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Background During the summer of 2019/2020, Australia experienced a catastrophic wildfire season that affected nearly 80% of Australians either directly or indirectly. The impacts of climate crisis on perinatal health have only recently begun to receive attention. The objective of this study was to understand experiences of perinatal women during the bushfire and smoke events of 2019–2020 regarding health, health care, and public health messaging. Methods Semistructured interviews were conducted by phone or web conferencing platforms with 43 participants living in the south-east of Australia who were either pregnant or who had recently had a baby during the 2019/2020 fires. Results The health impacts on participants of the fires, associated smoke, and evacuations for some, were both physical and psychological. Many participants sought information regarding how to protect their own health and that of their unborn/recently born children, but reported this difficult to find. Conclusions Pregnant women and new mothers exposed to bushfire events are a risk group for adverse physical and psychological outcomes. At the time of the 2019/2020 Australian bushfires, exposed women could not easily access evidence-based information to mitigate this risk. Family practitioners are well placed to provide pregnant women and new mothers with this sought-after information, but they need to be prepared well in advance of future similar events.

Background Dietary modification is the primary intervention strategy for management of gestational diabetes mellitus (GDM), which usually occurs in the third trimester of pregnancy when women have extra nutritional needs. There is a high migration rate of ethnic Chinese people to Western countries, and those women present a high-risk group for GDM. Little is known about diet, dietary self-management, and nutritional supplementation use among ethnic Chinese migrant women with GDM compared with members of the host population with GDM. Objective This study aimed to compare the perceptions and experiences of dietary self-management and nutritional needs of ethnic Chinese migrants with those of Australian-born white women with GDM in Australia. Design A predominantly qualitative mixed methods approach with a quantitative component was used. Data collection involved in-depth, semistructured interviews, and 3-day 24-hour recall diaries collected concurrently. Data analysis and management relied on NVivo (QSR International Pty Ltd), FoodWorks (FoodWorks Professional 2017, Xyris Software), and SPSS (SPSS Inc). Pearson χ2 test, independent-samples t test, and Mann-Whitney U test were used to compare nutrient intakes between groups. The Pearson correlation was used to determine the relationship between dietary patterns and nutrient intake. Participants A total of 44 ethnic Chinese and 39 Australian-born white participants with GDM were recruited from two large Australian maternity services located in tertiary hospitals. Results Ethnic differences in satisfaction with GDM education influenced GDM self-management. Ethnic Chinese women with GDM perceived dietary advice received from health professionals to be lacking in cultural relevance and detail and responded by restricting their dietary intake and relying on nutritional supplementation. The perceived benefits of specific supplements produced ethnic differences in the patterns of supplement use. Cultural dietary patterns influenced dietary adequacy in pregnancy. Conclusions This study suggests the need for provision of more concrete, prescriptive, and culturally relevant dietary and supplementation advice for ethnic Chinese women with GDM.

The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide. Ethnic differences in risk factors and perinatal outcomes are clinically important. Chinese women constitute approximately 10% of the world's population, and are an increasing migrant population, yet prevalence, risk factors, and outcomes of GDM in this population are insufficiently explored.A retrospective study of a large pregnancy dataset comparing GDM prevalence, risk factors, and perinatal outcomes between immigrant ethnic Chinese women and Australian-born Caucasian women was conducted using logistic regression.Overall, 73 517 births were extracted from the pregnancy databases of two of Australia's largest maternity services. Chinese women (n = 3419) had a 4-fold higher risk of GDM than Caucasians (n = 28 594) after adjusting for risk factors of GDM. A past history of GDM (adjusted odds ratio [aOR] 5.24; 95% confidence interval [95% CI] 2.91-9.42] was the main GDM risk factor in both groups. Other GDM risk factors varied between groups. Perinatal outcomes in Chinese women with and without GDM were similar, except for neonatal hypoglycemia (aOR 2.01; 95% CI 1.14-3.56]. Caucasian women with GDM had more adverse perinatal outcomes than women without GDM. After adjusting for confounders, Chinese women with GDM had a lower risk of labor induction, large-for-gestational-age babies, neonatal hypoglycemia, respiratory distress, and low Apgar scores than Caucasian women with GDM.Differences in prevalence, risk profile, and adverse outcomes in GDM were evident between ethnic Chinese and Caucasian women. A precision medicine approach to GDM may be warranted considering ethnicity and individual risk profiles rather than a one-size-fits-all approach.摘要: 背景 妊娠期糖尿病(gestational diabetes mellitus，GDM)的患病率在全球范围内不断上升。GDM危险因素以及围产期结局的种族差异具有重要的临床意义。中国女性约占世界人口的10%，并且其中移民人口越来越多，然而，目前尚未对这一人群中的GDM患病率、危险因素以及结局进行过充分的研究。 方法 这是一项利用大型妊娠数据集的回顾性研究，采用逻辑回归方法比较了华裔女性移民与澳大利亚出生的白人女性的GDM患病率、危险因素以及围产期结局的差异。 结果 从澳大利亚两个最大的产科服务机构的妊娠数据库中共提取了73 517名新生儿的相关数据。校正GDM的危险因素后，华裔女性(n=3419)患GDM的风险比白人女性(n=28 594)高4倍。在两组人群中既往GDM病史均为GDM的主要危险因素(校正后的比值比[aOR] 5.24；95%可信区间[95% CI] 2.91-9.42)。两组之间的其他GDM危险因素存在差异。除新生儿低血糖外(aOR 2.01；95% CI 1.14-3.56)，合并或者未合并GDM的华裔女性围产期结局相似。与未合并GDM的白人女性相比，合并GDM的白人女性的不良围产期结局更多。校正混杂因素后，与合并GDM的白人女性相比，合并GDM的华裔女性中引产、分娩大于胎龄儿、新生儿低血糖、呼吸窘迫和低Apgar评分的风险均较低。 结论 华裔女性与白人女性的GDM患病率、危险因素特征以及不良结局均存在明显差异。考虑到种族与个体危险特征均存在差异，对GDM患者需要采用精准的治疗方法，而不是一刀切的方法。.

