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Context: There is growing evidence supporting a shift towards 'grow your own' approaches to recruiting, training and retaining health professionals from and for rural communities. To achieve this, there is a need for sound methodologies by which universities can describe their area of geographic focus in a precise way that can be utilised to recruit students from their region and evaluate workforce outcomes for partner communities. In Australia, Deakin University operates a Rural Health Multidisciplinary Training (RHMT) program funded Rural Clinical School and University Department of Rural Health, with the purpose of producing a graduate health workforce through the provision of rural clinical placements in western and south-western Victoria. The desire to establish a dedicated Rural Training Stream within Deakin's Doctor of Medicine course acted as a catalyst for us to describe our 'rural footprint' in a way that could be used to prioritise local student recruitment as well as evaluate graduate workforce outcomes specifically for this region. Issue: In Australia, selection of rural students has relied on the Australian Statistical Geography Standard Remoteness Areas (ASGS-RA) or Modified Monash Model (MMM) to assign rural background status to medical course applicants, based on a standard definition provided by the RHMT program. Applicants meeting rural background criteria may be preferentially admitted to any medical school according to admission quotas or dedicated rural streams across the country. Until recently, evaluations of graduate workforce outcomes have also used these rurality classifications, but often without reference to particular geographic areas. Growing international evidence supports the importance of place-based connection and training, with medical graduates more likely to work in a region that they are from or in which they have trained. For universities to align rural student recruitment more strategically with training in specific geographic areas, there is a need to develop precise geographical definitions of areas of rural focus that can be applied during admissions processes. Lessons learned: As we strived to describe our rural activity area precisely, we modelled the application of several geographical and other frameworks, including the MMM, ASGS-RA, Primary Healthcare Networks (PHN), Local Government Areas (LGAs), postcodes and Statistical Areas. It became evident that there was no single geographical or rural framework that (1) accurately described our area of activity, (2) accurately described our desired workforce focus, (3) was practical to apply during the admissions process. We ultimately settled on a bespoke approach using a combination of the PHN and MMM to achieve the specificity required. This report provides an example of how a rural activity footprint can be accurately described and successfully employed to prioritise students from a geographical area for course admission. Lessons learned about the strengths and limitations of available geographical measures are shared. Applications of a precise footprint definition are described including student recruitment, evaluation of workforce outcomes for a geographic region, benefits to stakeholder relationships and an opportunity for more nuanced RHMT reporting.

Introduction Middle-aged multidomain risk reduction interventions targeting modifiable risk factors for dementia may delay or prevent a third of dementia cases in later life. We describe the protocol of a cluster randomised controlled trial (cRCT), HAPPI MIND (Holistic Approach in Primary care for PreventIng Memory Impairment aNd Dementia). HAPPI MIND will evaluate the efficacy of a multidomain, nurse-led, mHealth supported intervention for assessing dementia risk and reducing associated risk factors in middle-aged adults in the Australian primary care setting.Methods and analysis General practice clinics (n≥26) across Victoria and New South Wales, Australia, will be recruited and randomised. Practice nurses will be trained to implement the HAPPI MIND intervention or a brief intervention. Patients of participating practices aged 45–65 years with ≥2 potential dementia risk factors will be identified and recruited (approximately 15 patients/clinic). Brief intervention participants receive a personalised report outlining their risk factors for dementia based on Australian National University Alzheimer’s Disease Risk Index (ANU-ADRI) scores, education booklet and referral to their general practitioner as appropriate. HAPPI MIND participants receive the brief intervention as well as six individualised dementia risk reduction sessions with a nurse trained in motivational interviewing and principles of behaviour change, a personalised risk reduction action plan and access to the purpose-built HAPPI MIND smartphone app for risk factor self-management. Follow-up data collection will occur at 12, 24 and 36 months. Primary outcome is ANU-ADRI score change at 12 months from baseline. Secondary outcomes include change in cognition, quality of life and individual risk factors of dementia.Ethics and dissemination Project approved by Monash University Human Research Ethics Committee (ID: 28273). Results will be disseminated in peer-reviewed journals and at healthcare conferences. If effective in reducing dementia risk, the HAPPI MIND intervention could be integrated into primary care, scaled up nationally and sustained over time.Trial registration number ACTRN12621001168842.

