD). This study aims to determine if a home-based pulmonary rehabilitation program supported by mobile health (mHealth) technology is equivalent to center-based pulmonary rehabilitation in terms of improvements in exercise capacity and health status in people with COPD.

METHODS

This study is a prospective, multicenter, equivalence randomized controlled trial (RCT) with intention-to-treat analysis. A hundred participants with COPD will be recruited from 5 pulmonary rehabilitation programs. Following randomization, participants will be assigned in a concealed manner to receive either home-based pulmonary rehabilitation supported by mHealth or center-based pulmonary rehabilitation. Both programs will be 8 weeks and will include progressive exercise training, disease management education, self-management support, and supervision by a physical therapist. Co-primary outcome measures will be the 6-Minute Walk Test and the COPD Assessment Test. Secondary outcome measures will include the St George's Respiratory Questionnaire, the EuroQol 5 Dimension 5 Level, the modified Medical Research Council dyspnea scale, the 1-minute sit-to-stand test, the 5 times sit-to-stand test, the Hospital Anxiety and Depression Scale, daily physical activity levels, health care utilization, and costs. Outcomes will be measured at baseline and at the end of the intervention. Participant experience will be assessed through semistructured interviews at the end of the intervention. Utilization of health care and costs will also be measured again after 12 months.

IMPACT

This study will be the first rigorous RCT to examine the effects of a home-based pulmonary rehabilitation program supported by mHealth technology that includes comprehensive clinical outcome evaluation, assessment of daily physical activity, a health economic analysis, and qualitative analysis. If findings demonstrate that there is equivalence in clinical outcomes, that the mHealth program costs the least amount (and is thus cost-effective), and that the mHealth program is acceptable to participants, such programs should be widely implemented to improve access to pulmonary rehabilitation.

Targeted dietary approaches for the management of obesity and severe obesity in children and adolescents: A systematic review and meta-analysis

There is a need for a detailed understanding of effective dietary interventions for children with obesity. This systematic review examined the effectiveness of diets of varying energy content as a component of weight treatment in children and adolescents with obesity, severe obesity and obesity-related comorbidity. A systematic search of six databases, from 2000 to 2021, for intervention studies of targeted dietary treatment for obesity in children aged 2-18 years identified 125 studies. Dietary interventions were grouped according to diet type and energy target. Risk of bias was assessed using the Effective Public Healthcare Panacea Project assessment tool. Meta-analysis examined change in body mass index (BMI) at intervention end. A broad array of diet types were effective at reducing BMI in children with obesity. When dietary types were considered by energy target, a gradient effect was observed. Very-low energy diets were most effective with a - 4.40 kg/m² (n = 3; 95% CI -7.01 to -1.79). While dietary interventions with no specified energy target were ineffective, resulting in a BMI gain of +0.17 kg/m² (n = 22; 95% CI 0.05 to 0.40). Practical definitions of dietary energy target in the management of obesity and severe obesity are urgently required to ensure treatment seeking children have timely access to efficacious interventions.

Telehealth's future in Australian primary health care: a qualitative study exploring lessons learnt from the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, telehealth emerged as a means of safely providing primary healthcare (PHC) consultations. In Australia, changes to telehealth funding led to the reconsideration of the role of telehealth in the ongoing provision of PHC services.

AIM

To investigate GPs', registered nurses' (RNs), nurse practitioners' (NPs), and allied health (AH) clinicians perceptions of the sustainability of telehealth in PHC post-pandemic.

DESIGN & SETTING

Semi-structured interviews were undertaken with 33 purposively selected clinicians, including GPs (n = 13), RNs (n = 5), NPs (n = 9), and AH clinicians (n = 6) working in PHC settings across Australia. Participants were drawn from responders to a national survey of PHC providers (n = 217).

METHOD

The thematic analysis approach reported by Braun and Clarke was used to analyse the interview data.

RESULTS

Data analysis revealed that the perception of providers was represented by the following two themes: lessons learnt; and the sustainability of telehealth. Lessons learnt included the need for rapid adaptation to telehealth, use of technology, and the pandemic being a catalyst for long-term change. The sustainability of telehealth in PHC comprised four subthemes around challenges: the funding model, maintaining patient and provider safety, hybrid service models, and access to support.

CONCLUSION

Providers required resilience and flexibility to adapt to telehealth. Funding models must reward providers from an outcome focus, rather than placing limits on telehealth's use. Hybrid approaches to service delivery will best meet the needs of the community but must be accompanied by support and education for PHC professionals.

Utilising telehealth to support exercise and physical activity in people with Parkinson disease: a program evaluation using mixed methods

BACKGROUND

Physical activity and exercise play a key role in managing Parkinson disease. This study aimed to: 1) determine if physiotherapy supported by telehealth helped people with Parkinson disease (PwP) to adhere to a home-based exercise program and maintain their physical activity; and 2) understand their experiences of using telehealth during the COVID-19 pandemic.

METHODS

A mixed methods program evaluation involving a retrospective file audit from a student-run physiotherapy clinic and semi-structured interviews exploring participants' experiences of telehealth. Ninety-six people with mild to moderate disease received home-based telehealth physiotherapy for 21 weeks. The primary outcome was adherence to the prescribed exercise program. Secondary outcomes were measures of physical activity. Interviews were conducted with 13 clients and seven students and analysed thematically.

RESULTS

Adherence to the prescribed exercise program was high. The mean (SD) proportion of prescribed sessions completed was 108% (46%). On average clients spent 29 (12) minutes per session, and 101 (55) minutes per week exercising. Physical activity levels were maintained, with clients taking 11,226 (4,832) steps per day on entry to telehealth, and 11,305 (4,390) steps per day on exit from telehealth. The semi-structured interviews identified important features of a telehealth service required to support exercise; a flexible approach of clients and therapists, empowerment, feedback, a therapeutic relationship, and mode of delivery.

CONCLUSIONS

PwP were able to continue exercising at home and maintain their physical activity when physiotherapy was provided via telehealth. The flexible approach of both the client and the service was imperative.

