GPs in ‘unique position’ to help domestic violence victims

On International Day for the Elimination of Violence against Women, GPs are being reminded of their unique position at being one of the first people a victim may turn to.

RACGP President Dr Frank R Jones said GPs need to understand the nature of violence and abuse to help break the cycle.

“This includes identifying predisposing risk factors, understanding early signs and symptoms and managing the devastating consequences of family violence.”

The RACGP is one of a group of Australia’s peak medical bodies that have joined forces to help end domestic violence.

22 Colleges and peak health bodies issued a joint statement saying they will be wearing white ribbons in their workplaces and they will ‘indicate their willingness and availability to discuss this sensitive and difficult issue, should they be experiencing violence in their lives.’

Domestic violence tools

The RACGP’s white book Abuse and violence: working with our patients in general practice gives doctors evidence-based guideline on identifying domestic violence and how to respond. This edition also offers new insights into Aboriginal and Torres Strait Islander people as well as migrant, refugee and rural communities.
The National Sexual Assault, Domestic Family Violence Counselling Service 1800RESPECT last week launched a new toolkit to help GPs better recognise the signs of assault and empower them to respond. Visit 1800RESPECT to order your kit.
The AMA/Law Council of Australia document Supporting Patients Experiencing Family Violence kit contains information about specialist support services, including health, mental health, drug and alcohol, legal, family support and child protection services.
Victim support services and further reading on the AMA website.

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Upstream or downstream?

The river analogy helps describe the health continuum from prevention to treatment

Winner — Medical student category

When I first looked at a map of Alice Springs, the ephemeral Todd River was marked as a deceptive blue snake, winding its way through the centre of town. For the local Arrernte people, the river is known as Lhere Mparntwe. In my head, I pictured a desert oasis, brown-skinned children gleaming with sun and water, screaming with glee as they plunged from rope swings into the cool river water. During my first week in Alice, somebody told me that it’s only after you have seen the river flow three times that you can be considered a local. The rest of the time it is just a dusty creek bed, filled with the soft rusty sand that has now found its way into almost every item that I own.

In public health, there is the concept of “upstream” and “downstream” factors. The analogy of the river is used to describe how pre-existing social, cultural, financial, environmental and historical factors ultimately go on to influence health outcomes in a profound way.1

The children’s ward at Alice Springs Hospital is busy. The nurses exasperatedly chase a young boy down the corridor. This pint-sized patient is surprisingly speedy as he makes his naked bid for freedom. A happy little boy and exceptionally cute, this child has quickly become a favourite of mine. It’s close to a month since he was first admitted for ongoing weight loss on a background of acute gastroenteritis. He has had chronic diarrhoea since he’s been here, his stool best described as a microbiological zoo. His small body has been bombarded with every antibacterial, antifungal and antiparasitic agent we have. His poor gut is so damaged from his numerous recurrent infections that it’s essentially no more than a slippery dip. It’s difficult for him to absorb any nutrients from his food, and we desperately need him to gain weight so his body and brain can grow.

In the treatment room Bananas in Pyjamas is playing. The room is crowded. In between the paediatrician, two nurses, the surgical registrar, mum and a writhing, screaming patient, there are bubbles. So many bubbles. The young surgical trainee gingerly examines the numerous boils that cover the little girl’s legs and groin. They will require an operation to drain them. She too has been with us for a week already. Her kidneys are struggling, after her body mounted an autoimmune reaction to the streptococcal infection from the boils. We closely monitor her weight and blood pressure until her kidneys are out of the woods.

The diabetes educator and paediatrician discuss a 13-year-old girl, who has just been diagnosed with type 2 diabetes mellitus. Already she weighs over 100 kg. Her case being outside the realm of conventional paediatric practice, the paediatrician is seeking advice on the best management plan for this patient. The girl’s mother, in her 30s, already suffers from retinopathy from her diabetes. One of the challenges of managing type 2 diabetes in an adolescent is the general lack of evidence to inform practice. It’s simply too new a phenomenon. The evidence to inform the management of type 2 diabetes in an Indigenous child is virtually non-existent.

At the hospital, we are so far downstream that we are practically out to sea. Essentially, we patch the kids up, keep them from dying, and make an attempt at educating the child’s parents about what has happened and why. It is grossly inadequate when almost everything that we see is preventable.

How is it then, in a wealthy nation like Australia which boasts a universal health system that is arguably one of the best in the world, that the life expectancy of Indigenous Australians is still (at a conservative estimate) 10–17 years less than their non-Indigenous counterparts? Why do the babies of Aboriginal mothers die at more than twice the rate of non-Aboriginal mothers? Why are so many remote communities still plagued by poor hygiene, overcrowding and dysfunctional living conditions, condemning their inhabitants to lifelong chronic disease? To me, it’s incomprehensible.

The instinct of many is to blame the individual. I know that I am often tempted to do so, especially when you see children who are suffering. However, blaming or inducing guilt is counterproductive. It does not help anyone. If anything, it alienates and denigrates. It is simply not correct to suggest that a person engages in certain behaviours by “choice”, and choice alone. It is too simplistic. To do so ignores the fact that every individual is a member of a community and is shaped by that community, his or her environment, education, and a personal and collective history.

To date, many health promotion programs have made a grossly inaccurate assumption that health education will automatically translate to behaviour change. It’s the same flawed logic that tells me I should floss daily and do at least 30 minutes of moderate-to-vigorous physical activity each day. Does knowledge alone empower me to change my behaviour? Sometimes it can, but only when the environment allows. Can I prevent my children from getting scabies when 15 people live in my home, multiple people share mattresses and I don’t have running water in the house, let alone a washing machine? Unlikely.

There is no strategic plan or coordination between services to promote hygiene improvement in remote communities.2 The social determinants of health have been ignored or, at the very least, addressed in a piecemeal manner. Public servants in air-conditioned offices write hygiene promotion strategies that fail to address the functional state of housing infrastructure and the unique environmental conditions of remote communities. Obesity and micronutrient deficiency in remote communities is a direct result of food insecurity caused by low incomes and the high price of fresh, nutritious food. This is unlikely to ever be overcome as long as local stores (often the sole providers of food in remote communities) continue to be viewed as a small business, rather than an essential service such as health or education.3 The past and continuing erosion of Indigenous culture and language serves only to perpetuate the vicious cycle of poverty and poor health.4

Government departments are often only as far apart as a different floor in the same building, yet the level of communication and collaboration between departments would suggest there is in fact a chasm between them. Multisector collaboration and high-level engagement and partnership with Indigenous peoples are the only hope we have to “close the gap”.

Good health is not made in hospitals. Good health is made by the food we eat, the water we drink, by feeling safe, secure, loved and connected. It is the roof over our heads, our sense of purpose in the world. Education is not just power, but health too. It is health, not illness that I am passionate about. I need to be further upstream. Maybe I need to see the Todd River flow.

–

The Todd River, Alice Springs. Photo taken in March 2015.

General practitioners’ prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians, 2001–2013

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) bear a disproportionate burden of disease in Australia and have a life expectancy 13 years shorter than that of other Australians.1,2 Heart disease is the leading cause of death among both Indigenous and non-Indigenous Australians, and it is also the single largest contributor to the gap in life expectancy between the two populations.3,4 The mortality rate associated with cardiovascular disease is 60% higher in Indigenous than in non-Indigenous populations; the prevalence of cardiovascular disease is 30% higher and that of its risk equivalent, diabetes, is three times greater among Indigenous Australians.3–6

Promoting access to prescription drugs and improving the management of chronic disease are key components of the national strategy for reducing health disparities in Australia. In 1999, the Australian Government eliminated out-of-pocket drug costs for Indigenous patients attending remote Aboriginal community-controlled health clinics.7 Two subsequent initiatives, in 2008 and 2010, reduced medication co-payments for Indigenous patients who attended non-remote Aboriginal community-controlled clinics or mainstream general practices.8,9 Further, the Pharmaceutical Benefits Scheme modified its criteria for subsidised lipid-lowering medications to include all Indigenous Australians with diabetes or a blood total cholesterol level above 6.5 mmol/L.10 The Indigenous Practice Incentives Program of the federal Department of Health provides bonus payments to general practitioners who enrol chronically ill Indigenous patients and prepare chronic disease management plans for them.11

Whether these efforts have translated into increased prescribing of cardiovascular medications to Indigenous Australians or better control of cardiovascular risk factors is unknown. We therefore evaluated trends in the prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians seen in general practice. We focused on therapies that reduce blood lipid levels because treating this modifiable risk factor can reduce coronary events and mortality in selected patients.12,13

Methods

Study design, source of data and population

We conducted an observational time trend study, from April 2001 to March 2013, that determined the proportion of patient encounters in which GPs prescribed lipid-lowering medications. We analysed data from the Bettering the Evaluation and Care of Health (BEACH) survey, which randomly samples 1000 GPs each year.14 The source population included all registered GPs and GP registrars who had claimed at least 375 Medicare service items in the past 3 months.