Introduction: Globally, primary care organisations responded rapidly to COVID-19 physical distancing requirements through the adoption of telehealth to maintain the delivery of health care to communities. In Australia, temporary Medicare Benefits Schedule (MBS) telehealth items were introduced in March 2020 to enable the provision of telehealth services in the primary care setting. These changes included funding for two modes of telehealth delivery: videoconferencing and telephone consultations. As primary care organisations, Aboriginal Community Controlled Health Organisations (ACCHOs) rapidly adopted telehealth consultations to maintain the delivery of primary care services to Aboriginal and Torres Strait Islander clients. The aim of the present study was to evaluate the implementation (specifically the uptake, acceptability and requirements for delivery) of telehealth primary healthcare services for Aboriginal and/or Torres Strait Islander peoples by a rural ACCHO during COVID-19. Methods: A single-site convergent-parallel mixed-methods study was undertaken in the context of an ongoing research partnership established between a rural ACCHO and a university department of rural health. De-identified health service data from March 2020 to March 2021 was extracted, including MBS telehealth consultations and client demographics (eg age, gender and postcode). Variables were analysed using descriptive statistics to examine the uptake of telehealth by Aboriginal and Torres Strait Islander clients. A geographical analysis of postcode data was also undertaken. Semi-structured interviews were undertaken concurrently with a purposive sample of health service personnel (including health professionals) involved in the implementation or delivery of telehealth, and Aboriginal and/or Torres Strait Islander clients who had accessed telehealth, to explore the acceptability of telehealth and requirements for delivery. Thematic analysis using an inductive approach was undertaken. The analyses of quantitative and qualitative findings were merged to identify key concepts pertaining to the uptake, acceptability and requirements for telehealth delivery. Results: During the first year of implementation, 435 telehealth primary healthcare consultations were delivered to Aboriginal and/or Torres Strait Islander clients. Seven health personnel and six Aboriginal and/or Torres Strait Islander clients participated in interviews. Merged findings from an analysis of quantitative and qualitative data were grouped under three concepts: uptake of telehealth consultations by Aboriginal and Torres Strait Islander clients, maintaining the delivery of ACCHO services during COVID-19, and implications for sustaining telehealth in an ACCHO. Findings identified that telehealth maintained the delivery of ACCHO services to Aboriginal and/or Torres Strait Islander clients across the lifespan during COVID-19, despite a preference for face-to-face consultations. A greater uptake of telephone consultations compared to videoconferencing was identified. Barriers to the utilisation of videoconferencing were largely technology related, highlighting the need for additional support for clients. Conclusion: Telehealth was a useful addition to face-to-face consultations when used in the appropriate context such as the administration of long-term medication prescriptions by a GP. Engaging the ACCHO sector in the policy discourse around telehealth is imperative for identifying requirements for ongoing implementation.

Objectives This study sought first to empirically define dietary patterns and to apply the novel Dietary Inflammation Score (DIS) in data from rural and metropolitan populations in Australia, and second to investigate associations with cardiovascular disease (CVD) risk factors.Design Cross-sectional study.Setting Rural and metropolitan Australia.Participants Adults over the age of 18 years living in rural or metropolitan Australia who participated in the Australian Health survey.Primary outcomes A posteriori dietary patterns for participants separated into rural and metropolitan populations using principal component analysis. Secondary outcomes: association of each dietary pattern and DIS with CVD risk factors was explored using logistic regression.Results The sample included 713 rural and 1185 metropolitan participants. The rural sample was significantly older (mean age 52.7 compared with 48.6 years) and had a higher prevalence of CVD risk factors. Two primary dietary patterns were derived from each population (four in total), and dietary patterns were different between the rural and metropolitan areas. None of the identified patterns were associated with CVD risk factors in metropolitan or rural areas, aside diet pattern 2 being strongly associated with from self-reported ischaemic heart disease (OR 13.90 95% CI 2.29 to 84.3) in rural areas. There were no significant differences between the DIS and CVD risk factors across the two populations, except for a higher DIS being associated with overweight/obesity in rural areas.Conclusion Exploration of dietary patterns between rural and metropolitan Australia shows differences between the two populations, possibly reflective of distinct cultures, socioeconomic factors, geography, food access and/or food environments in the different areas. Our study provides evidence that action targeting healthier dietary intakes needs to be tailored to rurality in the Australian context.