Schools in Australia are required to promote equitable access to education and provide support services to students with chronic health conditions (CHCs). This qualitative study was conducted to explore stakeholders’ experiences and perceptions regarding school-based support. In-depth interviews were conducted with 38 parents of upper secondary school students with cystic fibrosis, anorexia nervosa or cancer (which were illustrative of different types of severe congenital, mental health or somatic CHCs). This enabled comparison of findings to determine whether there were any patterns in perceptions and experiences that were tied to the different CHCs. Data were analysed using a modified grounded theory approach to identify themes. Even though analysis indicated that all cohorts of parents viewed informed educators as best placed to provide tailored school-based support, major cohort differences were reported in parental experiences of school-based support as well as parental diagnosis disclosure b...

South Asians are a growing migrant population, both globally and in Australia. This group are at higher risk for both cardiovascular disease and type 2 diabetes. The aim of this qualitative study was to compare dietary practices of South Asians, n = 41 (Indian, n = 25; Sri Lankan, n = 16) and Anglo-Australians, n = 16, with these conditions, using semi-structured in-depth interviews. Findings suggest that both groups had a high level of awareness of dietary practices necessary for optimum disease management, both prior to and post diagnosis. Bi-directional effects of migration were noted in the dietary practices of both groups suggesting hybrid diets are evident in Australia. A key barrier to implementing dietary changes highlighted by both groups of participants was a lack of specific, timely and detailed dietary advice from clinicians. Both groups expressed that advice should be repeated and reinforced throughout the course of their disease. In addition, South Asian participants wanted more culturally relevant advice. Clinicians providing dietary advice need to recognise that preferences for staple food items are resistant to change and may affect adherence. Acculturation was evident in the dietary practices of the South Asian participants. Nevertheless, many maintained traditional food practices which were tied to their cultural identity. It is recommended that clinicians consider these factors when offering advice.

We present a case study involving the unexpected deaths of two young people whose parents were taking part in a qualitative study concerning adolescents with chronic disease. We explore and highlight the ethically important moments, both procedural and emotional, and the implications for the research team, the ethics committee, and for qualitative health researchers more broadly. Our reflections are drawn from team discussion and analysis of the trainee researcher’s responses to the situation. We focus on (a) reflexivity and ethical mindfulness as a strategy for enhancing emotional safety, (b) the concept of emotional safety for qualitative researchers, and (c) the procedural issues and emotional responses that led to engagement with the human research ethics committee and resulting changes in policy. The article concludes by proposing recommendations for the promotion of emotional safety in qualitative health research that is relevant for researchers, especially trainee researchers, as well as ethics committees.

Using personal insight and interpretation the authors summarise the results and discussion of the largest cross sectional empirical study of Australian Health Care Chaplains concerning their involvement in multiple bioethical issues encountered by patients, families and clinical staff within the health care context. The implications of this study concerning, health care chaplaincy, ecclesiastical institutions, health care institutions and government responsibilities are discussed and interpreted.

Introduction: Asthma is dependent on self-management to prevent deterioration, yet little is known about management strategies used by patients of different ethnic backgrounds. Methods: Asthma patients of Chinese or Anglo-Celtic ethnicity were recruited via public hospital clinics, physician consulting rooms and a community health foundation. Interviews were conducted in Mandarin, Cantonese or English. Participants completed validated asthma knowledge, control and quality of life (QoL) questionnaires in their language of choice. Results: We recruited 31 asthma patients (16 Chinese, 15 Anglo); 21 women and 10 men; mean[SD] age 47.4 [18.3] years. Clinical severity was mild in 16(52%), moderate in 13(42%) and severe in 2(6%) not differing significantly with ethnicity. Asthma knowledge was significantly lower in Chinese than Anglo patients (mean 73.8[9.6] v 56.1[9.8], p Conclusions: Asthma knowledge was lower in the Chinese group and lower still with less fluency in English. Whilst limited asthma knowledge was not associated with poorer asthma control or QoL, impact on ability to self-manage asthma cannot be excluded.

Research indicates that there are worryingly low levels of physical activity among South Asians compared with Anglo-Australians with type 2 diabetes and/or cardiovascular disease (CVD). We compared perceptions, barriers, and enablers of physical activity in these groups. We used a qualitative design, conducting in-depth, semistructured iterative interviews in Victoria with 57 South Asian and Anglo-Australian participants with either type 2 diabetes or CVD. While both groups exhibited knowledge of the value of physical activity in health maintenance and disease management, they wished for more specific and culturally tailored advice from clinicians about the type, duration, and intensity of physical activity required. Physical activity identities were tied to ethnic identities, with members of each group aspiring to meet the norms of their culture regarding engagement with physical activity as specific exercise or as incidental exercise. Individual personal exercise was deemed important by Anglo-Australians whereas South Asians preferred family-based physical activity.

This article explores the group dynamics of mixed methods health sciences research teams. The authors conceptualize mixed methods research teams as “representational groups,” in which members bring both their organizational and professional groups (e.g., organizational affiliations, methodological expertise) and their identity groups, such as gender or race, to the work of research. Although diversity and complementarity are intrinsic to mixed methods teams, these qualities also present particular challenges. Such challenges include (a) dealing with differences, (b) trusting the “other,” (c) creating a meaningful group, (d) handling essential conflicts and tensions, and (e) enacting effective leadership roles. The authors describe these challenges and, drawing from intergroup relations theory, propose guiding principles that may be useful to mixed methods health sciences research teams.