Each participating GP provided information about 100 consecutive patient encounters. The BEACH survey collects reasons for the encounter, problems addressed during the encounter, and clinical actions undertaken to manage each problem. GPs record up to four medications for each problem managed, and link each medication with a single managed problem. The final study sample encompassed 759 673 GP encounters with patients aged 30 years or over: 9594 with Indigenous and 750 079 with non-Indigenous patients.

Outcome measures

The primary outcome was the report that at least one lipid-lowering medication had been prescribed during an encounter. Lipid-lowering medications included five classes: statins, bile acid sequestrants, fibrates, niacin, and cholesterol absorption inhibitors. The primary independent variable was Indigenous status (dichotomous: yes v no), based on the GP’s record of the patient’s self-report during the encounter.

Statistical analyses

We calculated the unadjusted rate of prescribing lipid-lowering medications (ie, the proportion of encounters at which at least one such medication was prescribed) for Indigenous and for non-Indigenous patients. These data were further stratified by time period (1 April 2001 – 31 March 2005, 1 April 2005 – 31 March 2009, 1 April 2009 – 31 March 2013) and by the clinical condition that was addressed during an encounter (non-gestational diabetes mellitus, hypertension, ischaemic heart disease, lipid disorder). We also calculated the age–sex standardised rate of prescription of lipid-lowering medications for Indigenous patients, using 14 discrete age–sex subgroups (men and women in seven age groups spanning 10 years each). Age–sex standardisation yields an estimate of the lipid-lowering prescribing rate for encounters with Indigenous patients, assuming an age–sex structure identical to that of the non-Indigenous population.

A further subgroup analysis calculated the proportions of all lipid-lowering medications prescribed for each specified clinical condition. To assess whether there were statistically significant increases over time in the age–sex standardised rate of prescribing of lipid-lowering medications, we constructed logistic regression models, with the time period (the three 4-year time periods) as the independent variable.

All analyses were adjusted for clustering by GP using SAS 9.3 survey procedures (SAS Institute). Differences were considered statistically significant at P < 0.05. For routine analyses of BEACH data, we report a significant difference only if there was no overlap of the 95% confidence intervals of the two comparison groups. This is a stricter threshold than the usual P < 0.05 criterion, equivalent to P < 0.006, and reduces the risk of Type 1 errors when making multiple comparisons.

The University of Sydney Human Research Ethics Committee approved the study (reference 2012/130).

Results

Rate of prescription of lipid-lowering medications for Indigenous and non-Indigenous patient encounters

During the study period, lipid-lowering medications were prescribed during 4.9% (95% CI, 4.2%–5.6%) of encounters with Indigenous patients, and at 4.6% (95% CI, 4.5%–4.7%) of encounters with non-Indigenous patients. After age–sex standardisation (which adjusts the Indigenous but not the non-Indigenous rate), the rate of prescription during Indigenous patient encounters was 5.5% (95% CI, 4.7%–6.3%), significantly greater than that for non-Indigenous patient encounters.

For Indigenous patient encounters, the age–sex standardised rate of prescription of lipid-lowering medications increased from 4.1% during 2001–2005 to 6.4% during 2009–2013 (P = 0.013 for trend). For non-Indigenous encounters, the rate of prescription increased from 3.8% to 5.2% over the same period (P < 0.01) (Box 1). The point estimates for these proportions were higher for Indigenous patient encounters for each of the three time periods, but these individual differences were not statistically significant.

Specified clinical conditions addressed during Indigenous and non-Indigenous patient encounters

Diabetes and ischaemic heart disease were significantly more commonly managed at encounters with Indigenous patients than at those with non-Indigenous patients: in age-standardised analyses, diabetes was managed at 13.8% (95% CI, 12.6%–15.1%) of encounters with Indigenous patients and at 4.7% (95% CI, 4.6%–4.7%) of encounters with non-Indigenous patients. Ischaemic heart disease was managed at 3.2% (95% CI, 2.6%–3.8%) of encounters with Indigenous patients and at 1.7% (95% CI, 1.7%–1.8%) of those with non-Indigenous patients. Lipid disorders were managed significantly less frequently during Indigenous encounters (3.8%; 95% CI, 3.1%–4.5%) than during non-Indigenous encounters (4.6%; 95% CI, 4.5%–4.7%). There was no significant difference between the proportions of encounters at which hypertension was managed (12.6% for each group).

Rate of prescription of lipid-lowering medications, according to clinical condition

The proportion of Indigenous patient encounters involving diabetes, hypertension or ischaemic heart disease at which lipid-lowering medication was prescribed was similar to that for non-Indigenous patient encounters. However, for encounters at which GPs managed a lipid disorder, the age–sex standardised proportion at which lipid-lowering medication was prescribed was 78.4% (95% CI, 72.6%–84.2%) for Indigenous patient encounters, significantly greater than that for non-Indigenous patient encounters (65.2%; 95% CI, 64.5%–65.8%) (Box 2).

Proportion of lipid-lowering prescriptions linked with specific clinical conditions

Box 3 depicts the proportions of all 35 798 prescriptions for lipid-lowering medication according to the specified clinical conditions managed, and stratified by Indigenous status. Only the proportions linked with diabetes (Indigenous: 13.1% [95% CI, 9.1%–17.3%] v non-Indigenous: 4.2% [CI, 4.0–4.5]) and lipid disorders (Indigenous: 53.3% [95% CI, 46.1%–60.4%], v non-Indigenous 64.3% [95% CI, 63.5%–65.1%]) were significantly different between the two groups.

Discussion

There were three major findings from this nationally representative study of the prescribing of lipid-lowering medications for Indigenous and non-Indigenous adults managed in Australian general practice. First, the rates of prescription of lipid-lowering medication by GPs for both Indigenous and non-Indigenous Australians increased substantially from 2001–2005 to 2009–2013, with relative increases of 37% for non-Indigenous and 56% for Indigenous patients. Second, lipid-lowering medication was more likely to be prescribed at encounters with Indigenous patients than at those with non-Indigenous patients, including encounters at which lipid disorders were managed. Third, diabetes was about three times as likely to be managed at encounters with Indigenous patients.

We found that the rates of prescription of lipid-lowering medication were higher for all Indigenous patient encounters, and for encounters at which a lipid disorder was managed; the prescription rates at encounters during which diabetes, heart disease or hypertension were managed were similar for Indigenous and non-Indigenous patients. These findings may reflect extensive efforts by the Australian Government, clinicians and other stakeholders to identify and reduce cardiovascular risk among Indigenous people, to increase their access to medications, and to revise clinical and benefit guidelines for lipid-lowering prescriptions so that they include all Indigenous patients with diabetes or blood total lipid levels greater than 6.5 mmol/L.7–11 Our study cannot establish a causal link between these policies and increased prescribing of lipid-lowering agents. However, it is reassuring that, as lipid-lowering therapies have continued to diffuse into clinical practice over the past 15 years, we found no evidence that GPs were less likely to prescribe these agents to Indigenous patients.

As noted by other authors, screening for and managing cardiovascular risk in Australian general practice is suboptimal.15,16 It is therefore also possible that the equivalent prescribing rates may reflect underuse of these medications in both Indigenous and non-Indigenous patients who might benefit from these therapies. Future studies should characterise disparities in the proportion of clinically appropriate treatment candidates who are prescribed effective cardiovascular medications.