Abstract Background There is increasing recognition of the substantial burden of mental health disorders at an individual and population level, including consequent demand on mental health services. Lifestyle-based mental healthcare offers an additional approach to existing services with potential to help alleviate system burden. Despite the latest Royal Australian New Zealand College of Psychiatrists guidelines recommending that lifestyle is a ‘first-line’, ‘non-negotiable’ treatment for mood disorders, few such programs exist within clinical practice. Additionally, there are limited data to determine whether lifestyle approaches are equivalent to established treatments. Using an individually randomised group treatment design, we aim to address this gap by evaluating an integrated lifestyle program (CALM) compared to an established therapy (psychotherapy), both delivered via telehealth. It is hypothesised that the CALM program will not be inferior to psychotherapy with respect to depressive symptoms at 8 weeks. Methods The study is being conducted in partnership with Barwon Health’s Mental Health, Drugs & Alcohol Service (Geelong, Victoria), from which 184 participants from its service and surrounding regions are being recruited. Eligible participants with elevated psychological distress are being randomised to CALM or psychotherapy. Each takes a trans-diagnostic approach, and comprises four weekly (weeks 1-4) and two fortnightly (weeks 6 and 8) 90-min, group-based sessions delivered via Zoom (digital video conferencing platform). CALM focuses on enhancing knowledge, behavioural skills and support for improving dietary and physical activity behaviours, delivered by an Accredited Exercise Physiologist and Accredited Practising Dietitian. Psychotherapy uses cognitive behavioural therapy (CBT) delivered by a Psychologist or Clinical Psychologist, and Provisional Psychologist. Data collection occurs at baseline and 8 weeks. The primary outcome is depressive symptoms (assessed via the Patient Health Questionnaire-9) at 8 weeks. Societal and healthcare costs will be estimated to determine the cost-effectiveness of the CALM program. A process evaluation will determine its reach, adoption, implementation and maintenance. Discussion If the CALM program is non-inferior to psychotherapy, this study will provide the first evidence to support lifestyle-based mental healthcare as an additional care model to support individuals experiencing psychological distress. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12621000387820 , Registered 8 April 2021.

Abstract Background Pregnant teenagers in rural and regional areas experience distinct disadvantages, that are not simply a function of their age, and these have a substantial impact on their health and that of their baby. Studies demonstrate that antenatal care improves pregnancy outcomes amongst pregnant women, especially adolescents. Understanding teenager’s views and experiences of pregnancy and motherhood is important to ensure antenatal care meets young women’s needs. This study explored teenage women’s experiences and perceptions of barriers and facilitators to engaging in pregnancy care in rural and regional Victoria, Australia. Methods Between February–October 2017, pregnant women aged ≤19 years were purposively recruited from one regional and two rural health services in Victoria. Semi-structured, face-to-face interviews guided by naturalistic inquiry were conducted and an inductive approach to analysis was applied. Results Four key themes emerged from the analysis of the transcripts of 16 interviews: Valuing pregnancy care, Interactions with Maternity Service, Woman-centred care, and Support systems. Teenage women primary motivation to attend care was to ensure their baby’s wellbeing and lack of engagement occurred when the relevance of antenatal care was not understood. Appointment flexibility and an accessible location was important; most participants were reliant on others for transport. Continuity of carer and respectful, non-judgement communication by staff was highly valued. Many young women had fractured families with pregnancy diminishing their social world, yet having a baby gave them purpose in their lives. Conclusion Maternity services and health professionals that provide flexible, adaptable women-centred care and support through pregnancy and early motherhood will assist young women’s engagement in antenatal care.