Background and objective: Although guidelines for asthma emphasize the importance of spirometry for continuity and evaluation of care, it is underused in general practice. The objective of this study was to investigate the effect of spirometry and medical review on asthma control in general practice over 12 months. Methods: Patients were recruited through 31 practices, which were randomly allocated to one of three groups: Group A had 3-monthly spirometry with medical review, Group B spirometry only before and after the trial, and Group C usual care. Asthma control data were analysed by intention to treat using non-parametric tests and logistic regression models fitted to allow for confounders, repeated measures and clustering by practice. Results: The trial was completed by 195 patients (Group A 69, Group B 78, Group C 48). Asthma control improved in all groups during the 12 months trial, most impressively in Group A (odds ratio per 3 months = 1.27, 95% confidence interval: 1.08–1.49, P = 0.004), but the difference between the groups' respective 3-monthly changes was not significant. At 6 months, asthma control in Group A had increased more from baseline than in Groups B + C (P = 0.006). Conclusions: Regular spirometry with medical review was associated with improved asthma control in general practice patients, while there was less improvement in either the spirometry only or usual care group. The mechanisms of this improvement may include appropriate adjustment of medication and improved compliance.

Many parents support the ‘supervised introduction’ of alcohol to children. While initiation to regular alcohol consumption in early adolescence has been linked with alcohol-related problems in adult life, the findings from these studies cannot be extrapolated to early childhood. The definition of initiation to alcohol in early childhood is often not reliable and there is a dearth of research regarding the impact of the broader social and cultural context where initiation may occur. Whilst parents need to be supported to make decisions that are informed by ‘evidence’, policymakers need to be mindful of the role of ideology in policy development and the potential differences in risk factors for initiation to alcohol and the misuse of alcohol.

Aim: To examine process evaluation methods used by Australian dietitians in nutrition education of individual clients. ndi_1334 87..93 Methods: A qualitative–quantitative design was used. A purposive sample of 46 clinical dietitians working in Victorian hospitals, community or private practice attended audio-recorded focus groups or an in-depth interview. Themes identified were used to develop a questionnaire to survey Australian dietitians asking about client education strategies and evaluation methods. Two hundred and fifty-eight dietitians (16%) responded to a Web-based questionnaire. Criterion for extraction of results was 70% agreement. Descriptive statistics, chi-squared and Spearman’s rank order correlation analyses were used (if P 0.05). Results: Eleven process evaluation strategies were used by 84% of dietitians. Results clustered into a typology of four evaluation strategies: evaluating planning of the intervention; evaluating assimilation of new information; evaluating intention to change behaviour; and determining a patient’s satisfaction with a consultation. Only two methods were used ‘often’ by more than half the respondents, indicating a wide range in choice of strategies. Seven of 11 strategies in use evaluated information assimilation. There was no significant difference by work category, state of employment or seniority. Evaluative questions to be answered are: Did they agree to it? Did they learn it? Will they use it? What has changed? Conclusion: Process evaluation is best achieved by simultaneous teaching and evaluation. Dietitians may benefit from further skills training to more fully utilise patient-centred planning. Further investigation is warranted to define best practice.

Aim: The present study examined dietitians’ and clients’ perceptions of competence required for the process of nutrition education of individuals and used results to validate performance criteria. Methods: A sequential qualitative–quantitative design was used. A quota sample of dietitians in one Australian state (n = 46; 12%), working in hospital, community or private practice, attended a focus group or interview. A quota of their clients (n = 34) from eight centres was interviewed. Participants were asked about dietitians’ skills and attributes. Audio-taped data were transcribed verbatim and open-coded to identify themes; results were used to develop an 88-item questionnaire asking about educational strategies, counselling skills and professional attributes. Australian dietitians in the targeted population (n = 258; 16%) responded to a Web-based survey in 2006. Descriptive statistics were used for ranked data and between-group relationships were examined using c 2 . Criterion for item acceptance was 70% agreement. Results: Results from two phases of research and from dietitians and clients revealed agreement about dietitians’ desirable nutrition education skills. In the questionnaire results, no significant differences were found in educational strategies used by employment category, by year of qualification or experience. Forty-two performance criteria were confirmed and clustered into an eight-step process model. Underpinning skills of ‘nutrition knowledge’, ‘professional and ethical values’ and ‘communication skill’ were identified as necessary attributes and are described. Conclusions: Performance criteria for nutrition education of individuals were confirmed as valid. A process model is presented, which describes a proficient practice level. This should be evaluated further as a nutrition education and counselling practice assessment tool.

Aim: To critically examine Australian dietitians' experiences of nutrition education and counselling dilemmas arising from their training, competence and experience in education of individual clients. Methods: Participants were a self-selected sample of Australian dietitians who were working with clients in community, hospital, private practice or other employment. They responded to a researcher-developed Web-based questionnaire asking about skills required for education and counselling of individual clients in 2006. Data were collected electronically and descriptive statistics used to compare response distributions, and open-ended responses were examined by content and thematic analysis. Results: Of 258 respondents, half-qualified to enter dietetics since 1998. There was a change in the focus of practice from information-giving (as taught 30 years ago) to use of two-way communication. Dietitians aimed to use counselling, together with discussion and instruction, as methods for educating and interacting with clients. Four-fifths of dietitians recently qualified (1998–2006) were satisfied with their initial preparation for nutrition education and counselling roles. However, many commented that training courses were too focused on knowledge acquisition rather than skills development in nutrition counselling. Planned skill development in employment was described and dietitians were in favour of a system of mandatory counselling topics within continuing professional development CPD in order to improve counselling skill proficiency and aim for expert skills. Conclusion: Practising dietitians' perceptions indicated a need for greater focus on development of expert nutrition education and counselling skills, both in initial training and in the workplace, because these were seen as key skills for practice in the 21st century.