The Natural Helper approach to culturally responsive disease management: protocol for a type 1 effectiveness-implementation cluster randomised controlled trial of a cultural mentor programme

INTRODUCTION

Chronic disease is a leading cause of death and disability that disproportionately burdens culturally and linguistically diverse (CALD) communities. Self-management is a cornerstone of effective chronic disease management. However, research suggests that patients from CALD communities may be less likely to engage with self-management approaches. The Natural Helper Programme aims to facilitate patient engagement with self-management approaches (ie, 'activation') by embedding cultural mentors with lived experience of chronic disease into chronic disease clinics/programmes. The Natural Helper Trial will explore the effect of cultural mentors on patient activation, health self-efficacy, coping efforts and health-related quality of life (HRQoL) while also evaluating the implementation strategy.

METHODS AND ANALYSIS

A hybrid type-1 effectiveness-implementation cluster-randomised controlled trial (phase one) and a mixed-method controlled before-and-after cohort extension of the trial (phase 2). Hospital clinics in highly multicultural regions in Australia that provide healthcare for patients with chronic and/or complex conditions, will participate. A minimum of 16 chronic disease clinics (clusters) will be randomised to immediate (active arm) or delayed implementation (control arm). In phase 1, the active arm will receive a multifaceted strategy supporting them to embed cultural mentors in their services while the control arm continues with usual care. Each cluster will recruit an average of 15 patients, assessed at baseline and 6 months (n=240). In phase 2, clusters in the control arm will receive the implementation strategy and evaluate the intervention on an additional 15 patients per cluster, while sustainability in active arm clusters will be assessed qualitatively. Change in activation over 6 months, measured using the Patient Activation Measure will be the primary effectiveness outcome, while secondary effectiveness outcomes will explore changes in chronic disease self-efficacy, coping strategies and HRQoL. Secondary implementation outcomes will be collected from patient-participants, mentors and healthcare providers using validated questionnaires, customised surveys and interviews aligning with the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to evaluate acceptability, reach, dose delivered, sustainability, cost-utility and healthcare provider determinants.

ETHICS AND DISSEMINATION

This trial has full ethical approval (2021/ETH12279). The results from this hybrid trial will be presented at scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12622000697785.

Telehealth use in Australian primary healthcare during COVID-19: a cross-sectional descriptive survey

OBJECTIVE

This study aimed to investigate Australian primary healthcare professionals' experiences of the rapid upscaling of telehealth during COVID-19.

DESIGN

A cross-sectional survey.

PARTICIPANTS AND SETTING

Two hundred and seventeen general practitioners, nurses and allied health professionals employed in primary healthcare settings across Australia were recruited via social media and professional organisations.

METHODS

An online survey was disseminated between December 2020 and March 2021. The survey comprised items about individual demographics, experiences of delivering telehealth consultations, perceived quality of telehealth consultations and future perceptions of telehealth.

RESULTS

Telephone was the most widely used method of providing telehealth, with less than 50% of participants using a combination of telephone and video. Key barriers to telehealth use related to the inability to undertake physical examination or physical intervention. Telehealth was perceived to improve access to healthcare for some vulnerable groups and those living in rural settings, but reduced access for people from non-English-speaking backgrounds. Quality of telehealth care was considered mostly or somewhat the same as care provided face-to-face, with actual or perceived negative outcomes related to missed or delayed diagnosis. Overwhelmingly, participants wanted telehealth to continue with guaranteed ongoing funding. Some 43.7% of participants identified the need to further improve telehealth models of care.

CONCLUSION

The rapid shift to telehealth has facilitated ongoing care during the COVID-19 pandemic. However, further work is required to better understand how telehealth can be best harnessed to add value to service delivery in usual care.

Identifying airway obstruction in primary care: is there a role for physiotherapists?

Aims

To examine the implementation of a physiotherapist-driven spirometry case finding service in primary care to identify new cases of COPD and confirm diagnosis of existing cases of COPD.

Methods

Four general practices were recruited. ‘At risk’ participants (aged ≥ 40 years, current/ex-smoker) and people with ‘existing’ COPD were identified from practice databases and invited to attend an assessment with a cardiorespiratory physiotherapist in each general practice. The physiotherapist performed pre/post-bronchodilator spirometry to identify or confirm a diagnosis of COPD (FEV1/FVC < 0.7). Outcome measures included number (%) of new cases of COPD, number (%) confirmed diagnosis of COPD and number (%) of high quality spirometry assessments with accurate interpretation.

Results

One hundred forty eight participants (mean age 70 years (SD 11.1), 57% female) attended a baseline assessment (117 ‘at risk’, 31’existing’ COPD) from 748 people invited. Physiotherapists performed 145 pre/post bronchodilator spirometry assessments. Obstruction on post-bronchodilator spirometry was confirmed in 17% (19/114) of ‘at risk’ and 77% (24/31) of ‘existing’ COPD. Majority of cases were classified as GOLD Stage II (63%, n = 27). Quality of pre/post bronchodilator spirometries for FEV1 were classified as A (68%), B (19%) and C (5%).

Conclusion

Physiotherapists integrated into primary care performed high quality spirometry testing, successfully case finding ‘at risk’ patients and identifying potential misdiagnosis of obstruction in some ‘existing’ COPD cases.

Trial registration

ANZCTR, ACTRN12619001127190. Registered 12 August 2019 – Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx

Does resilience predict hospital length of stay after total knee arthroplasty? A prospective observational cohort study

Background

Resilience, or the ability to bounce back from stress, is a key psychological factor that is associated with ongoing functional independence and higher quality of life in older adults in the context of chronic health conditions. Emerging research has explored resilience and patient-reported outcomes after TKA. Our primary aim was to explore the relationship between resilience and acute hospital length of stay after total knee arthroplasty (TKA).

Methods

A prospective observational study recruited 75 participants one month before total knee arthroplasty from two Australian hospitals. Two preoperative psychological measures were used: the Brief Resilience Scale, and for comparison, the Depression, Anxiety and Stress Scale-21 (DASS-21). We collected sociodemographic, medical and surgical details, patient-reported pain, function, fatigue and quality of life one month before TKA. Health service data describing acute hospital length of stay, inpatient rehabilitation use, and physiotherapy occasions of service were collected after TKA. Non-parametric analysis was used to determine any differences in length of stay between those with low or high resilience and DASS-21 scores. Secondary regression analysis explored the preoperative factors affecting acute hospital length of stay.