Our study has some limitations. First, the BEACH data do not include information on whether patients filled or adhered to lipid-lowering prescriptions. Second, data concerning managed conditions, medications prescribed, and the patient’s self-identified ethnicity may include errors, although we have no reason to believe that rates of misclassification changed over time. Third, the sample in our study included only patients seen in primary care. Fourth, the sample sizes for some subgroup analyses were small. Fifth, the data were collected at the encounter level, precluding calculation of the overall prevalence of lipid-lowering therapy in Indigenous and non-Indigenous populations. Finally, we lacked laboratory values and comprehensive data on comorbid conditions to determine the clinical appropriateness of prescribing decisions or to adjust for casemix.

In conclusion, we detected substantial increases in the rate of prescribing of lipid-lowering medication at encounters with both Indigenous and non-Indigenous patients in Australian general practice between 2001 and 2013, and found no evidence that Indigenous patients were less likely to be prescribed these agents. Indigenous patients were more likely than non-Indigenous patients to be prescribed lipid-lowering therapy during encounters at which a lipid disorder was managed. Our findings suggest some measure of success in expanding access to medications and reducing cardiovascular risk in Indigenous populations. Further efforts are needed to promote long-term adherence to effective medications and to improve cardiovascular health for Indigenous people in Australia.

Box 1 –
Age–sex standardised proportions of patient encounters (with 95% CI) at which lipid-lowering medication was prescribed, by time period and Indigenous status

Box 2 –
Age–sex standardised proportions of patient encounters (with 95% CI) at which lipid-lowering medication was prescribed, by specified clinical condition and Indigenous status

* Significant difference: no overlap of 95% confidence intervals.

Box 3 –
Age–sex standardised proportion of lipid-lowering medication (with 95% CI) prescribed for each specified clinical condition, by Indigenous status

* Significant difference: no overlap of 95% confidence intervals.

Continuous quality improvement and metabolic screening during pregnancy at primary health centres attended by Aboriginal and Torres Strait Islander women

Attending to perinatal risk factors, such as diabetes and hypertension during pregnancy, obesity and excess gestational weight gain,1–5 is important for optimising maternal and infant health outcomes. Pregnancy is also a key period for implementing strategies that prevent long-term adverse health outcomes, as excess gestational weight gain and gestational diabetes mellitus (GDM) are respectively predictors of long-term obesity6 and the development of type 2 diabetes.7

Screening for and follow-up of metabolic risk factors are components of recommended pregnancy care in Australia.8 Ensuring that Aboriginal and Torres Strait Islander (respectfully referred to in this article as Indigenous) women receive such care is expected to contribute to giving babies a healthy start to life and to improving the health of their mothers. In Australia, low birth weight, premature birth and perinatal death are substantially more frequent in Indigenous than in non-Indigenous pregnancies.9 Obesity, pre-existing diabetes and GDM are some of the risk factors that are more common in Indigenous women.3,4,10 Later in life, cardiovascular disease and diabetes are major contributors to the difference in life expectancy between Indigenous and non-Indigenous Australians.11

As care can differ between health centres with different characteristics, such as urban and rural or remote locations,8 effective long-term strategies are needed across a range of settings to facilitate the provision of all components of recommended pregnancy care.12 The Audit and Best Practice for Chronic Disease (ABCD) National Research Partnership13,14 aims to improve the provision of care by primary health care centres (PHCs) serving mainly Indigenous populations. It uses a continuous quality improvement (CQI) framework to increase the efficiency and effectiveness of organisational systems. Previous ABCD Partnership research indicates that increases in self-ratings of organisational systems are associated with improvements in the delivery of health care for those with type 2 diabetes.15

We investigated screening for metabolic risk factors during pregnancy and follow-up actions by PHCs participating in the ABCD partnership. We also investigated associations between self-ratings by organisational systems and the proportion of women who undergo metabolic screening.

Methods

The study was approved by human research ethics committees in the relevant states and territories, and by Indigenous subcommittees where required.16 The analyses were approved by the Monash University Human Research Ethics Committee (CF12/3434-2012001670).

Study design and setting

The ABCD National Research Partnership study protocol has been described in detail elsewhere.13,16 This partnership links multiple PHCs and stakeholders across the health system in collaborative CQI research.14 One21seventy, the National Centre for Quality Improvement in Indigenous Primary Health Care, supports CQI in PHCs by providing evidence-based practical tools and training.14 The ABCD Partnership has access to One21seventy data from PHCs that have volunteered to participate in research.13,14 This article reports longitudinal analysis of data from 76 PHCs (2592 health records) involved in the ABCD Partnership across five Australian states and territories. The PHCs conducted up to four CQI cycles, comprising 58.5% (168 of 287) of the One21seventy maternal health audits conducted between 2007 and 2012. Twenty-one of the 76 PHCs began maternal health auditing in 2007; 13 commenced in 2008, 13 in 2009, 11 in 2010, 10 in 2011, and 8 in 2012. Depending on their needs, PHCs may focus in some years on CQI activities in other clinical areas; of 50 PHCs that had completed two or more maternal health audits, 11 (22.0%) conducted audits in non-consecutive years.

Intervention: continuous quality improvement cycles

At baseline, systems assessments and audits of health records were conducted and the results provided to PHCs in real-time by an automated CQI reporting system. PHCs use the reports for participatory interpretation and goal setting, and this is followed by the initiation of relevant actions. Data collection was repeated in subsequent years to assess success in improving care (end of cycle 1), and to identify new priorities for improvement (start of cycle 2). PHCs are encouraged to complete one cycle each year.

Maternal health audit tool

Recorded pregnancy care was assessed by auditing the health records of women with a recent pregnancy (mothers with an infant aged 2–14 months, who resided in the community during their pregnancy and attended for pregnancy care at least once).13,16 Audits were conducted by trained auditors (local PHC staff, staff from other PHCs, or CQI facilitators) supported by a standard protocol and regional CQI facilitators. The audit tool and parameters of the outcome measures were based on best practice guidelines, policy and research reports, and stakeholder consultations.16 At each PHC, the auditor used a standard sampling protocol to select a random sample of at least 30 records to audit (if fewer than 30 eligible records were available, all were audited).13

The Systems Assessment Tool

Structured assessments of PHC system strengths and weaknesses were conducted by PHC staff together with a trained external CQI facilitator using the Systems Assessment Tool (SAT).13,15 This consensus process produces a self-reported overall mean score (range, 0–11) for the state of development of PHC organisational systems, and five subscale scores (delivery system design, information systems and decision support, self-management support, external links, and organisational influence and integration).

Key outcome measures

The audit tool collected information on documentation of the following items in each health record:16

body weight, body mass index (BMI) and blood pressure (BP) screening in women attending at earlier than 13 weeks’ gestation;
BP checks at any point during the pregnancy;
a 50 or 75 gram glucose challenge test (GCT) and, if indicated, an oral glucose tolerance test (OGTT) at 20–30 weeks’ gestation;
for women with a BMI under 20 or over 30 kg/m²: development of a BMI management plan;
for women with high BP (≥ 140/90 mmHg): repeated BP measurements, urine tests for protein, examination by or referral to a general practitioner or obstetrician, or prescription of anti-hypertensive medication;
an OGTT for those with an abnormal GCT result (plasma glucose concentration ≥ 7.8 mmol/L 1 hour after a 50 g glucose load (morning, non-fasting), or ≥ 8.0 mmol/L after a 75 g glucose load).

“Follow-up” in this article refers to taking the next appropriate action after an abnormal screening result.