Objective: To describe Victorian private practitioner dietitians’ experience of the Enhanced Primary Care (EPC) program funded under national heath insurance. Design: Dietitians’ experience of the EPC program was investigated between August 2004 and July 2005. A purposive sample of 10% (n = 15) of Victorian dietitians in private practice was interviewed via semi-structured interviews or focus groups. Focus group/interview data were audio-taped, transcribed verbatim and thematically analysed using NVIVO software to manage data. Subjects: Victorian dietitians. Setting: Dietetic private practice. Main outcome measures: Issues identified from narrative themes. Results: Thirteen (86%) participants were registered with the Medicare Australia and managed EPC-referred patients. Two chose not to. All those using the program supported it but voiced frustrations experienced in the first year. Five themes emerged from narrative analysis involving difficulties with implementation in the following areas: referral issues, client preparedness, annual number of consultations limit, impact of financial cost on client and non-reimbursed administration costs. Conclusion: For clients with chronic illness, access to dietitians in private practice under Medicare EPC is an important service. As increasing numbers of dietitians nationally work with EPC patients with chronic illness or complex care needs, there is a need for information sharing between professional groups about billing procedures and chronic care management. More dietitians need to structure practice to initiate bulk-billing. Rigorous evaluation is needed to understand which diagnosis types can benefit from the program and to implement an evidence-based model of chronic care improvement for dietetics consultations.

Objectives The aim of the present study was to determine cardiovascular disease (CVD) risk factors and compare presentation and severity of ischaemic heart disease (IHD) among South Asians (SAs) and Anglo Australians (AAs). Methods A retrospective clinical case audit was conducted at a public tertiary hospital. The study population included SA and AA patients hospitalised for IHD. Baseline characteristics, evidence of diabetes and other CVD risk factors were recorded. Angiography data were also included to determine severity, and these were assessed using a modified Gensini score. Results SAs had lower mean (± s.d.) age of IHD presentation that AAs (52 ± 9 vs 55 ± 9 years, respectively; P = 0.02), as well as a lower average body mass index (BMI; 26 ± 4 vs 29 ± 6 kg/m2, respectively; P = 0.005), but a higher prevalence of type 2 diabetes (57% vs 31%, respectively; P = 0.001). No significant differences were found in coronary angiography parameters. There were no significant differences in the median (interquartile range) Gensini score between SAs and AAs (43.5 (27–75) vs 44 (26.5–68.5), respectively), median vessel score (1 (1–2) vs 2 (1–3), respectively) or multivessel score (37% (33/89) vs 54% (22/41), respectively). Conclusions The findings show that in those with established IHD, cardiovascular risk factors, such as age at onset and BMI, differ between SAs and AAs and these differences should be considered in the prevention and management of IHD. What is known about the topic? There is much evidence on CVD and SAs, it being a leading cause of mortality and morbidity for this population both in their home countries and in countries they have migrated to. Studies conducted in Western nations other than Australia have suggested a difference in the risk profiles and presentations of CVD among SA migrants compared with the host populations in developed countries. Although this pattern of cardiovascular risk factors among SAs has been well documented, there is insufficient knowledge about this population, currently the largest population of incoming migrants, and CVD in the Australian setting. What does this paper add? This paper confirms that a similar pattern of CVD exists in Australia among SAs as does in other Western nations they have migrated to. The CVD pattern found in this population is that of an earlier age of onset at lower BMI compared with the host AA population, as well as a differing cardiovascular risk profile, with higher rates of type 2 diabetes and lower smoking rates. In addition, this study finds similar angiographic results for both the SAs and AAs; however, the SAs exhibit these similar angiographic patterns at younger ages. What are the implications for practitioners? SAs in Australia represent a high cardiovascular risk group and should be targeted for more aggressive screening at younger ages. Appropriate preventative strategies should also be considered bearing in mind the differing risk factors for this population, namely low BMI and high rates of type 2 diabetes. More intensive treatment strategies should also be regarded by practitioners. Importantly, both policy makers and health professionals must consider that all these strategies should be culturally targeted and tailored to this population and not assume a ‘one-size fits all’ approach.

Objectives: To identify expressions used by patients to describe worsening asthma; to examine the relevance of the word “exacerbation” to patients’ experience; and to investigate whether their language is influenced by the severity of the episode and/or the target audience such as family members, friends and work colleagues. Design and setting: Qualitative study carried out from 1 January to 30 December 2004 among community volunteers to a research institute. Semistructured face-to-face interviews were used to elicit descriptions of episodes of worsening asthma, and further questioning was used to examine language used with family, employer and doctor. Participants: 25 people with asthma, aged 22–75 years. Main outcome measure: Themes identified by open coding about patient language for worsening asthma. Results: 12 participants were not familiar with “exacerbation” and only three would use it themselves. “Attack” was the only specific term spontaneously volunteered (20 participants), but it was used for anything from mild to life-threatening episodes. Patients often downplayed the severity of worsening asthma to their families. Different language was used with employers, sometimes to justify sick leave and sometimes because of fear of perceived discrimination. When communicating with clinicians about worsening asthma, patients used symptom descriptors rather than specific terms. Conclusion: There are important differences in the language patients and clinicians use to describe worsening asthma, and the word “exacerbation” has poor utility for

The concept of self-management is based on the notion that it will improve wellbeing and strengthen self-determination and participation in health care, while reducing health care utilisation and health costs. Increasing self-management is a desirable goal for the 15%-20% of children and adolescents who have a significant ongoing health care need related to a chronic health condition. Promoting self-management in young people with chronic illness can be difficult for parents and health care practitioners. Doctors can help parents recognise the potentially competing aspects of the parenting role--protecting young people's health while supporting their growing independence and autonomy. Optimal care may or may not be achievable, depending on a young person's level of development. As children mature through adolescence, they increasingly want their own voice to be heard, as well as the right to privacy and confidentiality in health care consultations. As well as listening to parents and supporting their roles, doctors should see young people alone for part of the consultation, taking a psychosocial history and carefully maintaining confidentiality.