Abstract Objective: To undertake a census of the healthfulness of food venues providing lunch or dinner meals in a rural Australian setting and compare healthfulness by remoteness, using two measurement tools. Methods: A census of the rural local government area food venues was undertaken using two validated tools: the Healthfulness Rating Classification System (HRCS) and the Nutrition Environment Measures Survey (NEMS‐R). Data were collected covering an area of 3,438 square kilometres in Victoria, Australia, with a population of >21,000. Healthfulness by remoteness was described and variability between tools was explored. Results: Data were collected from all 95 eligible food venues. Both tools classified the food venues as relatively unhealthy. The mean HRCS score was ‐2.9 (unhealthy) and the mean NEMS‐R score was 10.8 (SD 7.0; possible range ‐27 to 64). There were no significant differences in healthiness of venues by remoteness (as measured by the Modified Monash Model), although the outer‐rural region had lower scores. Conclusions: This census of a rural food retail environment showed low access to healthy menu options along with minimal provision of nutrition information and promotion of healthy food in food venues. This environment has the potential to affect the dietary intake of more than 21,000 rural‐dwelling Australians and action to improve rural food environments is desperately needed. Implications for public health: If unhealthful rural food environments are not addressed, inequalities in the diet‐related disease burden for rural Australians will continue to persist. This study shows that interventions are needed for independent venues that could be targeted by researchers, local health promotion officers, community nutritionists or community education programs.

Context: In Australia, Aboriginal Community Controlled Health Organisations (ACCHOs) are geographically proximal to where Aboriginal and Torres Strait Islander People reside and are valued for providing holistic and culturally safe primary health care. Partnering with ACCHOs in research is appropriate for redressing health inequities experienced by Aboriginal and Torres Strait Islander People, which includes a high burden of chronic disease. Historically, some approaches to Aboriginal and Torres Strait Islander health research have been unethical. Greater accountability in the research process, transparency in reporting, and use of culturally appropriate research methodologies are key recommendations to improving the ethical integrity of research. The need for strengthening the reporting of health research involving Aboriginal and Torres Strait Islander People and Indigenous peoples globally led to the development of the CONSolIDated critERia for strengthening the reporting of health research involving Indigenous peoples (CONSIDER statement), which is a synthesis of international ethical guidelines. This project report uses the CONSIDER statement to critically reflect on participatory research undertaken in partnership with an ACCHO in the rural context and to identify lessons of value for future research. Issue: By using the CONSIDER statement as a tool for critical reflection, it was identified that processes used to establish a research partnership with an ACCHO were key to setting the research agenda, including identifying ethical issues, the needs of local Aboriginal and Torres Strait Islander People, and expectations from the research. The participation of Aboriginal community members throughout the entire research process was not only methodologically important but was also ethically appropriate. Research activities in this project included opportunities for Aboriginal community members to directly share their perspectives and experiences and develop local solutions to issues affecting them. Outcomes included evidence to support future funding applications, community-derived priorities that assisted with government reporting, and locally identified methods for addressing chronic disease management. Key to this was building the research capacity and capability of local Aboriginal community members, which also reflected the ethical principles of reciprocity and equity. This also provided opportunities for non-Indigenous researchers to learn from local Aboriginal community members and develop skills in culturally appropriate research. Lessons learned: Using the CONSIDER statement was beneficial in enabling researchers to critically reflect on a participatory research project undertaken in partnership with a rural ACCHO. Researchers identified that participatory approaches can be used to generate research of relevance to local Aboriginal community members and their ACCHOs, and to support health service reporting, and future funding applications. Research timelines and activities needed to be flexible and adaptable, to allow for staff turnover and unforeseen events of cultural significance. Similarly, it is important for researchers to be receptive to change and open to learning. Although research partnerships are established on trust and mutual respect, it is recommended that greater formal provisions are required to protect the intellectual property of Aboriginal and Torres Strait Islander communities involved in research. These lessons are likely to be transferrable to other settings and are of value to researchers seeking to partner with ACCHOs in research.