Statistical methods

Analyses were conducted using Stata version 12.1 (StataCorp). P < 0.05 (2-sided) was defined as statistically significant. Differences in screening proportions at baseline and at the final audit were assessed with respect to PHC governance, location, population size (t tests or Mann–Whitney U tests) and state or territory (one-way analysis of variance or Kruskal–Wallis tests). Paired t tests assessed differences between the first and last SAT scores. Using each health record as the unit of analysis, random effects logistic regression analysis (generating odds ratios) assessed any associations between metabolic screening and CQI cycle number (Stata xtlogit command). Random effects logistic regression allowed for repeated measures of each outcome (eg, did a patient receive a BP check: yes or no) at each cycle per PHC. This method also allowed for adjustment for similarities in women within each PHC. The reference group comprised audit data from the PHCs before they had conducted a CQI cycle (ie, cycle 0 or baseline). We also tested for a trend to increased metabolic screening with each additional CQI cycle (Stata nptrend command).

For each PHC, the proportion of women receiving screening after each CQI cycle was calculated. Treating each PHC as the unit of analysis, univariable linear regression (generating β coefficients) assessed associations between:

the average proportion of women who underwent screening across all cycles, and average overall or subscale SAT scores;
the total change (from first to final cycle) in the proportion of women who underwent screening, and the total change in overall or subscale SAT scores.

Results

A range of PHC settings were included in the study. Most women who attended these PHCs for pregnancy care were Indigenous Australians (87.9%) (Box 1).

While most women who attended during the first trimester were weighed, the BMI was calculated for less than a third; but women attending after the PHC had conducted at least one CQI cycle were more likely to have had their BMI assessed than women attending PHCs that had not done so. Similar patterns were observed for BP checks at any point during the pregnancy and diabetes screening. Improvements in screening appeared to be sustained over sequential CQI cycles, and there were trends for additional improvements with each additional cycle (Box 2).

At baseline, the only significant differences in screening were those between states and territories for first trimester BP checks (P = 0.04), BP checks at any stage of the pregnancy (P = 0.02) and diabetes screening (P = 0.002). These differences were not significant at the PHCs’ final audits (all P > 0.05).

There were also indications of sustained improvements in the provision of follow-up actions after CQI participation, but the sample sizes were too small for statistical analysis. Follow-up actions for high BP included repeated BP assessment (pre-26 weeks, 88.1%; post-26 weeks, 91.9%), urine tests (pre-26 weeks, 88.1%, post-26 weeks, 83.9%), referral (pre-26 weeks, 85.7% post-26 weeks, 94.3%) and antihypertensive medication (pre-26 weeks, 42.9%, post-26 weeks, 26.4%). Follow-up OGTTs were reported for most women who received an abnormal GCT result. Few women with an abnormal BMI, however, had a documented BMI management plan (Box 3).

Systems assessment data were available for 35 PHCs (46.1%); data were available for more than one time point for 21. The mean overall SAT score at the final cycle (7.36) was statistically significantly higher than at the first cycle (6.23; P = 0.009), but there were no significant differences in SAT subscale scores between the first and final cycles (data not shown). Higher average self-ratings of some organisational systems were associated with greater provision of metabolic screening (Box 4). For example, the average provision of first trimester BP screening was 3.7 percentage points higher for each additional point scored on the SAT information systems and decision support domain. Diabetes screening was associated with higher overall self-ratings, as well as with higher ratings of self-management support systems, and of organisational influence and integration.

In addition, there was a statistically significant association between a one-point increase from first to final assessment in information systems and decision support scores and an increase of 5.7 percentage points in the proportion of women receiving diabetes screening between the first and final audits (β = 5.7; 95% CI, 0.6–10.9; P = 0.03). However, no other significant associations between changes in SAT scores and screening were detected (data not shown).

Discussion

This large longitudinal study of PHCs found substantial improvements in routine metabolic screening in pregnancy associated with participation in a CQI initiative. Improvements were sustained over multiple cycles, with evidence for additional improvements with each consecutive CQI cycle. Initiation of follow-up actions also improved after CQI participation. Higher self-ratings of some organisational systems were significantly associated with greater metabolic screening.

Screening at baseline was incomplete for all the metabolic risk factors investigated, consistent with reports from other Indigenous communities.17 It is unclear whether metabolic screening coverage in other maternity care settings is incomplete, as this information is not reported in other routine perinatal data collections. However, improvements associated with CQI participation were observed with respect to BMI and BP assessment and screening for diabetes during pregnancy. Measurement of BMI early in pregnancy is important because maternal and neonatal morbidity increases with maternal BMI,3 and the recommended gestational weight gain depends on the BMI category.1 Measurement of BMI may be influenced by both the mothers’ and health professionals’ understanding of the importance of healthy gestational weight gain and awareness of weight gain guidelines, and by the confidence of health professionals that they can discuss weight with women without causing undue concern.18 It is encouraging that we encountered no instances of women who declined to be weighed. Similarly, first trimester BP assessment and universal second trimester GDM screening are also recommended in Australia, and these remain areas for improvement. It is important to explore potential barriers to GDM screening, both because the prevalence of diabetes during pregnancy is higher among Indigenous women than in non-Indigenous women4 and because of the importance of diabetes management during pregnancy.4

Pregnancy is an opportune time for health practitioners to discuss weight management with women.19 However, few women in this study with an abnormal BMI had a management plan, which may reflect suboptimal action taken, a lack of documentation of the actions taken, or both. Excess weight gain increases pregnancy risks, such as macrosomia, preterm birth and the need for caesarean delivery,1 as well as the long-term risk of obesity,6 making active management vital for the wellbeing of mother and child. Potential barriers to developing weight management plans include limited resources for referral, food security concerns, and inadequate staff time, especially in remote communities. Development of resources or programs for gestational weight management tailored to the needs of Indigenous women may assist.

Most women with an abnormal GCT result subsequently underwent a diagnostic OGTT. Recent controversy about diabetes screening20 may have created barriers to screening and follow-up. While large-scale implementation of the International Association of Diabetes in Pregnancy Study Group guidelines, starting in 2015,21 may partially resolve these problems, the number of women diagnosed with GDM will also increase,22 with potential resource implications for PHCs.

The positive associations between self-ratings of organisational systems and first trimester BP and diabetes screening in our study support targeting of organisational systems as a strategy for improving the provision of metabolic screening during pregnancy. However, further large-scale improvements in systems and processes that support health professionals in conducting metabolic screening and management are vital if the long-term consequences of these complications in pregnancy are to be reduced. We hope that our findings encourage further discussion about how pregnancy care for Indigenous women might be improved. All levels of the health system have roles to play, and systems-based research networks, such as the ABCD Partnership, are ideally placed to develop appropriate strategies.

Our study was limited by the fact that SAT data were available for only some PHCs (35 of 76, 46.1%), reducing the statistical power of our analysis to detect associations. Selection bias was also possible, as this study included only the One21seventy PHCs that volunteered their data for research (58.5% of the audits conducted overall). Our data may not be representative of PHCs not participating in the One21seventy initiative, but this extensive network includes a large population, and there are currently no other comparable data sources in Australia. Bias caused by the possibility that PHCs with lesser improvement would be less likely to remain in the CQI initiative is difficult to gauge, as commencement years varied and PHCs may have conducted maternal health audits in non-consecutive years. However, the generalisability of our results may have been enhanced by the fact that PHCs used the audit tool according to their needs, rather than as a research requirement. As we performed multiple statistical tests, there was a risk of finding significant associations by chance. This possibility was reduced by not undertaking statistical tests for follow-up actions, as the small numbers involved were inadequate for meaningful comparisons.

The CQI initiative continues, and further assessment of its effects on service delivery and health outcomes is planned as the sample size increases. Future directions include investigating the effects on service provision of the audit year, the year of commencement, and the duration of CQI participation. A cluster randomised controlled trial is an alternative study design that could be used to test hypotheses arising from the current findings.

Despite the limitations, our study has significant strengths that increase the generalisability of its findings. Most previous CQI research in pregnancy care has been hospital-based, implemented in a single service, not focused on metabolic screening, or not conducted in Australia.23–25 Our research applied a unique system-wide participatory approach to assess systemic issues commonly affecting provision of care.14 It used a detailed, longitudinal dataset to investigate long-term sustainability, and included many PHCs across several settings.

Our study shows the potential of a CQI initiative supported by a systems-based research network to improve the provision of recommended pregnancy care at PHCs attended by Indigenous women. These findings are encouraging, and suggest a successful approach for achieving further improvement in pregnancy care provision.