Results

No significant difference was detected in length of stay between those with a low or a high resilience score before TKA. However, the group reporting psychological symptoms as measured by the DASS-21 before TKA had a significantly longer acute hospital length of stay after TKA compared to those with no psychological symptoms [median length of stay 6 (IQR 2.5) days vs. 5 (IQR 2) days, respectively (Mann-Whitney U = 495.5, P=0.03)]. Multivariate regression analysis showed that anesthetic risk score and fatigue were significant predictors of length of stay, with the overall model demonstrating significance (χ2=12.426, df = 4, P=0.014).

Conclusions

No association was detected between the brief resilience score before TKA and acute hospital length of stay after TKA, however, symptoms on the DASS-21 were associated with longer acute hospital length of stay. Preoperative screening for psychological symptoms using the DASS-21 is useful for health services to identify those at higher risk of longer acute hospital length of stay after TKA.

1012 A Close Loop Audit of Acute Food Bolus Obstruction at a District General Hospital

Aim

The British Society of Gastroenterology (BSG) recommends biopsies from two different regions in the oesophagus. A close loop audit was undertaken to assess performance at a district general hospital, against these guidelines and following newly agreed trust guidelines after the first audit cycle of a follow up OGD within 6 weeks of the presentation.

Method

Data was collected of patients admitted with a food bolus over the first cycle (March2019 to February 2021) and the second cycle (1/10/21 to 14/10/21). Exclusion criteria were age of less than 18 and sharp food bolus.

Results

69 patients were identified. Average age was 60 years. There were 67% male patients and 33% female. 20% of patients underwent a follow up OGD in the first cycle and 45%underwent a follow up OGD within six weeks. 7% had two regions biopsy in the first cycle and21% in the second cycle. Average OGD follow up time was 92 days in the first cycle and 59days in the second cycle. Commonest findings on histology results were eosinophilic oesophagitis and Barrett's oesophagus (22% each), GORD (15%) and carcinoma (7%).

Discussion

Food bolus obstruction indicates the presence of pathology of the oesophagus and should be investigated as so, even despite spontaneous recovery from the acute event. Number of patients undergoing OGD within six weeks and a two regions biopsy improved through this audit by implementing the new trust guidelines.

Prevalence and determinants of physical activity, sedentary behaviour and fatigue five years after total knee replacement

OBJECTIVE

To determine the prevalence and predictors of physical activity, sedentary behaviour and fatigue five years after total knee replacement surgery.

DESIGN

A longitudinal cohort study.

SETTING

Community-dwelling adults who had previously undergone total knee replacement.

METHODS

Five-year follow-up questionnaire data were obtained from participants previously enrolled in a randomised controlled trial examining rehabilitation after total knee replacement. Main study outcomes at one year did not differ between randomisation groups, hence data were pooled for the present longitudinal analysis. Before and one and five years after surgery, participants completed questionnaires (Active Australia Survey, WOMAC, SF12 v2, demographics and fatigue).

RESULTS

272/422 community-dwelling adults (45-74 years) completed the questionnaires at five years. Excessive sedentary behaviour was evident in 91% of the cohort, predicted by excessive sedentary behaviour and lack of energy at one year. Inadequate physical activity at five years was evident for 59% of the cohort, predicted by higher fatigue and comorbidity scores pre-surgery and inadequate physical activity at one year. Just under half (47%) of the cohort experienced clinically-important fatigue at five years, predicted by clinically-important fatigue before and one year after surgery, lack of sleep before surgery and physical activity one year after surgery.

CONCLUSION

Documenting physical activity, sedentary behaviour and fatigue before and one year after knee replacement is important to identify those at risk of longer-term inadequate physical activity, excessive sedentary behaviour and clinically-important fatigue. Interventions to maintain activity and reduce sedentary behaviour are needed to reap the potential health benefits of total knee replacement surgery.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

'What is this about? Let's play this out': the experience of integrating primary health care registered nurses with school learning and support teams

Changes in public health profiles and moves towards inclusive models of education have led to significant number of students in mainstream schools with special health needs. Addressing these needs requires collaboration between health professionals, educators and families. Integrated models of school-based health care can facilitate this collaboration; however, there is little evidence to guide their implementation. The School-Based Primary Health Care Service (SB-PHCS) is one such service that has been established in far west New South Wales. The School-Based Primary Health Care Service embeds health district-employed registered nurses with school learning support teams to increase service access, and improve health and education outcomes for students. We conducted focus groups with nurses and learning support teams to explore their experiences of implementing the School-Based Primary Health Care Service. Focus group transcripts were analysed using framework analysis. We found that defining the role and working across systems were challenges to program implementation, whereas a collaborative culture, relationship building and flexibility in work processes facilitated the integration of nurses into the school teams. We recommend others embarking on similar initiatives involve key stakeholders early in service development, understand each other's systems and processes, and provide clarity about the new role, but plan to adapt the role to fit the context. This study will be of interest to those involved in the implementation of integrated models of school-based health care.

The role of quality improvement collaboratives in general practice: a qualitative systematic review

Background

This systematic review used qualitative methodologies to examine the role of quality improvement collaboratives (QICs) in general practice. The aim was to inform implementers and participants about the utility of using or participating in QICs in general practice.

Methods

Included studies were published in English, used a QIC intervention, reported primary research, used qualitative or mixed methods, and were conducted in general practice.

A Medline search between January 1995 and February 2020 was developed and extended to include Embase, CINAHL and PsycInfo databases. Articles were sought through chaining of references and grey literature searches.

Qualitative outcome data were extracted using a framework analysis. Data were analysed using thematic synthesis. Articles were assessed for quality using a threshold approach based on the criteria described by Dixon-Woods.

Results

15 qualitative and 18 mixed-methods studies of QICs in general practice were included. Data were grouped into four analytical themes which describe the role of a collaborative in general practice: improving the target topic, developing practices and providers, developing the health system and building quality improvement capacity.

Discussion

General practice collaboratives are reported to be useful for improving target topics. They can also develop knowledge and motivation in providers, build systems and team work in local practice organisations, and improve support at a system level. Collaboratives can build quality improvement capacity in the primary care system. These roles suggest that QICs are well matched to the improvement needs of general practice.

General practice participants in collaboratives reported positive effects from effective peer interaction, high-quality local support, real engagement with data and well-designed training in quality improvement.

Strengths of this study were an inclusive search and explicit qualitative methodology. It is possible some studies were missed. Qualitative studies of collaboratives may be affected by selection bias and confirmation bias.

PROSPERO registration number

CRD4202017512.