Background. Major epidemiological studies in asthma use the question: "How many attacks of asthma have you had in the last 12 months?" We set out to study what constitutes an asthma attack from the perspective of people with asthma. We also examined concordance between qualitative responses and standard quantitative measures of this question. Methods. Individuals aged 18 to 70 years who sought care for asthma at Emergency Departments in an Australian central city, a suburban and a regional hospital were recruited. Sixty two (43 women and 19 men) participants were interviewed in depth. All interviews were taped, transcribed and thematically analyzed. Demographic data and responses to respiratory health data were also collected. Findings. Widely varying responses to the question, "How many attacks of asthma have you had in the last 12 months?" were found in the quantitative data set. Comparison of quantitative and qualitative data sets showed good agreement between these two responses (intraclass correlation 0.66). People defined asthma attacks as "major" and "minor," as determined by the degree of personal control they were able to exercise. A strongly unifying description of a severe attack was that it was "out of control." Patient's recognized that upper respiratory tract infections commonly triggered major attacks. Interpretation. A commonly asked question about the number of asthma attacks in the past year needs refinement in order to enhance validity. Asthma action plans should use the words "out of control" when defining a severe attack of asthma.

The UN Convention on the Rights of the Child acknowledges the right for children to express opinions about issues affecting them and the right to have these views heard (Davis, 1998). There has been an increase in the number of international studies including children as informants in research, but there is noticeably less published research including children as informants in Australia if they have a disability. Rather, there has been a reliance on parents/carers for insight into their child's experiences. In this article we present the results of a qualitative pilot study where we interviewed parents and their children who have cerebral palsy about their perceptions and experiences of communication in the medical consultation. We found that the views of children and parents were different, further reiterating the need to seek the perceptions of children as well as their parents.

In this analysis, we sought to determine factors that predicted the level of asthma knowledge in a sample of adolescents with asthma and their parents. Eighty-five young people aged 10-24 years attending tertiary care asthma clinics and 46 of their parents answered validated respiratory and asthma knowledge questionnaires. Older adolescents were more knowledgeable about asthma than were younger adolescents (r=0.36, p=0.001). Young people with severe asthma (p=0.015) scored higher on the asthma knowledge questionnaire than those with mild/moderate asthma. Asthma knowledge among young people was related to that of their mothers (r=0.47, p=0.014), however, only age and the asthma knowledge of fathers significantly predicted adolescent asthma knowledge. Adolescents develop increasing autonomy for asthma self-management as they mature, but parents remain an important source of information about asthma for young people.

The aim of this qualitative study was to improve the understanding of the interface between health and educational sectors. Parents of adolescents with anorexia nervosa (AN, n=11), cancer (n=11) and cystic fibrosis (CF, n=16) were recruited through two tertiary hospitals in Victoria. Audio-recorded in-depth interviews were conducted and transcribed verbatim. Consistent themes emerged across the three cohorts, with parents agreeing that schools needed to know of a diagnosis for health safety, academic support and positive peer relationships. However there were significant condition-specific differences. Only parents of adolescents with AN engaged in misdirection (providing a different diagnostic label) or secrecy; a significant number elected not to disclose the AN diagnosis to schools in response to their child's request. In contrast, parents of adolescents with CF who reported that their children did not wish schools to know of the diagnosis when secondary school commenced overruled such requests. Diagnosis disclosure did not emerge as an issue for adolescents with cancer; all parents promptly informed the school of the diagnosis. In summary, parents articulated consistent reasons across disease cohorts for sharing the diagnosis of a chronic health condition with schools, yet experienced different challenges in implementing this, with implications around health safety, academic support and peer relationships.

Educational participation is central to adolescent peer relations, emotional wellbeing and future financial independence. The aim of this qualitative study was to explore the interface between the health and educational sectors to better understand how to support adolescents with chronic health conditions. Parents of adolescents with anorexia nervosa (AN, n=11), cancer (n=11) and cystic fibrosis (n=16) were recruited through two tertiary hospitals in Victoria, Australia. Audio-recorded in-depth interviews were conducted and transcribed verbatim. Just under half (5) of the AN parent cohort reported that their child changed schools during treatment due to identity concerns and a desire for a 'fresh start'; this was not apparent within the cancer or cystic fibrosis cohorts. Experience of stigmatisation was perceived as the major reason to change schools, which also appeared to explain why many parents did not inform the new school of the diagnosis. Efforts to avoid discredited social identity reduced opportunities for educational support as parents of students with AN had less opportunity, or less overt legitimate cause, to know about and access educational supports for children with chronic conditions than the other cohorts. In conclusion, the diagnosis of AN was frequently associated with school change and reduced opportunities for educational support.

Purpose: Extensive literature documents the high value adolescents place on seeing doctors alone for confidential health care. This is articulated in clinical guidelines that promote confidentiality for adolescents. However, little research has explored parents’ views and beliefs regarding their adolescent children seeing doctors alone for confidential care. Method: A qualitative study was undertaken to investigate the beliefs and opinions of parents about confidential care for adolescents. In-depth semi-structured interviews were conducted with 17 parents of adolescents recruited through the Centre for Adolescent Health at the Royal Children’s Hospital in Melbourne, Australia. Interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed using content and thematic analyses. Results: Parents demonstrated a wide variety of opinions about confidentiality for adolescents in the health setting, with several expressing concern about not being involved in their children’s care. Parents’ opinions appeared to be underpinned by two key factors; the way in which they perceived their role as a parent and the level of trust they held in health professionals generally but also, specifically, their child’s doctor. Conclusion: In this study, parental desires regarding confidentiality for their adolescent children in the health setting were not always in accordance with current guidance provided to health professionals. Consequently, the provision of confidential care for young people may be more successful if health professionals invest in building trust with parents, as well as with adolescents, to facilitate parental acceptance of confidential health care for adolescents.