Box 1 –
Characteristics of the 76 primary health care centres included in the study, and of the 2592 women whose records were audited

Characteristics of the primary health care centres

Governance structure

Government-operated

49 (64.5%)

Community-controlled

27 (35.5%)

Location

Remote

56 (73.7%)

Urban or regional

20 (26.3)

Service population size

≥ 1000 people

39 (51.3%)

< 1000 people

37 (48.7%)

State or territory

Northern Territory

28 (36.8%)

Queensland

27 (35.5%)

Western Australia

11 (14.5%)

New South Wales

6 (7.9%)

South Australia

4 (5.3%)

Characteristics of the women

Indigenous status^∗

2141 (87.9%)

Aboriginal

2028 (83.3%)

Torres Strait Islander

57 (2.3%)

Aboriginal and Torres Strait Islander

56 (2.3%)

Age^†

Median, years

24.4 (IQR, 20.6–29.6)

< 20 years

545 (21.1%)

20–34 years

1807 (69.9%)

≥ 35 years

233 (9.0%)

First attendance for pregnancy care occurred before 13 weeks’ gestation^‡

1321 (51.0%)

Median number of pregnancy care visits

7 (IQR, 5–10)

IQR = interquartile range. ∗n = 2435 (data missing for 157 women). †n = 2585 (data missing for 7 women). ‡n = 2591 (data missing for 1 woman).

Box 2 –
Documented metabolic screening during pregnancy after completion of each continuous quality improvement (CQI) cycle, and associations between metabolic screening and primary health care centre (PHC) participation in each CQI cycle

Metabolic screening

CQI cycle

P (for trend)

076 PHCs

150 PHCs

228 PHCs

38 PHCs

46 PHCs

Weight measured in first trimester (1321 women)

440/562 (78.3%)

344/418 (82.3%)

153/202 (75.7%)

49/65 (75.4%)

56/74 (75.7%)

Odds ratio (95% CI)

1.0

1.4 (0.9–2.0) P = 0.10

1.0 (0.6–1.6) P = 0.89

1.2 (0.6–2.4) P = 0.59

1.4 (0.7–2.8) P = 0.34

0.38

BMI calculated in first trimester (1321 women)

132/562 (23.5%)

126/418 (30.1%)

63/202 (31.2%)

25/65 (38.5%)

31/74 (41.9%)

Odds ratio (95% CI)

1.0

2.4 (1.6–3.5) P < 0.001

3.4 (2.0–5.6) P < 0.001

5.1 (2.4–10.7) P < 0.001

9.4 (4.6–19.4) P < 0.001

< 0.001

Blood pressure check in first trimester (1321 women)

485/562 (86.3%)

370/418 (88.5%)

180/202 (89.1%)

56/65 (86.2%)

59/74 (79.7%)

Odds ratio (95% CI)

1.0

1.3 (0.8–1.9) P = 0.27

1.5 (0.9–2.7) P = 0.15

1.6 (0.7–3.7) P = 0.24

1.1 (0.5–2.3) P = 0.78

0.51

Blood pressure check at any point during the pregnancy (2592 women)

1123/1201 (93.5%)

745/758 (98.3%)

383/388 (98.7%)

131/135 (97.0%)

110/110 (100.0%)

Odds ratio (95% CI)

1.0

3.7 (1.9–7.3) P < 0.001

7.0 (2.5–19.4) P < 0.001

2.0 (0.6–6.5) P = 0.25

—

< 0.001

Diabetes screening (2541 women)^∗

669/1192 (56.1%)

469/736 (63.7%)

234/380 (61.6%)

86/135 (63.7%)

74/98 (75.5%)

Odds ratio (95% CI)

1.0

1.3 (1.0–1.6) P = 0.04

1.2 (0.9–1.7) P = 0.15

1.7 (1.1–2.6) P = 0.02

3.4 (1.9–5.9) P < 0.001

< 0.001

BMI = body mass index. ∗In 2010, the audit tool was refined to include “not applicable” if women had already been diagnosed with diabetes, or were offered but declined BMI or blood pressure assessment or diabetes screening. Since 2010, 26 women were recorded as having pre-existing diabetes, and 25 women declined diabetes screening. This reduced the denominator for diabetes screening to 2541. There were no recorded instances of women declining BMI or blood pressure checks.

Box 3 –
Recorded metabolic abnormalities during pregnancy and subsequent follow-up after each continuous quality improvement (CQI) cycle

Metabolic risk factors and follow-up

CQI cycle

76 PHCs

50 PHCs

28 PHCs

8 PHCs

6 PHCs

Abnormal BMI in first trimester (377 women)

39/132 (29.6%)

34/126 (27.0%)

17/63 (27.0%)

5/25 (20.0%)

8/31 (25.8%)

BMI management plan (103 women)

6/39 (15.4%)

10/34 (29.4%)

6/17 (35.3%)

4/5 (80.0%)

4/8 (50.0%)

High blood pressure in first trimester (1150 women)

11/485 (2.3%)

12/370 (3.2%)

5/180 (2.8%)

1/56 (1.8%)

0/59

Blood pressure follow-up < 26 weeks (73 women)

13/32 (40.6%)

17/27 (63.0%)

7/9 (77.8%)

2/2 (100.0%)

3/3 (100.0%)

High blood pressure at any time during pregnancy (2492 women)

72/1123 (6.4%)

51/745 (6.8%)

25/383 (6.5%)

2/131 (1.5%)

8/110 (7.3%)

Blood pressure follow-up ≥ 26 weeks (110 women)

34/49 (69.4%)

30/35 (85.7%)

17/20 (85.0%)

no cases

6/6 (100.0%)

Abnormal GCT result (1530 women)

120/667 (18.0%)

92/469 (19.6%)

41/234 (17.5%)

15/86 (17.4%)

9/74 (12.2%)

Follow-up OGTT (277 women)

104/120 (86.7%)

81/92 (88.0%)

40/41 (97.6%)

14/15 (93.3%)

7/9 (77.8%)

PHC = primary health care centre; BMI = body mass index; GCT = glucose challenge test; OGTT = oral glucose tolerance test.

Box 4 –
Associations between the average proportions of women undergoing metabolic screening and average Systems Assessment Tool scores (across all cycles) for 35 primary health care centres (β-coefficient, 95% CI)

Overall score

Delivery system design

Information systems and decision support

Self-management support

External links

Organisational influence and integration

BMI calculated in first trimester

4.2 (−3.5 to 11.9)

2.7 (−4.8 to 10.2)

5.5 (−1.3 to 12.2)

3.5 (−1.6 to 8.6)

1.9 (−4.5 to 8.4)

1.2 (−5.1 to 7.4)

Blood pressure check in first trimester

2.6 (−0.6 to 5.8)

1.9 (−1.3 to 5.0)

3.7^∗ (0.9 to 6.4)

1.5 (−0.6 to 3.7)

−0.6 (−3.4 to 2.1)

2.5 (−0.0 to 5.1)

Blood pressure check at any point during pregnancy

0.9 (−0.9 to 2.6)

0.5 (−1.2 to 2.2)

1.3 (−0.2 to 2.9)

0.3 (−0.9 to 1.5)

0.3 (−1.2 to 1.8)

0.7 (−0.8 to 2.1)

Diabetes screening

5.3^∗ (0.6 to 10.1)

4.6 (−0.1 to 9.3)

3.8 (−0.6 to 8.2)

3.4^∗ (0.2 to 6.7)

1.2 (−3.1 to 5.4)

4.9^∗ (1.1 to 8.6)

BMI = body mass index. ∗P < 0.05.

The 12 mental health indicators we should be focusing on

Australia spends $7.6 billion on mental health services annually, but experts question whether anyone is getting better and say we need to change our focus.

“Despite 20 years of rhetoric, Australia’s approach to accountability in mental health is overly focused on fulfilling governmental reporting requirements rather than using data to drive reform,” Sebastian Rosenberg, senior lecturer at the University of Sydney’s Brain and Mind Centre (BMC) and co-authors write in this week’s Medical Journal of Australia.