Introduction: Inequitable distribution of health workforce limits access to healthcare services and contributes to adverse health outcomes. WHO recommends tracking health professionals from their points of entry into university and over their careers for the purpose of workforce development and planning. Previous research has focused on medical students and graduates' choice of practice location. Few studies have targeted nursing and allied health graduates' practice intentions and destinations. The Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study is investigating factors affecting Australian nursing and allied health students and graduates' choice of graduate practice location over the course of their studies and up to 10 years after graduation by linking multiple data sources, including routinely collected university administrative and professional placement data, surveys of students and graduates, and professional registration data. Methods: By using a prospective cohort study design, each year a new cohort of about 2000 students at each participating university (Deakin University, Monash University and the University of Newcastle) is tracked throughout their courses and for 10 years after graduation. Disciplines include medical radiation practice, nursing and midwifery, occupational therapy, optometry, paramedicine, pharmacy, physiotherapy, podiatry and psychology. University enrolment data are collected at admission and professional placement data are collected annually. Students' practice destination intentions are collected via questions added into the national Student Experience Survey (SES). Data pertaining to graduates' practice destination, intentions and factors influencing choice of practice location are collected in the first and third years after graduation via questions added to the Australian Graduate Outcomes Survey (GOS). Additionally, participants may volunteer to receive a NAHGOT survey in the second and fourth-to-tenth years after graduation. Principal place of practice data are accessed via the Australian Health Practitioner Regulation Agency (Ahpra) annually. Linked data are aggregated and analysed to test hypotheses comparing associations between multiple variables and graduate practice location. Results: This study seeks to add to the limited empirical evidence about factors that lead to rural practice in the nursing and allied health professions. This prospective large-scale, comprehensive study tracks participants from eight different health professions across three universities through their pre-registration education and into their postgraduate careers, an approach not previously reported in Australia. To achieve this, the NAHGOT study links data drawn from university enrolment and professional placement data, the SES, the GOS, online NAHGOT graduate surveys, and Ahpra data. The prospective cohort study design enables the use of both comparative analysis and hypothesis testing. The flexible and inclusive study design is intended to enable other universities, as well as those allied health professions not regulated by Ahpra, to join the study over time. Conclusion: The study demonstrates how the systematic, institutional tracking and research approach advocated by the WHO can be applied to the nursing and allied health workforce in Australia. It is expected that this large-scale, longitudinal, multifactorial, multicentre study will help inform future nursing and allied health university admission, graduate pathways and health workforce planning. Furthermore, the project could be expanded to explore health workforce attrition and thereby influence health workforce planning overall.

Systems thinking is increasingly applied to understand and address systemic drivers of complex health problems. In Australia, group model building, a participatory method from systems science, has been applied in various locations to engage communities in systems-based health promotion projects. To date there is limited evidence regarding GMB use with Australian Aboriginal communities. This study aimed to determine the value and acceptability of group model building (GMB) as a methodological approach in research with Aboriginal communities and identify any adaptations required to optimise its utility. Semi-structured interviews were undertaken with 18 Aboriginal health and university staff who had prior experience with a GMB research project. Interview transcripts were inductively analysed using thematic analysis and key themes were organised using an Indigenous research framework. Participants reported that GMB methods generally aligned well with Aboriginal ways of knowing, being, and doing. Participants valued the holistic, visual and collaborative nature of the method and its emphasis on sharing stories and collective decision-making. Group model building was viewed as a useful tool for identifying Aboriginal-led actions to address priority issues and advancing self-determination. Our findings suggest that by bringing together Aboriginal and non-Aboriginal knowledge, GMB is a promising tool, which Aboriginal communities could utilise to explore and address complex problems in a manner that is consistent with their worldviews. In adapting group model building methods, non-Aboriginal researchers should aspire to move beyond co-design processes and enable Aboriginal health research to be entirely led by Aboriginal people.

Abstract Background To evaluate the impact of the Dementia Care in Hospitals Program (DCHP) on clinical and non-clinical staff job satisfaction, level of confidence and comfort in caring for patients with cognitive impairment (CI). Staff perceptions of how organisational support and hospital environment met the needs of patients with CI were also assessed. Methods The DCHP was implemented across four acute hospital sites across Australia. Clinical and non-clinical staff received training on CI screening and communication strategies for patients with CI. A staff satisfaction survey was administered pre- and post-implementation of the DCHP. Results One thousand seven hundred forty-eight staff received DCHP education and 1375 staff participated in the survey. Self-reported confidence and level of comfort in caring for patients with CI significantly improved following implementation. Staff also reported increased job satisfaction and organisational support at all hospital sites. Conclusions The DCHP implementation within an acute hospital setting was found to show an improvement in staff confidence, comfort, and job satisfaction when caring for patients with CI. This study has significant implications for the improvement of care for patients with CI as well as staff retention and job satisfaction. Further research is required to determine whether these improvements are sustained in the longer term.

