INTRODUCTION: Overweight and obesity prevalence has increased significantly over the past two decades, currently impacting greater than 60% of Australians. It is unclear if a social perception of a healthy weight has been obscured by the increase in prevalence and thus has become inconsistent with the medical definitions. METHODS: An electronic questionnaire was distributed via email and social media using the authors' informal networks. Australian adults were eligible to participate. Participants were asked to categorise their own body size using medically accepted words and previously published silhouettes, before identifying underweight, healthy weight, overweight or obesity in a series ofsilhouettes. RESULTS: Eight hundred six questionnaires were completed, a majority of participants had attained a high level of education and were employed female health professionals. Under half the studied population had a Body Mass Index (BMI) corresponding to overweight or obese categories (n = 349, 47%). Accuracy in self-perceived weight status using medicalised words was higher among respondents with BMI corresponding to the healthy weight category (n = 311, 85%) and overweight category (n = 133, 74%) than for respondents with BMI corresponding to obesity (n = 79, 45%) or underweight (n = 5, 31%). A majority of respondents were able to accurately self-perceive their weight status using silhouettes (n = 469, 70%). Females were significantly more likely to be accurate in their self-perception than males, using both medicalised words (p = < 0.001) and silhouettes (p = 0.045). Respondents with a BMI corresponding to the obese category were significantly more likely to be accurate with weight status self-perception using silhouettes than words (87% versus 46% respectively, p = < 0.001). Less than half (41%) of respondents accurately perceived silhouettes corresponding to an overweight BMI and less than one in ten respondents (9%) accurately perceived the lower limit of the silhouettes corresponding to an obese BMI. CONCLUSIONS: Repondents were challenged to accurately perceive silhouettes corresponding to an obese BMI in themselves and others. Weight status misperception was more likely to exist among those with a BMI less than 18.5 or 30 or more (underweight BMI and obese BMI). Accuracy decreased as BMI increased. Respondents with a BMI in the obese category were significantly more likely to accurately self-perceive their weight status using silhouettes than medicalised words. Silhouettes may act as an effective visual cue in initiating weight related discussions.

OBJECTIVES: This study sought to explore patients' experiences of living with, and adapting to, chronic obstructive pulmonary disease (COPD) in the rural context. Specifically, our research question was 'What are the barriers and facilitators to living with and adapting to COPD in rural Australia?' DESIGN: Qualitative, semi-structured interviews. Conversations were recorded, transcribed verbatim and analysed using thematic analysis following the COnsolidated criteria for REporting Qualitative research guidelines. SETTING: Patients with COPD, admitted to a subregional hospital in Australia were invited to participate in interviews between October and November 2016. MAIN OUTCOME MEASURES: Themes were identified that assisted with understanding of the barriers and facilitators to living with, and adapting to, COPD in the rural context. RESULTS: Four groups of themes emerged: internal facilitators (coping strategies; knowledge of when to seek help) and external facilitators (centrality of a known doctor; health team 'going above and beyond' and social supports) and internal/external barriers to COPD self-management (loss of identity, lack of access and clear communication, sociocultural challenges), which were moderated by feelings of inclusion or isolation in the rural community or 'village'. CONCLUSIONS: Our findings suggest that community inclusion enhances patients' ability to cope and ultimately self-manage COPD. This is facilitated by living in a supportive 'village' environment, and included a central, known doctor and a healthcare team willing to go 'above and beyond'. Understanding, or supplementing, these social networks within the broader social structure may assist people to manage chronic disease, regardless of rural or metropolitan location.