“The existing system is both fragmented and outcome blind. Australia has failed to develop useful local and regional approaches to benchmarking in mental health,” they say.

They believe that hundreds of mental health indicators and reports should be scrapped and data collection should be refocused into 12 indicators.

These “modest but achievable” indicators would provide a more accurate picture of mental health in Australia.

The group suggests the indicators would “emphasise proximal factors (eg, death rates in the 12 months following discharge from a health facility) that can drive reform, rather than distal outcomes that are likely to reflect more complex determinants acting over longer time frames (eg, life expectancy)”.

The indicators suggested are:

Health domain indicators

Suicide rate: attempts and completions
Death rates after discharge from any mental health facility
Proportion of the population receiving mental health care services
Prevalence of mental illness

Social domain indicators

Employment rates
Education and training rates
Stable housing
Community attitudes towards mental illness

System domain indicators

Experience of care
Hospital readmission rates
Life expectancy
Accessing to specialised programs

“All Australian governments should agree now to refocus their reporting priorities around these 12 indicators. Governance of their collection should reside in a body suitably independent from government which can identify gaps and inequity”, they write.

“Local empowerment is the engine of mental health reform, and timely, useful accountability data are the fuel.”

To read the full article, visit the Medical Journal of Australia.

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Salvaging a prison needle and syringe program trial in Australia requires leadership and respect for evidence

Many countries, including Australia, support needle and syringe programs … but not for prisons

People who inject drugs (PWID) are grossly overrepresented in Australian prisons. Up to 58% of prisoners nationally report lifetime injecting histories.1 The prevalence of blood-borne viruses (BBVs) — commonly transmitted through sharing injecting equipment — is also substantial in prison,1 with high rates of intraprison hepatitis C (HCV) transmission reported.2 However, unlike in the community, PWID in Australian prisons cannot access sterile needles and syringes. Incarcerating PWID in prison environments where drugs are widely available, BBV prevalence is disproportionately high and access to sterile injecting equipment is prohibited breaches basic human rights and international law that ascribes prisoners’ rights to health care standards equivalent to those in the community.3

Prison needle and syringe programs (PNSPs) are endorsed by Australian health and medical peak bodies, including the Australian Medical Association, Australasian Society for HIV Medicine and the Royal Australasian College of Physicians, as well as global bodies like the World Health Organization, UNAIDS and the United Nations Office on Drugs and Crime. Advocacy success resulting in PNSP implementation has been well characterised;4 however, only eight countries currently maintain PNSPs. This leaves 74 countries — including Australia — that support community needle and syringe programs but not PNSPs, in the belief that they implicitly condone illicit behaviour and present particular challenges if applied to correctional settings.

Australian policy and practice targeting BBV prevention in prisons has been inconsistent and largely piecemeal. Despite all four National Hepatitis C Strategies acknowledging people in custodial settings as a priority population, endorsement of effective prevention approaches has varied. The Third National Strategy (2010–2013),5 approved by the Commonwealth and all jurisdictional health ministers, made a strong commitment “for state and territory governments to identify opportunities for trialling [needle and syringe programs] in Australian custodial settings”. In the current, Fourth Strategy (2014–2017),6 however, there is no reference to PNSPs, with only endorsement of substantially less efficacious prevention (eg, bleach provision) or drug demand reduction (eg, drug treatment) approaches.

This lack of an evidence-based BBV prevention policy has supported a reliance on haphazard and largely ineffective interventions in Australian prisons. Despite Australian drug policies being underpinned by harm minimisation approaches that include supply, demand and harm reduction, only costly and ineffective interdiction-based supply reduction approaches and, to a lesser extent, treatment-based demand reduction, have been implemented substantively in prisons.7 Pragmatic regulation to reduce drug-related harm is also found in South Australian, Queensland and Victorian prisons, with lesser penalties for possession of drugs perceived as less harmful (eg, cannabis).8 This approach demonstrates that public health benefits can occur through security regulations and within corrections legislative regimens that prioritise security over prisoner health and human rights. However, there remains an overriding belief in Australian correctional systems that PNSPs are incompatible with security; a contention not borne out by international experience.

While limited progress towards a PNSP trial in Australia is disappointing in a country that once led the world in drug harm reduction policy and practice, one jurisdictional government has consistently demonstrated political leadership on the issue. Successive Australian Capital Territory chief ministers, Jon Stanhope and Katy Gallagher, steadfastly supported trialling a PNSP at the Alexander Maconochie Centre (AMC) — a prison commissioned in 2009 on human rights principles in accordance with the Human Rights Act 2004 (ACT). The 2011 evaluation of drug policies and services at the AMC9 recommended a trial PNSP, while the subsequent government-commissioned report recommended suitable PNSP models and consultation processes based on international experience.10 Key stakeholders, including prison officers and the Community and Public Sector Union (CPSU), were closely involved with each step of this process.

In April, an end to the long-running enterprise bargaining agreement (EBA) stalemate between the ACT Government and the CPSU that centred on a PNSP trial was announced. In his press release,11 the ACT Minister for Justice Shane Rattenbury maintained the “Government’s commitment to implementing an NSP”, but emphasised “the need for this to be developed with input from ACT Corrective Services staff … [to] recognise the genuine concerns”. A Deed of Agreement enabling the EBA states that majority staff support is needed for any PNSP trial to proceed. Given the CPSU’s historical resistance to PNSPs, this requirement may doom any prospect of an AMC PNSP trial.

CPSU resistance nationally has mostly centred on workplace health and safety concerns and encouraging drug use in custody. These concerns are not supported by over 20 years of PNSP operations in 13 countries. Research and evaluation evidence shows no increase in drug use or availability following PNSP implementation and no reports of needles and syringes provided by PNSPs being used as weapons, or safety problems associated with syringe disposal. Evaluations have also noted PNSPs reduce BBV transmission risk, facilitate entry into drug treatment programs, coexist with drug interdiction strategies and contribute to workplace safety.4

The Deed of Agreement states that PNSP negotiations with the CPSU must be conducted in good faith. The discordance between PNSP experiences and the current CPSU position makes it crucial that AMC staff have opportunities to review and openly discuss evidence supporting the benefits of PNSPs for prisoners, staff and the community as part of good faith negotiations. Guidelines and recommendations for engaging effectively with prison staff have been documented internationally, alongside prominent examples of shifts in attitude towards PNSPs by staff before and after PNSP implementations.4 The potential for honest negotiations to deliver such attitudinal shifts in the ACT also exists, given the significant number of AMC prison officers interviewed in the 2011 evaluation who privately supported a trial PNSP, but feared peer and CPSU recriminations if they were to openly express this support.9

With ongoing policy inertia on prison BBV prevention in other Australian jurisdictions, the ACT can show genuine leadership by becoming the first Australian jurisdiction to introduce a PNSP. The recently tabled House of Representatives report on HCV in Australia12 specifically notes that outcomes of a PNSP in the ACT will inform broader Australian debate. While it is hoped that AMC staff might depart from the CPSU’s historical resistance to PNSPs, the ACT Government must show the leadership lacking in other jurisdictions by allowing evidence and expert advice, rather than unions, guide public health policy.

Geographic inequity in healthy food environment and type 2 diabetes: can we please turn off the tap?