Exercising with Parkinson's: The good, the bad and the need for support to keep exercising. A qualitative study

OBJECTIVES

To explore the experiences of people with Parkinson's disease exercising and to determine if the location (home versus centre) or exercising in a group impacted on their experience.

DESIGN

A qualitative study.

PARTICIPANTS

Community-dwelling people with mild to moderate Parkinson's disease who had undertaken a 10-week exercise intervention.

METHOD

Semi-structured interviews were conducted with 17 participants; nine participants had completed 10-weeks of predominately home-based exercise and eight participants had predominately centre-based excercise. Interviews were recorded, transcribed verbatim and analysed using inductive thematic analysis.

RESULTS

Four key themes emerged. Two themes: 'targeted exercise is important when you have Parkinson's disease' and 'support helps me to gain the most from the exercise', were related to exercising with Parkinson's disease and were not specific to location. Two themes encompassed the perceptions when exercising at a centre in a group compared to exercising at home: 'the good and the bad of exercising in a group' and 'exercising at home, can I do it?'

CONCLUSION

Experiences of people with Parkinson's disease when exercising were primarily influenced by the prescription of specific exercise and the support provided. There was no clear preference for the location of exercise but maintaining the motivation to exercise at home was challenging.

Accuracy of the COPD diagnostic questionnaire as a screening tool in primary care

BACKGROUND

The COPD Diagnostic Questionnaire (CDQ) was developed to identify people who would benefit from spirometry testing to confirm Chronic Obstructive Pulmonary Disease (COPD). The aim of this study was to determine the usefulness of a cut-off score of 16.5 on the CDQ in identifying those at increased risk of obstruction, in a mixed population of people 'at risk' of COPD and those with an 'existing' COPD diagnosis.

METHODS

People 'at risk' of COPD (aged > 40 years, current/ex-smoker) and those with 'existing' COPD were identified from four general practices and invited to participate. Participants completed the CDQ and those with a CDQ score ≥ 16.5 were categorised as having intermediate to increased likelihood of airflow obstruction. Pre and post-bronchodilator spirometry determined the presence of airway obstruction (FEV₁/FVC ratio < 0.7). Sensitivity, specificity and accuracy of the CDQ was determined compared to spirometry as the gold standard.

RESULTS

One hundred forty-one participants attended an initial assessment ('at risk' = 111 (79%), 'existing' COPD = 30 (21%)). A cut-off score of 16.5 corresponded to a sensitivity of 81%, specificity of 36% and accuracy of 50%, in the entire mixed population. The area under the ROC curve was 0.59 ± 0.50 indicating low diagnostic accuracy of the CDQ. Similar results were found in the 'existing' COPD group alone.

CONCLUSION

Whilst a cut-off score of 16.5 on the CDQ may result in a large number of false positives, clinicians may still wish to use the CDQ to refine who receives spirometry due to its high sensitivity.

TRIAL REGISTRATION

ANZCTR, ACTRN12619001127190. Registered 12 August 2019 - Retrospectively registered, http://www.ANZCTR.org.au/ACTRN12619001127190.aspx.

Brief physical activity counselling by physiotherapists (BEHAVIOUR): protocol for an effectiveness-implementation hybrid type II cluster randomised controlled trial

BACKGROUND

Physical inactivity is a leading risk factor for chronic disease. Brief physical activity counselling delivered within healthcare systems has been shown to increase physical activity levels; however, implementation efforts have mostly targeted primary healthcare and uptake has been sub-optimal. The Brief Physical Activity Counselling by Physiotherapists (BEHAVIOUR) trial aims to address this evidence-practice gap by evaluating (i) the effectiveness of a multi-faceted implementation strategy, relative to usual practice for improving the proportion of patients receiving brief physical activity counselling as part of their routine hospital-based physiotherapy care and (ii) effectiveness of brief physical activity counselling embedded in routine physiotherapy care, relative to routine physiotherapy care, at improving physical activity levels among patients receiving physiotherapy care.

METHODS

Effectiveness-implementation hybrid type II cluster randomised controlled trial with embedded economic evaluation, qualitative study and culturally adapted patient-level outcome measures. The trial will be conducted across five hospitals in a local health district in Sydney, Australia, with a lower socioeconomic and culturally diverse population. The evidence-based intervention is brief physical activity counselling informed by the 5As counselling model and behavioural theory, embedded into routine physiotherapy care. The multi-faceted strategy to support the implementation of the counselling intervention was developed with key stakeholders guided by the Consolidated Framework for Implementation Research and the Capabilities, Opportunities, Motivation-Behaviour (COM-B) theoretical model, and consists of clinician education and training, creating a learning collaborative, tailored strategies to address community referral barriers, team facilitation, and audit and feedback. Thirty teams of physiotherapists will be randomised to receive the multi-faceted implementation strategy immediately or after a 9-month delay. Each physiotherapy team will recruit an average of 10 patients (n=300) to collect effectiveness outcomes at baseline and 6 months. The primary effectiveness outcome is self-reported planned physical activity using the Incidental and Planned Exercise Questionnaire, and the primary implementation outcome is reach (proportion of eligible new physiotherapy patients who receive brief physical activity counselling). Secondary effectiveness and implementation outcomes will also be collected.

DISCUSSION

This project focuses on physiotherapists as health professionals with the requisite skills and patterns of practice to tackle the increasing burden of chronic disease in a high-risk population.

TRIAL REGISTRATION

ANZCTR, ACTRN12621000194864 . Registered on 23 February 2021.

Allied health are key to improving health for people with chronic disease: but where are the outcomes and where is the strategy?

The global burden of chronic disease has forced health systems to focus on improved care. This has led to improved health outcomes for some populations, but not for all people or for all conditions. The rising prevalence of chronic disease has also significantly increased demands on healthcare systems, with unsustainable costs to funders. To improve health and social outcomes for all people with chronic disease, it is critical to embrace allied health professionals as key members of primary healthcare teams. The recognised efficacy and cost-effectiveness of many allied health interventions suggest that implementation into usual care would result in enhanced outcomes for people accessing healthcare, their families and communities, and for health systems. Our aim is to highlight the current unacceptable lack of allied health integration into primary healthcare teams, and illustrate the potential value of improved and equitable access to allied health professionals for managing chronic conditions and multimorbidity.