BACKGROUND: Spirometry is the ‘gold standard’ for diagnosing asthma and chronic obstructive pulmonary disease (COPD) but is rarely used in general practice. AIMS: To compare doctor diagnoses with patient reports/spirometry and to determine doctors' perceptions of spirometry. METHODS: Patients prescribed inhaled medication were recruited from 31 practices. Doctor diagnoses were extracted from practice records. Patients completed a questionnaire and spirometry before and after bronchodilator. In-depth interviews were conducted with a sample of doctors. RESULTS: Doctor diagnoses were available for 278 patients: asthma 192 (69%), COPD 38 (14%), asthma/COPD 40 (14%), and eight patients (3%) with other conditions. The diagnosis of asthma was correctly reported by 93% of patients, but only by 61% of those with COPD alone. Among those with both diagnoses, 83% reported asthma and 48% reported COPD. Of those with a diagnosis of COPD, 65% had fixed airflow limitation. Conversely, only 14% of those had been diagnosed with COPD alone. There was no significant difference in reversibility in forced expiratory volume in 1 second between diagnoses. While recognising the value of spirometry in differentiating between asthma and COPD, most general practices only used spirometry in diagnostically difficult cases. CONCLUSIONS: Doctor-diagnosed asthma is accurately reported by patients. However, COPD remains substantially under-diagnosed. Spirometry needs to be more widely used to improve the accuracy of respiratory diagnoses in general practice.

SummaryBackgroundPurchase of short-acting β2-agonist (SABA), but not anti-inflammatory asthma medication, is permitted in Australia without a doctor’s prescription. This has been associated with worse asthma outcomes. We sought to compare the asthma outcomes between those purchasing SABA with and without a doctor’s prescription.MethodsDesign: Cross-sectional study, using stratified randomisation of pharmacies. Setting: 43 pharmacies in Victoria, Australia.ParticipantsUp to 10 consecutive adults purchasing β2-agonists were recruited from each pharmacy, with 316 adults in total.Outcome measuresParticipants underwent spirometry and questionnaires on respiratory health, asthma control, Quality of Life and medication adherence. Asthma severity was determined by GINA medication step. Regression analyses were performed that allowed for clustering by pharmacy.ResultsOf 316 individuals recruited (65% participation rate), 191 (60%) purchased a β2-agonist with a prescription. Purchase of SABA without prescription was not associated with worse asthma outcomes or lung function. Mean (±SD) asthma control score (ACQ) was 1.65 ± 1.03; only 63 (20%) had well-controlled asthma (ACQ

AIM: To investigate ownership and perceived utility of written asthma action plans (WAAPs) in general practice. METHODS: Questionnaires were completed by 225 adults and 75 children with GP-diagnosed asthma from 31 practices. Regression models for WAAP ownership allowed for confounders and clustering by practice. Five audio-recorded focus groups were conducted before questionnaire implementation and, 12 months later, six focus groups and additional in-depth interviews with 29 patients and 16 doctors were conducted. Transcripts were submitted to content and thematic analyses. RESULTS: A total of 37% of adults and 47% of children had WAAPs. Adults reporting spontaneous shortness of breath, an emergency presentation in the previous 12 months, or frequent GP visits were more likely to have a WAAP. Qualitative data indicated that few acknowledged receipt or use of one. Those who remembered receiving a WAAP found it useful in asthma management in conjunction with verbal advice given by their GP. WAAPs were perceived by some patients as an indicator of doctor competence which, in turn, was viewed as signifying better management of asthma by the patient even if the WAAP was never actually used. CONCLUSIONS: Ownership of WAAPs is still low. Additional and more effective strategies are required to improve rates of GP prescription of WAAPs.

Objective: To determine whether spirometry with regular medical review improves the quality of life or other health outcomes among patients with asthma or chronic obstructive pulmonary disease (COPD) managed in general practice. Design, setting and participants: Cluster randomised controlled trial conducted in 31 general practices in Melbourne during 2007–2008. Practices recruited 305 adult patients who had been prescribed inhaled medication in the preceding 6 months. Intervention: Practices were randomly assigned to one of three groups: Group A patients received 3-monthly spirometry performed by a respiratory scientist with results returned to the practice and regular medical review; Group B patients received spirometry only before and after the trial; and Group C patients received usual care. Main outcome measures: Quality of life, assessed with the 36-item Short Form (SF-36) Australian (English) Version 2 questionnaire at baseline and 3, 6, 9 and 12 months. Secondary outcomes were assessed with the European Community Respiratory Health Survey at baseline and 12 months. Results: The trial was completed by 253 participants: 79 in Group A, 104 in Group B, and 70 in Group C. Median age was 58 years (range, 18–70 years), and 167 participants (66%) were women. There were no significant changes in SF-36 Physical and Mental Component Summary scores from baseline to 12 months, or significant differences between groups on either scale or any subscale of the SF-36. There were also no significant differences in respiratory symptoms, asthma attacks, written asthma action plans, days lost from usual activities or health care utilisation. Conclusion: Three-monthly spirometry and regular medical reviews by general practitioners are not associated with any significant improvement in quality of life or other health outcomes for patients with asthma and/or COPD. Trial registration: Australian New Zealand Clinical Trials Registry

Background: Nutrition screening using evidence-based clinical practice is important for identifying patients whose nutritional status may be compromised, so that they receive appropriate treatment. Introduction of the Malnutrition Universal Screening Tool (`MUST') in two wards in two Melbourne hospitals resulted in low screening completion rates by nursing staff. Nurses’ screening practices were explored to understand personal and workplace barriers to compliance. Methods: Surveys of patients’ medical records and focus groups with nurses were used to gather data. Audio-recorded group narratives were transcribed verbatim, and then coded thematically to develop understandings of response patterns. Results: A survey of admitted patients (n = 46) showed low screening rates by ward (17% and 62%). Eighteen nurses in two wards participated in three focus groups. The five main themes that emerged were: ‘screening role’, ‘task priorities’, ‘recognition of evidence-based practice’, ‘uncertainty of protocols’ and ‘degree of competence’. Screening completion was limited by workloads, uncertainty about screening policy and also individuals’ skill in use of the tool. Conclusions: Application of `MUST' can be facilitated by increasing nurses’ competence through training and by the provision of ongoing support. When implementing nutrition risk screening, dietitians’ roles should include continually working with nurses to identify and reduce the barriers that prevent the adoption of universal screening. Enhancement of collaboration is essential to ensure that optimal nutrition care occurs.