We need fairer policies and investment in change that may only be realised in the long term

The human, financial and wider societal costs of type 2 diabetes mellitus (T2DM) in Australia are high,1 but not inevitable.2 Studies indicate that lifestyle interventions involving weight reduction can reduce T2DM risk.3 Prevention and better management of T2DM can also help to prevent cardiovascular complications.4 So, to paraphrase the title of a recent editorial in the Journal, if we know what to do, what is the problem?5

One problem is that the complexity of sustaining the prevention effort has not been captured well by randomised trials,6,7 which veer towards individual-level (sometimes referred to as “high-risk”) strategies rather than evaluations of structural interventions at the population level.8 General practitioners have a very valuable role to play, but placing the burden of prevention squarely on them will not work.9 The determinants of T2DM risk are intergenerational, relational, multifaceted and inequitably distributed.10 Legions of scientists have engaged with the idea that where we live and work, and where our children grow up and attend school, all have some influence on our life chances — for better and for worse.11 Pollution, green space, sidewalks, vandalism and so on — these “social determinants” accumulate, support, insult, provide resilience, wear us down and conspire in no small way to shape the manifestation of geographic inequities in health that our best efforts appear unable to budge. In fact, there is increasing appreciation that some health interventions actually widen health inequities.12

We recently highlighted the spatial disparity in T2DM risk in the metropolitan area of Sydney, Australia: lower risk in the eastern suburbs and north shore, and much higher risk in the west, particularly around Blacktown and Mount Druitt.13 For members of the health workforce in those communities, this was no revelation. Addressing this inequity has been a core motivation in the development of the Western Sydney Diabetes Prevention and Management Initiative — a consortium led by the Western Sydney Local Health District and the Western Sydney Primary Health Network (formerly the Western Sydney Medicare Local), involving the University of Western Sydney and other local universities, councils, non-governmental organisations and other locally operating institutions. This initiative recognises that, for the most part, people who receive support from the health sector remain exposed to the same quantum of determinants that contributed to their health condition. The health sector has little control over features of our neighbourhoods that we think may have a powerful downstream impact on health across our lives. To use a well-trodden metaphor, the health sector is bailing water from the sink but cannot reach the tap.

What are these spatially manifesting risk factors that promote T2DM and potentially hinder its effective management? Food environment, or perhaps inequity of healthy food environment (eg, ample access to fresh produce) more specifically, is a prime candidate because what we eat is fundamental to our health. Accordingly, the Mapping food Environments in Australian Localities (MEAL) Project was initiated in 2014 to explore geographic inequities in food environment in metropolitan Sydney. Also, members of our MEAL Project team have subsequently joined forces with the Australian Prevention Partnership Centre Liveability Project team to engage in related epidemiological studies across the country.14 Here, we report preliminary findings from the MEAL Project.

Gathering geocoded data from the Yellow Pages (circa 2012), we used a geographic information system to calculate the number of greengrocers, supermarkets, takeaway shops and alcohol outlets within a 1.6 km road network distance from a person’s home. We chose a 1.6 km catchment to reflect a walking distance of about 15–20 minutes, although we acknowledge that there will be some variation in how far people are prepared to walk to purchase food. Australian Bureau of Statistics residential Mesh Blocks, released for the 2011 census and containing between 30 and 60 dwellings each, were used as a proxy for home. We report results comparing selected areas of Sydney’s west (3148 Mesh Blocks) and north shore (2744 Mesh Blocks), where T2DM prevalence was just below 7% and a little above 2%, respectively, according to the National Diabetes Services Scheme Australian Diabetes Map (2013).

The maps in the Box tell a story that is in part surprising, yet also no surprise at all. The first map shows that in these selected areas of western Sydney and the north shore, most neighbourhoods did have access to at least one greengrocer or supermarket. Those neighbourhoods in blue (379 [6%]), however, did not have a greengrocer or supermarket within 1.6 km. It was more common in the west than in the north (261 [8%] v 118 [4%]) for residents to most likely rely on public or private transport to obtain fresh produce.

The second and third maps show the number of takeaway shops or alcohol outlets relative to the number of greengrocers and supermarkets available within 1.6 km. Neighbourhoods where takeaway shops and alcohol outlets outnumbered greengrocers and supermarkets by at least 3:1 are highlighted in red. About 28% (868 of 3148) of neighbourhoods in the west had at least the aforementioned ratio of takeaway shops to greengrocers and supermarkets, in comparison with 20% (546 of 2744) in the north. The equivalent results for alcohol outlets were 12% (365 of 3148) in the west and 5% (131 of 2744) in the north.

Overall, there is by no means a dearth of alcohol or takeaway options if one lives in the affluent north shore. But there are multiple venues for purchasing fresh produce within a reasonable walking distance from home should a person choose to do so. Importantly, much the same can be said in many neighbourhoods in the west of Sydney, even although that area is comparatively less well off. But for many other communities in the west, the availability of fresh produce within a reasonable walking distance is limited. Meanwhile, the provision of takeaway shops and alcohol outlets outnumbers greengrocers and supermarkets in many neighbourhoods in the west. In some of those communities, there is a takeaway shop but no greengrocer or supermarket.

These results are preliminary and subject to limitations, not least in the possible undercount of takeaway shops because many of them are local independent retailers with no need to advertise in the Yellow Pages. But if the real number of takeaway shops is substantially higher, that only serves to deepen our concern. Analysis of smaller catchments (eg, a 400 m road network distance from a person’s home) may also reveal sharper inequities in these indicators. This research is currently underway, and we are also comparing food consumption patterns and health in relation to local food environment.

Nonetheless, there is an important question of what evidence is necessary to fuel effective policies and practices, because large-scale investments in structural change may not guarantee the desired impacts. In the United States and the United Kingdom, studies of takeaway shop bans and introduction of supermarkets to communities that did not previously have one, for example, have revealed little behavioural change in the short term.15–17 On the other hand, life course theory indicates that engrained behaviour is unlikely to change drastically at the flick of a policy switch; we have to invest in multisectoral change for which the health benefits may only be realised in the long term.10

Meanwhile, potentially unintended short-term consequences should also be taken into account, because takeaway shops and alcohol outlets are also places of work for many people. Removing them may not only result in the loss of livelihoods and potential social networks but could also increase car dependency if more attractive, healthier and affordable substitutes are not provided within a reasonable walking distance from home. Rather than just addressing the problem as if it were somehow in a vacuum or laboratory, we also need to be wary of the possibility of shifting these potentially “obesogenic” circumstances from one location to another. To enhance the business case for the multisectoral approach for prevention, we need to have greater confidence in what works locally. This means that the health impact of structural change in the built environment, such as the ongoing developments in western Sydney, needs to be evaluated with as much rigor as possible. To this end, investment in local evidence and in academia–industry partnerships is fundamental so that those evaluations are well developed and resourced from the get-go. The aforementioned studies and other wisdom from overseas, although relevant and to be taken into consideration, are no substitutes for well-crafted experimental and observational studies conducted in our patch.

To conclude, we re-emphasise that geographic inequities demonstrably manifest within cities and the related issues of T2DM and food environment are ones that we ought to pay close attention to in the health sector. In Australia’s largest city, there is a clear spatial mismatch, in which many communities — where access to a car is not guaranteed and public transport options can be thin, where social and economic pressures weigh heavy, and where diet-related health challenges are considerable — have few opportunities to purchase fresh produce close to home. We know not whether land-use zoning, better public transport or other structural changes will provide the upstream silver bullet for preventing the myriad chronic diseases that challenge us collectively as a society. But policies that ensure opportunities to purchase fresh produce that is affordable and available within a reasonable walking distance from home in communities where this is not presently the case would be fairer. We would not build neighbourhoods without roads, clean water and sanitation, so why do we build neighbourhoods without other things that are essential, such as good access to fresh produce? Investment in gathering local evidence driven by multisector initiatives (such as the Western Sydney Diabetes Prevention and Management Initiative) has to be part of the solution. What seems clear is that more of the same and a failure to take action on the status quo are unlikely to stem the flow of bad news for our fellow human beings who are living with and fighting T2DM. It is time we all work together to turn off that tap.

Indicators of food environment within a 1.6 km road network distance of residential Mesh Blocks in selected areas of western Sydney and the north shore

Indigenous constitutional recognition – more than symbolism

The AMA takes its commitment to closing the gap in Indigenous health outcomes seriously, and this involves engaging regularly with Indigenous leaders and communities, and with others committed to addressing social disadvantage.

The Garma Festival, which is held in Arnhem Land each year, brings together a diverse group of people to discuss Indigenous rights and culture, including health, education, and other social issues. I was fortunate to attend this year.

Garma is an opportunity to engage with Australia’s Indigenous leaders and to hear from Indigenous peoples, in their own words, what is needed to improve the health and lives of Australia’s First people.