Demonstrating the processes and outcomes of a rural Community Mental Health Rehabilitation Service: A realist evaluation

BACKGROUND

As part of significant mental health reform, the Community Mental Health Rehabilitation Service (CMHRS) was implemented in rural South Australia. The CMHRS is a 10-bed mental health residential program offering rehabilitative mental health support to rural residents.

AIM

To analyse the CMHRS service delivery model and its impact on recovery outcomes for consumers.

METHODS

A mixed method, realist evaluation approach was utilised. A purposive sample of CMHRS staff (n = 6) and consumers (n = 8) were recruited. Consumer recovery was measured using the RAS-DS (on admission and discharge). Participants' perspectives of the service were gained via one staff focus group (n = 6) and individual semi-structured interviews (consumers n = 6; staff n = 2). Pre-post RAS-DS scores were analysed using paired t-tests/Wilcoxon paired-signed rank test, with qualitative data analysed thematically.

RESULTS

Significant positive increases in RAS-DS total scores were observed at discharge, supported by the qualitative themes of (re)building relationships and social connections and recovering health and wellbeing. Contextual factors (e.g. staffing) and program mechanisms (e.g. scheduling) impacting on service implementation were identified.

CONCLUSION

Maintaining a rehabilitation recovery-focused approach, balanced with an appropriately trained multi-disciplinary team, are vital for maximising positive consumer outcomes.

SIGNIFICANCE

This realist evaluation identifies critical factors impacting rural mental health rehabilitation service delivery.

A Mixed-Methods Investigation into Patients' Decisions to Attend an Emergency Department for Chronic Pain

OBJECTIVE

This study explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born.

DESIGN AND METHODS

This mixed-methods study was underpinned by the Behavioral Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy, and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5 focus groups) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilization and contributing factors for both cohorts.

RESULTS

ED attendance was a product of escalating distress, influenced by the degree to which participants' perceived needs outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure, and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophizing, lower health literacy, and greater social challenges present for the CALD cohort.

CONCLUSION

This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for health care providers to recognize features of higher vulnerability and consider streamlining access to available support services.

Challenges and opportunities for conducting a vaccine trial during the COVID-19 pandemic in the United Kingdom

The COVID-19 pandemic has resulted in unprecedented challenges for healthcare systems worldwide. It has also stimulated research in a wide range of areas including rapid diagnostics, novel therapeutics, use of technology to track patients and vaccine development. Here, we describe our experience of rapidly setting up and delivering a novel COVID-19 vaccine trial, using clinical and research staff and facilities in three National Health Service Trusts in Cambridgeshire, United Kingdom. We encountered and overcame a number of challenges including differences in organisational structures, research facilities available, staff experience and skills, information technology and communications infrastructure, and research training and assessment procedures. We overcame these by setting up a project team that included key members from all three organisations that met at least daily by teleconference. This group together worked to identify the best practices and procedures and to harmonise and cascade these to the wider trial team. This enabled us to set up the trial within 25 days and to recruit and vaccinate the participants within a further 23 days. The lessons learned from our experiences could be used to inform the conduct of clinical trials during a future infectious disease pandemic or public health emergency.

Six-week behaviour change intervention to reduce sedentary behaviour in people with chronic obstructive pulmonary disease: a randomised controlled trial

INTRODUCTION

This study aimed to determine whether a 6-week behaviour change intervention was more effective than a sham intervention for reducing sedentary behaviour (SB) in people with chronic obstructive pulmonary disease (COPD).

METHODS

People with stable COPD on the waitlist for entry into pulmonary rehabilitation were recruited to this multicentre trial with randomisation (independent, concealed allocation) to either an intervention group or sham group, assessor blinding and intention-to-treat (ITT) analysis. The behaviour change intervention consisted of once weekly sessions for 6 weeks with a physiotherapist to reduce SB through education, guided goals setting and real-time feedback on SB. The sham intervention consisted of once weekly phone calls for 6 weeks to monitor health status. SB was measured continuously over 7 days using thigh-worn accelerometry (activPAL3 micro). The primary outcome was time spent in SB. Participants with at least 4 days of ≥10 hours waking wear time were included in the ITT analysis and those who reported achieving ≥70% of goals to reduce SB or who completed all sham calls were included in a per-protocol analysis.

RESULTS

70 participants were recruited and 65 completed the study (mean±SD age 74±9 years, mean FEV₁ 55%±19% predicted, 49% male). At 6 weeks, no between-group differences in time spent in SB were observed in the ITT analysis (mean difference 5 min/day, 95% CI -38 to 48) or per-protocol analysis (-16 min/day, 95% CI -80 to 48).

DISCUSSION

A 6-week behaviour change intervention did not reduce time in SB compared with a sham intervention in people with stable moderate-to-severe COPD prior to pulmonary rehabilitation.

Sagittal spine shape literacy in the general adult population, assessed by a novel, simple graphical tool

[Purpose] The sagittal shape of the spine is associated with back-pain, balance and quality of life. We developed, evaluated and report the responses of a graphical tool to assess sagittal spine shape knowledge (literacy). [Participants and Methods] Two hundred and fifty adults were randomly assigned, in a cross-sectional crossover study, to free-hand draw and select the “ideal” sagittal spine shape. We evaluated the inter and intra-rater reliability and agreement between tests and the sagittal and lordotic spine literacy between the drawing and selection test versions. [Results] Drawing test inter- and intra-rater agreement was 79% and 80% respectively. Drawing vs. selection agreement was 43%. More participants drew than selected the correct spine (30% vs. 21%) (p<0.001) and lumbar lordosis shape (56% vs. 42%) (p<0.001). Test order did not affect spine shape literacy scores. A significantly poorer literacy trend was observed with spine pain presence (p=0.02). [Conclusion] We developed a reliable method to evaluate spine shape literacy and established that only 21% and 42% of our sample demonstrated correct sagittal spine and lordotic spine shape literacy, respectively. The low literacy scores suggests that consideration of including spine shape literacy in health literacy and self-management programs may be warranted, especially in ageing populations.