BACKGROUND: High quality, contemporary data regarding patterns of chronic disease is essential for planning by health services, policy makers and local governments, but surprisingly scarce, including in rural Australia. This dearth of data occurs despite the recognition that rural Australians live with high rates of ill health, poor health behaviours and restricted access to health services. Crossroads-II is set in the Goulburn Valley, a rural region of Victoria, Australia 100-300 km north of metropolitan Melbourne. It is primarily an irrigated agricultural area. The aim of the study is to identify changes in the prevalence of key chronic health conditions including the extent of undiagnosed and undermanaged disease, and association with access to care, over a 15 year period. METHODS/DESIGN: This study is a 15 year follow up from the 2000-2003 Crossroads-I study (2376 households participated). Crossroads-II includes a similar face to face household survey of 3600 randomly selected households across four towns of sizes 6300 to 49,800 (50% sampled in the larger town with the remainder sampled equally from the three smaller towns). Self-reported health, health behaviour and health service usage information is verified and supplemented in a nested sub-study of 900 randomly selected adult participants in 'clinics' involving a range of additional questionnaires and biophysical measurements. The study is expected to run from October 2016 to December 2018. DISCUSSION: Besides providing epidemiological and health service utilisation information relating to different diseases and their risk factors in towns of different sizes, the results will be used to develop a composite measure of health service access. The importance of access to health services will be investigated by assessing the correlation of this measure with rates of undiagnosed and undermanaged disease at the mesh block level. Results will be shared with partner organisations to inform service planning and interventions to improve health outcomes for local people.

BACKGROUND: People living in rural and remote communities commonly experience significant health disadvantages. Geographical barriers and reduced specialist and generalist services impact access to care when compared with metropolitan context. Innovative models of care have been developed for people living with chronic diseases in rural areas with the goal of overcoming these inequities. The aim of this paper was to describe the characteristics and outcomes of studies investigating innovative models of care for people living with chronic disease in rural areas of developed countries where a metropolitan comparator was included. METHODS: An integrative systematic review was undertaken. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to understand the empirical and theoretical data on clinical outcomes for people living with chronic disease in rural compared with metropolitan contexts and their models of care in Australia, New Zealand, United States, Canada and the United Kingdom. RESULTS: Literature searching revealed 620 articles published in English between 1st January 2000 and 31st March 2019. One hundred sixty were included in the review including 68 from the United States, 59 from Australia and New Zealand (5), 21 from Canada and 11 from the United Kingdom and Ireland. 53% (84) focused on cardiovascular disease; 27% (43) diabetes mellitus; 8% (12) chronic obstructive pulmonary disease; and 13% (27) chronic kidney disease. Mortality was only reported in 10% (16) of studies and only 18% (29) reported data on Indigenous populations. CONCLUSIONS: This integrated review reveals that the published literature on common chronic health issues pertaining to rural and remote populations is largely descriptive. Only a small number of publications focus on mortality and comparative health outcomes from health care models in both urban and non-urban populations. Innovative service models and telehealth are together well represented in the published literature but data on health outcomes is relatively sparse. There is significant scope for further directly comparative studies detailing the effect of service delivery models on the health outcomes of urban and rural populations. We believe that such data would further knowledge in this field and help to break the deadly synergy between increased rurality and poorer outcomes for people with chronic disease.

BACKGROUND: Among methods for preventing pneumonia and possibly also bacteremia in intensive care unit (ICU) patients, Selective Digestive Decontamination (SDD) appears most effective within randomized concurrent controlled trials (RCCT's) although more recent trials have been cluster randomized. However, of the SDD components, whether protocolized parenteral antibiotic prophylaxis (PPAP) is required, and whether the topical antibiotic actually presents a contextual hazard, remain unresolved. The objective here is to compare the bacteremia rates and patterns of isolates in SDD-RCCT's versus the broader evidence base. METHODS: Bacteremia incidence proportion data were extracted from component (control and intervention) groups decanted from studies investigating antibiotic (SDD) or non-antibiotic methods of VAP prevention and summarized using random effects meta-analysis of study and group level data. A reference category of groups derived from purely observational studies without any prevention method under study provided a benchmark incidence. RESULTS: Within SDD RCCTs, the mean bacteremia incidence among concurrent component groups not exposed to PPAP (27 control; 17.1%; 13.1-22.1% and 12 intervention groups; 16.2%; 9.1-27.3%) is double that of the benchmark bacteremia incidence derived from 39 benchmark groups (8.3; 6.8-10.2%) and also 20 control groups from studies of non-antibiotic methods (7.1%; 4.8 - 10.5). There is a selective increase in coagulase negative staphylococci (CNS) but not in Pseudomonas aeruginosa among bacteremia isolates within control groups of SDD-RCCT's versus benchmark groups with data available. CONCLUSIONS: The topical antibiotic component of SDD presents a major contextual hazard toward bacteremia against which the PPAP component partially mitigates.