Abstract Background Women with gestational diabetes have low diet quality. We evaluated the effectiveness of a group-based lifestyle modification program for improvement of dietary quality in women with previous gestational diabetes predominantly within their first postnatal year. Methods Women were randomised to intervention (n = 284) or usual care (n = 289). Dietary data was collected at baseline and twelve months using a food frequency questionnaire and recoded into the Australian Recommended Food Score (ARFS). Mixed model analyses investigated the intervention effect on ARFS (per-protocol-set (PPS) excluded women without the minimum intervention exposure). Results Baseline mean total ARFS was low (31.8 ± 8.9, maximum score = 74) and no significant changes were seen in total ARFS (Cohen’s D = − 0.06). 2% reduction in alcohol for intervention (0.05, 0.26) compared with − 1% for usual care (Odds ratio: 0.68; 95%CI 0.46, 0.99). Dairy ARFS sub-category significantly improved (low fat/saturated fat foods) in the intervention group over time compared with usual care for the PPS analysis (dairy + 0.28 in intervention (95%CI 0.08, 0.48) compared with + 0.02 in usual care (95%CI -0.14, 0.18) (group-by-treatment interaction p = 0.05, Cohen’s D = 0.14)). Conclusions Engaging with the intervention improved aspects of diet quality that aligned with minimum intervention exposure, but the total diet quality remains low. Further research is needed to improve diabetes prevention program engagement. Trial registration Australian New Zealand Clinical Trials Registry ANZCTRN12610000338066, April 2010.

Background Patient engagement in safety has shown positive effects in preventing or reducing adverse events and potential safety risks. Capturing and utilising patient-reported safety incident data can be used for service learning and improvement.Objective The aim of this study was to characterise the nature of patient-reported safety incidents in primary care.Design Secondary analysis of two cross sectional studies.Participants Adult patients from Australian and English primary care settings.Measures Patients’ self-reported experiences of safety incidents were captured using the validated Primary Care Patient Measure of Safety questionnaire. Qualitative responses to survey items were analysed and categorised using the Primary Care Patient Safety Classification System. The frequency and type of safety incidents, contributory factors, and patient and system level outcomes are presented.Results A total of 1329 patients (n=490, England; n=839, Australia) completed the questionnaire. Overall, 5.3% (n=69) of patients reported a safety incident over the preceding 12 months. The most common incident types were administration incidents (n=27, 31%) (mainly delays in accessing a physician) and incidents involving diagnosis and assessment (n=16, 18.4%). Organisation of care accounted for 27.6% (n=29) of the contributory factors identified in the safety incidents. Staff factors (n=13, 12.4%) was the second most commonly reported contributory factor. Where an outcome could be determined, patient inconvenience (n=24, 28.6%) and clinical harm (n=21, 25%) (psychological distress and unpleasant experience) were the most frequent.Conclusions The nature and outcomes of patient-reported incidents differ markedly from those identified in studies of staff-reported incidents. The findings from this study emphasise the importance of capturing patient-reported safety incidents in the primary care setting. The patient perspective can complement existing sources of safety intelligence with the potential for service improvement.