Background Little is known about how dietitians conduct their communication with individual patients in the process of nutrition education. To study this issue, both practitioners’ and patients’ perceptions of dietitians’ skills were examined in the first phase of a two-phase study. The resulting narratives were used to develop a questionnaire to survey Australian dietitians involved in clinical practice. Methods A purposive sample of dietitians in one state (n = 46; 12%), working in hospital, community or private practice, and a quota of their adult patients (n = 34), were interviewed. In the second stage, Australian dietitians (n = 258; 16%) responded to a national survey in 2006, which asked about educational strategies, communication skills, and professional attributes. Descriptive statistics were used to compare response distributions, and nonparametric statistics were used to examine between-group relationships. Criterion for item acceptance was established as ‡70% agreement. Triangulation of results revealed strong agreement between data sources. Results Four main communication competencies were established: interpersonal communication skill, nonverbal communication, professional values, and counselling skill. There was no significant difference in practice by work category or experience. The communication competencies, together with 26 accompanying skills, are described. Conclusion An understanding of this guide to communication practice might help enhance dietitian–patient relations.

Background: To explore the meaning of amblyopia from both parents’ and children’s perspectives and to seek correlations between the experiential aspects of the condition and its treatment, the clinical characteristics of amblyopia and any apparent psychopathology. Methods: Children with amblyopia and their parents were engaged in semistructured in-depth interviews. Children also underwent a vision assessment and, where applicable, parents and children completed a psychological inventory, the Behaviour Assessment System for Children. Results: Dealing with stigma and the perceptions and responses of peers were found to be of central significance to the experience of amblyopia therapy. This had adverse consequences for some children’s identity and psychosocial well-being. The clinical manifestations of amblyopia did not correlate with the social implications of the condition. However, children with strabismus were noted to have significantly greater conduct and externalizing problems. Conclusions: Given that amblyopia can affect children’s psychosocial well-being, health outcomes need to integrate both vision and psychosocial implications of treatment. Although treatment should aim to reverse amblyopia and restore visual acuity, efforts to minimise any negative psychosocial consequences of treatment should be made. A way to balance managing amblyopia and ensuring children’s psychosocial well-being should to be considered by clinicians and included in treatment guidelines.

OBJECTIVES: To ascertain what general practitioners' priorities are for achieving optimal outcomes in people with asthma, and the barriers they face in delivering this care. DESIGN: A qualitative study using the Nominal Group Technique (a highly structured meeting to gain information from experts about a particular issue) was conducted between August 2002 and September 2003. GPs in six discussion groups were asked "What do you think is needed to achieve best outcomes for asthma care?" To augment analysis of the discussion, sessions were taped and transcribed. PARTICIPANTS: Forty-nine GPs were recruited: 34 from metropolitan and 15 from rural areas. RESULTS: All groups nominated asthma education for patients and continuing professional education for GPs as major priorities, but they also described educational and structural barriers to achieving these priorities. Other priorities were: medication adherence, facilitating regular patient review, negotiated treatment/management plans, making the correct diagnosis, increased remuneration and consultation time, and safer asthma medications and access to these. Health promotion initiatives and increased public awareness were also priorities. Spirometry was a significant cause of uncertainty. Overall, written asthma action plans were not considered a high priority. CONCLUSIONS: Remarkable consistency was found between GPs' priorities for delivering best asthma care. Our study identified barriers to asthma guideline adherence, including accessible, relevant education for GPs, and structural, time and cost barriers GPs must overcome in providing asthma treatment and patient education.

2004; 21: 166–172.Background. Asthma treatment guidelines currently recommend a ‘therapeutic partnership’to achieve best care. It is frequently assumed that individuals presenting to emergency depart-ments with asthma do not have a good doctor–patient relationship. We asked what is the natureof patients’ relationships with their doctors in those presenting to hospital emergencydepartments for asthma care.Methods. A qualitative study of all consenting individuals aged 18–70 years who presented toa hospital emergency department over 2 months was carried out. Sixty-two participants (19male) engaged in in-depth interviews which were taped, transcribed and underwent thematicanalysis. Questionnaire data were also collected and asthma severity determined.Results. Nearly all patients (61/62) had a doctor whom they saw for their asthma. Patientsmade thoughtful choices on where they sought care according to their needs. Our findingsidentified that perceptions of doctors’ competence, listening to patients and time constraintswere important influences on doctor–patient relationships. Participants had strong expectationsthat their personal disease experience would be acknowledged by their doctors.Conclusion. This group of patients had doctors who cared for their asthma. The acceptabilityof medical care was determined as much by patient choice as by the quality of thedoctor–patient relationship.Keywords. Adherence, asthma, bodily experience, chronic illness, discourse, doctor–patientrelationships.

Objective To explore the reasons why individuals recurrently present with asthma to hospital emergency departments. Design A predominantly qualitative study in which participants were interviewed in-depth about their asthma. Data on medication use, respiratory health and asthma knowledge were also collected, and asthma severity was determined from medical records. Setting A tertiary teaching hospital and a suburban hospital emergency department (ED) from 1 March to 30 April 2000, and a rural hospital ED from 1 July to 31 August 2000. Participants The participation rate was 32% of an initial 195 ED attendees (183 of whom were eligible) aged 18-70 years: 32 had presented to an ED for asthma care on more than one occasion over the preceding 12 months (reattendees), and 29 were non-reattendees. Results Two-thirds (22/32) of reattendees had chronic severe asthma and presentation to ED was deemed appropriate for 18 of these, indicated by recurrent severe asthma attacks despite seeking prior medical intervention. Reasons for re-presentation identified in a third of all reattendees included poor asthma knowledge, and financial and other barriers to medication use. Conclusions We identified potentially preventable issues in about a third of patients (most of whom had mild to moderate asthma) who recurrently presented to EDs for treatment. The remainder of the participants sought emergency asthma treatment appropriately after failing to respond to medical care, and this was frequently in accordance with their asthma management plans.