Current Practice of Physical Activity Counselling within Physiotherapy Usual Care and Influences on Its Use: A Cross-Sectional Survey

Physical activity counselling has demonstrated effectiveness at increasing physical activity when delivered in healthcare, but is not routinely practised. This study aimed to determine (1) current use of physical activity counselling by physiotherapists working within publicly funded hospitals; and (2) influences on this behaviour. A cross-sectional survey of physiotherapists was conducted across five hospitals within a local health district in Sydney, Australia. The survey investigated physiotherapists’ frequency of incorporating 15 different elements of physical activity counselling into their usual healthcare interactions, and 53 potential influences on their behaviour framed by the COM-B (Capability, Opportunity, Motivation-Behaviour) model. The sample comprised 84 physiotherapists (79% female, 48% <5 years of experience). Physiotherapists reported using on average five (SD:3) elements of physical activity counselling with at least 50% of their patients who could be more active. A total of 70% of physiotherapists raised or discussed overall physical activity, but less than 10% measured physical activity or contacted community physical activity providers. Physiotherapists reported on average 25 (SD:9) barriers influencing their use of physical activity counselling. The most common barriers were related to “opportunity”, with 57% indicating difficulty locating suitable community physical activity opportunities and >90% indicating their patients lacked financial and transport opportunities. These findings confirm that physical activity counselling is not routinely incorporated in physiotherapy practice and help to identify implementation strategies to build clinicians’ opportunities and capabilities to deliver physical activity counselling.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Distinct functional and structural connections predict crystallised and fluid cognition in healthy adults

White matter pathways between neurons facilitate neuronal coactivation patterns in the brain. Insight into how these structural and functional connections underlie complex cognitive functions provides an important foundation with which to delineate disease‐related changes in cognitive functioning. Here, we integrate neuroimaging, connectomics, and machine learning approaches to explore how functional and structural brain connectivity relate to cognition. Specifically, we evaluate the extent to which functional and structural connectivity predict individual crystallised and fluid cognitive abilities in 415 unrelated healthy young adults (202 females) from the Human Connectome Project. We report three main findings. First, we demonstrate functional connectivity is more predictive of cognitive scores than structural connectivity, and, furthermore, integrating the two modalities does not increase explained variance. Second, we show the quality of cognitive prediction from connectome measures is influenced by the choice of grey matter parcellation, and, possibly, how that parcellation is derived. Third, we find that distinct functional and structural connections predict crystallised and fluid abilities. Taken together, our results suggest that functional and structural connectivity have unique relationships with crystallised and fluid cognition and, furthermore, studying both modalities provides a more comprehensive insight into the neural correlates of cognition.

Assessing health literacy among adult outpatients attending allied health clinics in western sydney: A cross-sectional survey using a multidimensional instrument

ISSUE ADDRESSED

Low health literacy disproportionately affects adults from culturally and linguistically diverse backgrounds. This study investigated the health literacy of adults attending outpatient allied health services in western Sydney, a highly diverse region in Sydney with residents from a range of cultural and linguistic backgrounds.

METHODS

A cross-sectional survey was undertaken between March and April 2017 using the Health Literacy Questionnaire (HLQ). Participants, aged over 18 years and with a primary language of English, Arabic, Chinese or Hindi, were recruited from outpatient allied health clinics at Westmead Hospital. Means (standard deviation) for each of the nine HLQ domains were calculated and associations with demographic variables were investigated using analysis of variance (ANOVA).

RESULTS

Two hundred and thirty people were included with mean age of 45.1 years (SD = 19.0), the majority were female (75.5%), over half were born overseas (55.7%) and 77.6% reported speaking English at home. The highest mean score on a HLQ domain (out of 5) was "Understanding health information well enough to know what to do" (M = 4.19; SD = 0.67), and the lowest mean score (out of 4) was "Appraisal of health information" (M = 2.97; SD = 0.54). Participants who did not speak English at home had significantly lower scores on seven of the nine HLQ domains.

CONCLUSIONS

Important health literacy strengths and limitations of a diverse sample of adults attending outpatient allied health services in western Sydney were identified. Findings should be considered in the light of the cross-sectional survey methodology with non-random sampling.

SO WHAT

Data will inform future interventions to improve health literacy and health outcomes among vulnerable population groups in western Sydney.

Home-based exercise monitored with telehealth is feasible and acceptable compared to centre-based exercise in Parkinson's disease: A randomised pilot study

OBJECTIVES

To investigate the feasibility and acceptability of a home-based exercise program monitored using telehealth for people with Parkinson's disease.

DESIGN

Pilot randomised control trial.

SETTING

University physiotherapy clinic, participants' homes.

PARTICIPANTS

Forty people with mild to moderate Parkinson's disease, mean age 72 (6.9).

INTERVENTION

In Block 1 (5 weeks) all participants completed predominantly centre-based exercise plus a self-management program. Participants were then randomised to continue the centre-based exercise (n = 20) or to a home-based program with telehealth (n = 20) for Block 2 (5 weeks). The exercises targeted balance and gait.

OUTCOMES

The primary outcomes were the feasibility and acceptability of the intervention. Secondary outcomes were balance, gait speed and freezing of gait.

RESULTS

Adherence was high in Block 1 (93%), and Block 2 (centre-based group = 93%, home-based group = 84%). In Block 2, the physiotherapist spent 6.4 hours providing telehealth to the home-based group (mean 10 (4) minutes per participant) and 32.5 hours delivering the centre-based exercise classes (98 minutes per participant). Participants reported that exercise was helpful, they could follow the home program and they would recommend exercising at home or in a group. However, exercising at home was less satisfying and there was a mixed response to the acceptability of the self-management program. There was no difference between groups in any of the secondary outcome measures (preferred walking speed mean difference -0.04 (95% CI: -0.12 to 0.05).

CONCLUSION

Home-based exercise monitored using telehealth for people with Parkinson's disease is feasible and acceptable.

'We're definitely that link': the role of school-based primary health care registered nurses in a rural community

Children and adolescents in rural Australia experience poorer health and educational outcomes than those in urban areas. This paper presents findings from a qualitative study exploring the role of primary health care registered nurses (RNs) working in the School-Based Primary Health Care Service in Broken Hill, far west New South Wales. The Service integrates health district-employed RNs with school learning and support teams to increase service access and improve health and education outcomes for students. The findings show that RNs used care navigation to reduce barriers to care by addressing healthcare candidacy with students and families. The RNs also linked schools, families and health and social care services, and facilitated intersectoral collaboration to improve the support provided to students experiencing health and developmental issues. Integrating health district-employed RNs with existing student support services is a promising approach to improving the health and education of disadvantaged students. This study provides individual- and system-level explanations of the role of the school-based primary health care RN and can inform the development of similar services elsewhere.