One of the most important features of the program is the key forum. Sitting in the traditional meeting place of the Yolngu clan, high on an escarpment looking out to the Arafura Sea, it seems a long way from Canberra or the SCG. However, topics of constitutional recognition and racism towards Indigenous people in our society, including footballers, were among those most discussed.

The Aboriginal concept of ‘health’ centres on social and emotion wellbeing – a concept that applies to anyone. Indigenous people face racism on a daily basis. The treatment of Adam Goodes raises an important questions for the nation, for non-Indigenous people, and our commitment to issues such as raising the standards of health, education, and economic outcomes of Indigenous people.

There was clearly anger, which was well articulated by Noel Pearson’s speech on the topic, in which he asked “how well do we know our fellow Australians”? He called on the better parts of ourselves and this nation to triumph over racism.

The AMA is a supporter of Recognise – the campaign for constitutional recognition of Australia’s First Peoples. This is more than about symbolism. It is an important part of reconciliation and about the value that this nation places on Indigenous members of the Australian community. While there is bipartisan support for this process, the next step is for Indigenous people to agree on what form the change should take, and subsequently the specific wording of the question that should be taken to any referendum.

There was palpable disappointment at Garma at the response from the Prime Minister in rejecting a proposal for a series of Indigenous meetings to come to an agreement before wider discussion. It was pointed out that Indigenous people are often asked to take responsibility. There was a significant consensus around the need for Indigenous people to take this role.

Perhaps there is concern about the results of that process, and the model that is offered. Whatever the reason, unless there is unity behind the proposal, the referendum risks failing – and that would be a grim day for all Australians.

Many of the most important legal battles for Aboriginal land rights involve Arnhem Land and the While at Garma, there was also time to discuss some of the more concrete health issues. I sat with Professor Alan Cass, Dr Paul Laughton, and Senator Nova Peris discussing the high rates of renal failure in the Northern Territory, the role of prevention in addressing chronic kidney disease, the impacts of dialysis on patients and their families, along with the need to increase the rate of kidney transplantation.

As most chronic kidney disease is preventable, our discussion again highlighted the need for good primary care, particularly in Indigenous health. The Aboriginal community controlled health system is so important, particularly in the Northern Territory. It is one of the reasons why the AMA campaigned so strongly on the Government proposals that threatened funding for primary health care, such as the co-payment proposals and the freeze on Medicare indexation. These proposals all effectively defund primary health care.

While there was time for discussing health, in line with the Government’s Indigenous Advancement Strategy, there was a lot of discussion around education and employment. There is good work being done but, as was highlighted in some of the conversations on the sidelines with people working in schools and communities, health has to underpin these strategies. There cannot be any relaxing of our commitment to Close the Gap.

Perspectives from the field: Ebola response in Sierra Leone

On Christmas Day 2014, I started a 6-week placement at the Australian-flagged Ebola Treatment Centre, managed by Aspen Medical, in Freetown, Sierra Leone. I joined about 30 doctors, nurses, environmental health officers, and management and support staff from across Australia and New Zealand, working alongside 120 Sierra Leoneans.

A societal disaster

The West African Ebola virus disease (EVD) outbreak is a medical and societal disaster. Most patients die, leaving devastated families and communities. EVD spreads by interpersonal contact, so the community prevention message is “Avoid Body Contact” — ABC. However, body contact makes us human, and the ABC protocol is freakish in all cultures. Dramatic community-wide behaviour change is needed to control an EVD outbreak.

The EVD outbreak is occurring in West African countries already devastated by ecological, economic and governance crises. Access to food is limited; many people require food aid. Schools have closed, and a generation may never reach their potential. Health care services have collapsed — deaths from malaria, tuberculosis, HIV and diarrhoea will far exceed deaths from EVD.1

Challenges in the Ebola Treatment Centre

Outbreaks of EVD are brutal. The Ebola Treatment Centre assists in controlling the outbreak by isolating patients with EVD infection. A razor wire fence surrounds the treatment centre. Incinerators spew smoke as contaminated clothes, bedding, food and personal belongings are burnt. Controlled access to the treatment centre, and its white, green and red zones, prevents spread of the disease within the centre.

Survivors of Ebola virus disease leave their mark on this special wall at the Freetown Ebola Treatment Centre as they return home free of the disease. Image courtesy of Aspen Medical
.

Clean gloves are part of the personal protective equipment (PPE) used every time anyone enters the red zone of an Ebola Treatment Centre. For tasks that do not require dexterity, thick gloves are used. All PPE is carefully removed on exiting the red zone, and the gloves are washed in chlorine and dried in the sun for reuse. Image courtesy of Aspen Medical.

Inside the Ebola Treatment Centre, personal protective equipment (PPE) is conspicuous. This equipment is required for entry to the red zone and is donned under supervision. Scrubs, boots, overalls, double gloves, an apron, an N95 mask, a hood and goggles must cover the entire body. The PPE soon becomes hot and goggles fog up, so time in the red zone is limited to 60 minutes. Patient care is restricted by these time limitations and by the PPE itself, which impairs communication and makes the stethoscope useless. Frequent chlorine spraying damages the available medical equipment.

Personal reflections

Despite the Ebola Treatment Centre’s restrictions and the lack of specific treatment for EVD, the work was satisfying. We offered symptom relief, particularly fluids and opiates, along with compassion, counselling and support. We witnessed life and death and celebrated each EVD survivor. The placement gave me insights into how health determinants can be so cruel, yet individuals so inspiring.

Bullying and harassment: can we solve the problem?

The prevalence of sexual harassment and bullying in medicine has recently been highlighted in the media. This matter is not, of course, restricted to medicine. However, in medicine, harassment and bullying appear to be most evident among very hierarchical, male-dominated specialities such as surgery.

Although the focus of the complaint alluded to above was the Royal Australasian College of Surgeons (RACS), all colleges, and their specialist societies, must respond to these allegations. In Australia, these colleges and societies are responsible for postgraduate training of medical specialists. They produce a highly-trained, fit-for-purpose doctor based on a sound clinical curriculum and appropriate skills training.

The Colleges already have codes of conduct and a limited capacity to counsel, censor and discipline Fellows, but these have not worked and a new approach is required. First, they must seek information to determine the extent of the problem, understand the perspective of those who have been harassed or bullied, and consider what options are available to solve the problem. The RACS has commissioned an expert panel to, in effect, perform a root-cause analysis of the problem, and make recommendations on how to solve it. In response to the panel’s findings, new empowered policies and new educational models must be developed.

Lucey and Souba have suggested a shift away from classical educational paradigms based on a “carrot and stick” philosophy of education, and a move to such strategies as rewarding good behaviour, reinforcing rules, providing role models and removing those who falter.1 The authors asserted that rules and regulations alone do not change behaviour. They argue that, while an employer can counsel, censor, reprimand or even dismiss offending clinicians, the problem can only be solved if the individuals concerned recognise that their behaviour is inappropriate and then determine to change that behaviour.1 In cases of bullying or harassment, they must see such behaviour as not in keeping with their personal expectations. For many older clinicians, this will be difficult. Behaviour that made them successful is being challenged and is no longer legitimate. Further, many clinicians will accept the rules of professionalism but behave differently or deny their behaviour is inappropriate. Lucey and Souba identified five teachable skills: self-awareness and self-control, situational awareness, alternative strategy development, crisis communication and peer coaching.1 These skills could provide the foundation of educational interventions. They could be incorporated into new educational programs. The colleges are ideally placed to undertake this role as the larger colleges have excellent educational resources and an excellent track record of educational innovation.

Such interventions could begin at medical school. Students learn not just by observation of poor behaviour, but also by observing examples of good behaviour which are far more powerful.2 This approach is also relevant to trainees.

The Sydney surgeon who made claims about sexual harassment has already publicly expressed doubts that the RACS’s expert panel will make a difference.3 Cynicism that a lasting solution can be found is understandable. Repeatedly in history, when confronted by questions of professionalism, the profession has responded with well meaning codes of conduct, but these have done little to solve the problem. Sometimes a catalyst is needed to change embedded behaviour, and perhaps this is it. The response so far by the RACS is commendable, but it will need to act transparently on the expert panel’s recommendations and not shrink from difficult decisions.