Abstract Background Cardiovascular diseases (CVD) are the largest cause of death and disability in Australia. Australian national guidelines for the primary prevention of CVD recommend that all adults without CVD and aged 45 years or more are screened for their absolute risk of CVD every 2 years. Despite the compelling evidence to address CVD risk, treatment gaps remain and evidence suggests that much of the shortcomings are attributed to the performance of primary care practices. To address this issue, a quality improvement initiative is being implemented in a large urban multidisciplinary primary care practice in the South West region of Victoria, Australia. The key outcome of this intervention will be to increase the use and acceptability of CVD risk assessment guidelines. To ensure the intervention is tracking toward its objectives, a robust monitoring and evaluation framework was established. Method/design A novel framework that assimilates key traditional and theory-driven evaluation practices was developed to assess the impact of the intervention. The framework approach is termed the integrated model of evaluation (IMoE). Researchers and stakeholders convened several times to discuss and develop the evaluation protocol and align it with the quality intervention. The main objective here is to explore the feasibility of an integrated approach to evaluating clinical quality improvement interventions. The sub-objectives are to test the alignment of the IMoE to clinical quality improvement projects and its ability to derive findings to the satisfaction of stakeholders. The design and establishment of the evaluation approach is discussed in further detail in this article. Discussion The novel feature of the IMoE is its emphasis on tracking ‘change’ in practices that lead to quality improvement. This emphasis suits the quality improvement theme of this initiative as identification of change elements and explanation behind change is necessary to sustain and promote quality improvement. The other principle behind development of this model, which emphasises practicality in implementation, is to ensure stakeholders gain greatest value from the commissioning of program evaluation. By incorporating practical components and leaving out esoteric concepts, this approach ensures evaluation can be undertaken in realistic timeframes. Ethics approval The quality improvement intervention and evaluation framework received approval from the Deakin University Human Research Ethics Committee (Approval Number: 2017-313).

BackgroundGestational diabetes mellitus (GDM) is an increasingly prevalent risk factor for type 2 diabetes. We evaluated the effectiveness of a group-based lifestyle modification program in mothers with prior GDM within their first postnatal year.Methods and findingsIn this study, 573 women were randomised to either the intervention (n = 284) or usual care (n = 289). At baseline, 10% had impaired glucose tolerance and 2% impaired fasting glucose. The diabetes prevention intervention comprised one individual session, five group sessions, and two telephone sessions. Primary outcomes were changes in diabetes risk factors (weight, waist circumference, and fasting blood glucose), and secondary outcomes included achievement of lifestyle modification goals and changes in depression score and cardiovascular disease risk factors. The mean changes (intention-to-treat [ITT] analysis) over 12 mo were as follows: -0.23 kg body weight in intervention group (95% CI -0.89, 0.43) compared with +0.72 kg in usual care group (95% CI 0.09, 1.35) (change difference -0.95 kg, 95% CI -1.87, -0.04; group by treatment interaction p = 0.04); -2.24 cm waist measurement in intervention group (95% CI -3.01, -1.42) compared with -1.74 cm in usual care group (95% CI -2.52, -0.96) (change difference -0.50 cm, 95% CI -1.63, 0.63; group by treatment interaction p = 0.389); and +0.18 mmol/l fasting blood glucose in intervention group (95% CI 0.11, 0.24) compared with +0.22 mmol/l in usual care group (95% CI 0.16, 0.29) (change difference -0.05 mmol/l, 95% CI -0.14, 0.05; group by treatment interaction p = 0.331). Only 10% of women attended all sessions, 53% attended one individual and at least one group session, and 34% attended no sessions. Loss to follow-up was 27% and 21% for the intervention and control groups, respectively, primarily due to subsequent pregnancies. Study limitations include low exposure to the full intervention and glucose metabolism profiles being near normal at baseline.ConclusionsAlthough a 1-kg weight difference has the potential to be significant for reducing diabetes risk, the level of engagement during the first postnatal year was low. Further research is needed to improve engagement, including participant involvement in study design; it is potentially more effective to implement annual diabetes screening until women develop prediabetes before offering an intervention.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12610000338066.

Access to health care is a universal human right and key indicator of health system performance. Spatial access encompasses geographic factors mediating with the accessibility and availability of health services. Equity of health service access is a global issue, which includes access to the specialized nursing workforce. Nursing research applying spatial methods is in its infancy. Given the use of spatial methods in health research is a rapidly developing field, it is timely to provide guidance to inspire greater application in cardiovascular research. Therefore, the objective of this methods paper is to provide an overview of spatial analysis methods to measure the accessibility and availability of health services, when to consider applying spatial methods, and steps to consider for application in cardiovascular nursing research. Central Illustration: Central Illustration [ABSTRACT FROM AUTHOR]