How to implement patient experience surveys and use their findings for service improvement: a qualitative expert consultation study in Australian general practice

Objective

To identify barriers (patient, provider, practice and system levels) to consider when implementing patient experience surveys in Australian general practice and enablers of their systematic use to inform service improvement in clinical practice as well as the broader health system.

Methods and analysis

An expert consultation and qualitative content analysis of cross-sectional, open-text survey data. Data were collected from key international and Australian experts in the areas of measurement and quality improvement in general practice.

Results

Responses from 20 participants from six countries were included in the study. Participants discussed the importance of ensuring value and relevance of surveys to stakeholders. Lack of resources, IT infrastructure, capacity building and sustained funding were identified as barriers to implementing surveys. Participants discussed the importance of clearly defining and communicating the purpose of surveys and agreed on the value of using patient experience to inform reflective, team-based learning at the practice level. Opinions differed on the use of patient experience data at the system level, with some questioning its utility or fairness for external performance reporting. Others recommended the aggregation and reporting of these data under certain conditions, including for the purpose of triangulation with other quality and outcome data. The study identified an evidence gap in the assessment and interpretation of patient experience data at the practice and system levels, including the analysis and contextualisation of survey findings at the system level.

Conclusion

Patient experience surveys have potential for guiding practice level quality improvement, but many barriers to their implementation remain. There is need for greater research and policy efforts to understand how this information can be used at the system level for improving Australian general practice.

The feasibility of an innovative GP-physiotherapist partnership to identify and manage chronic obstructive pulmonary disease (INTEGRATED): study protocol

BACKGROUND

Chronic obstructive pulmonary disease (COPD) contributes significantly to mortality, hospitalisations and health care costs worldwide. There is evidence that the detection, accurate diagnosis and management of COPD are currently suboptimal in primary care. Physiotherapists are well-trained in cardiorespiratory management and chronic care but are currently underutilised in primary care. A cardiorespiratory physiotherapist working in partnership with general practitioners (GPs) has the potential to improve quality of care for people with COPD.

METHODS

A prospective pilot study will test the feasibility of an integrated model of care between GPs and physiotherapists to improve the diagnosis and management of people with COPD in primary care. Four general practices will be selected to work in partnership with four physiotherapists from their local health district. Patients at risk of developing COPD or those with a current diagnosis of COPD will be invited to attend a baseline assessment with the physiotherapist, including pre- and post-bronchodilator spirometry to identify new cases of COPD or confirm a current diagnosis and stage of COPD. The intervention for those with COPD will involve the physiotherapist and GP working in partnership to develop and implement a care plan involving the following tailored to patient need: referral to pulmonary rehabilitation (PR), physical activity counselling, medication review, smoking cessation, review of inhaler technique and education. Process outcomes will include the number of people invited and reviewed at the practice, the proportion with a new diagnosis of COPD, the number of patients eligible and referred to PR and the number who attended PR. Patient outcomes will include changes in symptoms, physical activity levels, smoking status and self-reported exacerbations.

DISCUSSION

If feasible, we will test the integration of physiotherapists within the primary care setting in a cluster randomised controlled trial. If the model improves health outcomes for the growing numbers of people with COPD, then it may provide a GP-physiotherapist model of care that could be tested for other chronic conditions.

TRIAL REGISTRATION

ANZCTR, ACTRN12619001127190. Registered on 12 August 2019-retrospectively registered.

Core surgical field camps: a new deanery-based model for enhancing advanced skills in core surgical trainees through simulation

Hands-on wet lab simulation training is a vital part of modern surgical training. Since 2010, surgical 'boot camps' have been run by many UK deaneries to teach core surgical trainees basic entry level skills. Training in advanced skills often requires attendance at national fee-paying courses. In the Wessex Deanery, multiple, free of charge, core surgical 'field camps' were developed to provide more advanced level teaching in the particular specialty preference of each core surgical trainee. After the COVID-19 pandemic, national hands-on courses will be challenging to provide and deanery-based advanced skills training may be the way forward for craft-based specialties. The experiences over 2 years of delivering the Wessex core surgical field camps are shared, giving a guide and advice for other trainers on how to run a field camp.

Implementation of a community-based, physiotherapy-led, multidisciplinary model of care for the management of knee osteoarthritis: protocol for a feasibility study

INTRODUCTION

There is a gap between the care people with knee osteoarthritis (OA) should receive according to evidence-based guidelines and the care they do receive. This feasibility study aims to test the feasibility of developing and implementing a codesigned, physiotherapy-led, multidisciplinary, evidence-based model of care for knee OA, among community physiotherapy practices in Australia, where community practice is defined as a professional physiotherapy business that is not controlled or paid for by the government.

METHODS AND ANALYSIS

A mixed-methods quasi-experimental (pre/postintervention) study. In the preintervention phase, all consented physiotherapists working in nine metropolitan-based, community physiotherapy practices, and 26 patients with knee OA will be recruited. Patients will be recruited from all practices by the physiotherapists, using the outlined inclusion/exclusion criteria. An audit of physiotherapy treatment notes will occur using a proforma, to gain an understanding of current community physiotherapy treatment and documentation. Patient and physiotherapist interviews will be conducted to determine current practice for the management of knee OA. A codesign phase will follow, where a model of care will be developed by researchers, patients, clinical staff, members of the public and other stakeholders, based on current guidelines for conservative management of knee OA. In the postintervention phase, a further 26 patients will be recruited, and the assessment process repeated to determine whether there is a change in practice. The feasibility outcome measures are: (1) number of patients who are recorded as receiving care according to current evidence-based guidelines; (2) number of patients who have patient-reported outcomes incorporated into their assessment and management plan; and (3) acceptability of the developed model to patients and physiotherapists. The clinical outcomes will include assessment of patient-reported outcome measures (pain, function, etc) in the preintervention and postintervention phases (baseline and 12 weeks) to assess trends towards change in participant symptoms.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of New South Wales human ethics committee (approval number HC180864, approval period 6 February 2019 to 5 February 2024). The preintervention stage of this study is complete. The next stage is to implement the intervention and compare outcomes between the preintervention and postintervention phases. The results will be disseminated via peer-reviewed publications and presentations at conferences.