The phenomenon of adherence, also known as compliance, is the vital link that allows effective medications to have the desired clinical effect when self-administered. It is often assumed that the population is generally adherent, but more than 50% of people with chronic illness do not take their medication as prescribed. We highlight how the terminology and language of non-adherence act to conceptualize adherence as a patient problem in a manner that is inadvertently judgmental, narrowly focused and clinically unhelpful. In contrast, knowledge of the dynamic nature of adherence promotes the conceptualization of adherence as the common problem that it is, where the responsibility for improving it lies primarily with the health professional. The example of asthma is used to highlight how individually focused clinical strategies can fit within a population perspective that, in its entirety, can be conceptualized as a framework of adherence-promoting strategies.

To explore the burden of asthma on the lives of people presenting to hospital emergency departments for asthma treatment.A qualitative study. Consenting individuals with asthma who presented to emergency departments were interviewed in-depth, and interviews were taped, transcribed and thematically analysed. Questionnaire data on medication use, respiratory health and asthma knowledge were also collected. Asthma severity was determined from the medical records.A tertiary teaching hospital and a suburban hospital during March and April 2000, and a rural hospital during July and August 2000.Sixty-two participants (19 male and 43 female), aged 18-70 years.The burden of asthma was broad, affecting social life, personal relationships, employment and finances. The cost of asthma medication was an issue for nearly two-thirds of participants. Individuals performed their own "cost-benefit analysis" for medication use, weighing up expense, perceived side effects and potential benefits. As a consequence, several participants chose to alter their medication dose, or not to take prescribed medications. For some participants, asthma directly contributed to diminished employment opportunities.To achieve a therapeutic partnership, doctors need to be aware of the substantial social, personal and financial burden of asthma for their patients. They should also recognise that patients' perceptions of treatment cost may compromise treatment adherence.

Objective: To identify factors that influence a woman's decision to breast-feed. Methodology: Five hundred and fifty-six women were recruited from the maternity wards of two Perth hospitals. Data were collected from a self-administered questionnaire completed by participants prior to discharge. Logistic regression analysis was used to determine factors influencing the initiation of breast-feeding. Results: At discharge from hospital 83.8% of women were breast-feeding, including 6% who were giving complementary formula feeds. After controlling for potentially confounding demographic and biomedical factors, the father's reported preference for breast-feeding was found to be the most important factor influencing a woman's decision to breast-feed (OR 10.18). Conclusion: Fathers participate in and influence the choice of infant feeding method and should be included in breast-feeding discussions.

Analysis of breast-feeding data from the 1989–90 National Health Survey suggests that since peaking in the mid-1980s, breast-feeding initiation and duration rates have declined in Australia. Data from a recent prospective study of infant feeding practices among 556 women indicates that in Perth, at least, breast-feeding rates have remained relatively stable for the past nine years.

Current models of chronic disease self-management incorporate an understanding that people with chronic illnesses, their carers and clinicians need to work together in addressing illness management issues (Von Korff, Gruman, Schaefer, Curry, & Wagner, 1997) and that this process enhances personal control of health (Lorig, Ritter et al., 2000). The question we ask is whether the understandings in these models, both implicit and explicit, apply to those people living with mental illness in rural areas in Australia. In-depth interviews were used to explore and examine the way in which carers of people living with mental illness in rural Victoria experienced and perceived the nature of chronic disease self-management. Our findings indicate that illness management in rural areas occurs predominantly as a partnership between the person with mental illness and the family members who act as caregivers, rather than a partnership with health professionals. This confirms that the lack of resources in the rural mental health care system results in a crisis-oriented service rather than a service that is able to respond to preventative and ongoing mental health care. This is recognised as a considerable burden for many families and requires further examination. In addition, a finding of considerable clinical and policy importance in this arena is the experience of family caregivers as partners in not only the support of the ?management? aspects of self-management of mental illness, but also in supporting the person living with mental illness in the maintenance of the ?self? aspect of self-management.

It is almost a truism to state that Australia has experienced a health transition from infectious and acute diseases to chronic disease, impairment and disability in the last century (Murray & Lopez, 1996; Beaglehole & Bonita, 1997; Australian Institute o

While there is a tradition of recognising and contending with the emotional content of ethnography (e.g. informant emotions, researcher empathy), there are few accounts of research which illustrate clearly the emotional work done by researchers, and the value of such work as an analytical tool. Yet, in the human services, and especially where trauma is involved, ignoring emotional dynamics actually runs the risk of 'dumbing down' our analyses. The current paper draws on ethnographer experiences during an evaluation of a youth suicide prevention project at the Connexions agency in inner-city Melbourne. The organisation, which is a part of Jesuit Social Services, provides outreach, therapy and other services (e.g. drop-in, labour market program) to marginalised young people. The paper argues that researcher emotions are actually important to isolate and examine in order to adequately capture the meanings participants attribute to their realities and actions. Nevertheless, through the exploration of specific dilemmas, it is shown that recognising and processing difficult emotions can be a confronting yet rewarding exercise for researchers, both personally and in terms of research outcomes. The paper also discusses how the ethnographer managed to conduct research in a setting involving trauma.

There are a number of issues which need to be raised when examining the impact of vision impairment on children's lives. In a pilot study, the problems raised predominantly by primary caregivers of children with mild to moderate vision impairments indicate that current health care practices still tend to be defined in narrow biomedical terms in this area. This is because the psychosocial impacts of these degrees of impairment are not adequately understood by families, health and other professionals and are therefore not effectively dealt with. This often creates a situation in which families are sent from one health service delivery domain to another with no one service taking responsibility for providing the needed assistance - often with parents taking on advocacy roles which in human terms produce extreme strain (Rees & Emerson, 1984).