TRIAL REGISTRATION NUMBER

The preintervention phase of the study is retrospectively registered at ClinicalTrials.gov with registration number: ACTRN12620000188932. The intervention and postintervention phase of the study is prospectively registered at ClinicalTrials.gov with registration number: ACTRN12620000218998.

Implementing the Patient Activation Measure (PAM) in clinical settings for patients with chronic conditions: a scoping review

Objective

The Patient Activation Measure (PAM) assesses the knowledge, skills and confidence of patients to manage their health, and has been consistently used as an outcome measure of health interventions. Using the PAM to tailor interventions to a patient’s activation level is less understood. This literature review aimed to examine evidence for interventions using the PAM to tailor care for patients with chronic conditions, including enablers and barriers to implementation, and the impact on quality of care.

Methods and analysis

A scoping review methodology was used to identify literature reporting on PAM-tailored interventions. The Insignia Health website and Medline database were searched. Included papers were published in English from 2004 to 2017, from Organisation for Economic Cooperation and Development countries, included adult patients with chronic conditions, and a PAM-tailored intervention. Eligible full-text papers were assessed against the inclusion criteria. Data were extracted into tables and summarised to assess the key findings, recurring themes and differences across papers.

Results

Twenty-one papers describing the use of PAM-tailored interventions (n=21) were identified. Interventions included motivational interviewing, health coaching, self-management planning and risk profile assessment. The perceived value and function of the PAM held by organisations, clinicians and patients influenced implementation and use. Evidence for the impact of PAM-tailored interventions on quality of care was limited.

Conclusion

The PAM is being used to tailor a range of interventions for patients with chronic conditions. Clinician perceptions and understanding about the PAM’s value and purpose influenced implementation. Further research is needed about how PAM-tailored interventions can be integrated into clinical practice, and guide the patient-clinician interaction, in ways that improve the quality of patient care.

The KOMPACT-P study: Knee Osteoarthritis Management with Physiotherapy informed by Acceptance and Commitment Therapy-Pilot study protocol

INTRODUCTION

Incidence of total knee arthroplasty (TKA) is projected to rise 276% in 2030, and psychological distress affects up to 42% of people with knee osteoarthritis undergoing TKA, with demonstrated detrimental effects on postoperative outcomes. Few studies have assessed psychological treatment in people awaiting TKA, and these have been psychologist-delivered treatments. No evidence exists regarding psychologically-informed interventions delivered by health professionals currently embedded in TKA clinical pathways. The primary aim of this pilot study is to explore the safety, acceptability and feasibility of the Knee Osteoarthritis Management with Physiotherapy informed by Acceptance and Commitment Therapy (KOMPACT) approach in people awaiting TKA.

METHODS AND ANALYSIS

51 community-dwelling adults scheduled for a primary TKA at two hospitals will be recruited to this pilot, mixed-methods, prospective randomised controlled trial with assessor blinding. Participants will be randomised in a 1:2 ratio to either usual care (education class) or usual care plus KOMPACT (2 hours 20 min of preoperative physiotherapy informed by Acceptance and Commitment Therapy). Our primary outcome measures are safety (length of stay, complications and psychological health after KOMPACT), acceptability (treatment credibility and qualitative data) and feasibility (recruitment, retention and intervention fidelity) of the KOMPACT approach. Secondary outcomes include health service outcomes, patient-reported physical and psychological outcomes, and physical performance measures. Quantitative data collection was conducted at baseline, 1-2 weeks before TKA, 6 weeks after TKA and 6 months after TKA. Qualitative data collection is 1-2 weeks before TKA. Data analysis will take a quantitative-led approach with triangulation after thematic analysis of the qualitative data.

ETHICS AND DISSEMINATION

This study has full ethics approval (HREC/18/WMEAD/440). Results from this study will be published in peer-reviewed journals and presented at local and international conferences.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry (ACTRN12618001867280p).

What do consumers with chronic conditions expect from their interactions with general practitioners? A qualitative study of Australian consumer and provider perspectives

Background

More than half of Australian adults manage one or more chronic conditions through ongoing interactions with general practitioners (GPs). Their experience of general practice interactions has important implications for their health outcomes and is thus important to explore in‐depth. Consumer expectations have emerged as a key consideration in this regard. How well they met in care settings can inform consumers' satisfaction and response to the care received. However, consumer expectations in Australian general practice are not well researched.

Objective

To identify key consumer expectations in clinical interactions in Australian general practice based on consumer and GP perspectives.

Design

Qualitative, phenomenological approach using thematic analysis of semi‐structured interviews.

Setting and participants

Thirty‐one participants: 18 patients with one or more chronic (persisting > 6 months) conditions, 10 GPs and 3 GP registrars in Sydney, Australia.

Results

Consumer expectations were strongly related to the context of their ongoing therapeutic relationship with a regular GP. Themes relating to some of the most commonly reported consumer expectations were as follows: (a) the importance of longevity and continuity; (b) having good rapport; (c) GP's respect for consumer opinions and expertise; (d) having effective communication; and (e) addressing mental health.

Conclusion

Australian GPs and consumers prioritize a positive, long‐term clinical relationship in which they respect one another and can communicate their expectations freely. This has implications for consumer satisfaction and in turn ensuring relational continuity, which is particularly relevant to the ongoing care and management of consumers with chronic conditions.

Culturally Diverse Patient Experiences and Walking Interviews: A Co-Design Approach to Improving Organizational Health Literacy

People from diverse cultural and linguistic backgrounds are more likely to have low health literacy and less appropriate access to health services than other Australians. Interventions to improve health literacy have demonstrated moderate improvements in health service use. Most of these interventions focus on simplifying communication as opposed to navigation support. A comprehensive and multilevel response is required if the health care system and organizations are to be more responsive to different levels of health literacy. This includes obtaining feedback from patients on their experience of accessing health care. This study piloted the use of a co-design process to develop a culturally appropriate mechanism of elucidating the perspectives of community members of culturally diverse groups on their experiences of accessing a health service to identify the strengths and weaknesses of an organization's health literacy. This co-design process involved the adaptation of an existing "Walking Interview" tool to the location and language groups being targeted, as well as determining the process for recruiting participants and conducting the walking interviews. The interviews provided valuable insights into the experiences of culturally diverse groups in accessing Canterbury Hospital and identified areas for improvement, such as clearer signage and access to interpreter services. [HLRP: Health Literacy Research and Practice. 2019;3(4):e238-e242.].