Chronic breathlessness is a common, burdensome and distressing symptom in many advanced chronic illnesses. Self-management strategies are essential to optimise treatment, daily functioning and emotional coping. People with chronic illness commonly search the internet for advice on self-management. A review was undertaken in June 2015 to describe the content and quality of online advice on breathlessness self-management, to highlight under-served areas and to identify any unsafe content. Google was searched from Sydney, Australia, using the five most common search terms for breathlessness identified by Google Trends. We also hand-searched the websites of national associations. Websites were included if they were freely available in English and provided practical advice on self-management. Website quality was assessed using the American Medical Association Benchmarks. Readability was assessed using the Flesch-Kincaid grades, with grade 8 considered the maximum acceptable for enabling access. Ninety-one web pages from 44 websites met the inclusion criteria, including 14 national association websites not returned by Google searches. Most websites were generated in the USA (n=28, 64%) and focused on breathing techniques (n=38, 86%) and chronic obstructive pulmonary disease (n=27, 61%). No websites were found to offer unsafe advice. Adherence to quality benchmarks ranged from 9% for disclosure to 77% for currency. Fifteen (54%) of 28 written websites required grade ⩾9 reading level. Future development should focus on advice and tools to support goal setting, problem solving and monitoring of breathlessness. National associations are encouraged to improve website visibility and comply with standards for quality and readability.

Australia’s mainstream health services located in rural contexts are mandated to provide health care to the entire local population. However, complex power relations embedded and reflected within the cultures of mainstream generalist health services are excluding the most marginalised residents from health care. This paper argues that unless inclusion in rural, generalist mainstream health services is improved, the health experiences of these residents will not substantially change and Australia will continue to report significant health differentials within its population. The concept of culturally inclusive health care is difficult for Australian mainstream generalist health practitioners to engage with because there is limited understanding of what culture is and how it operates within diverse communities. This makes it challenging for many in mainstream health institutions to begin deconstructing how it is that exclusion occurs. Frequently, ‘culture’ is assigned to ‘Others’, and there is little recognition that all people, including White, mainstream Australians, are cultural beings, and that health disciplines, services and systems have particular cultures that make assumptions about how to be in the world. Consequently, current approaches to the provision of culturally inclusive health care are not shifting the power relations that (re)produce exclusion. In this paper, we outline a new interdisciplinary methodology that operationalises Foucault’s concepts of power, resistance and discourse within a Participatory Action Research (PAR) design and utilises Continuous Quality Improvement (CQI) processes to respond to these power relations and provide health institutions with a process to improve their inclusivity, specifically for Australia’s most marginalised residents. It is suggested that employing this new methodology will promote a different way of thinking and acting in health institutions, producing a deconstructed process for health services to adapt to improve their inclusivity.

BACKGROUND: Ovarian cancer is a metastatic disease and one of the leading causes of gynaecology malignancy-related deaths in women. Cancer stem cells (CSCs) are key contributors of cancer metastasis and relapse. Integrins are a family of cell surface receptors which allow interactions between cells and their surrounding microenvironment and play a fundamental role in promoting metastasis. This study investigates the molecular mechanism which associates CSCs and integrins in ovarian cancer metastasis. METHODS: The expression of Oct4A in high-grade serous ovarian tumors and normal ovaries was determined by immunofluorescence analysis. The functional role of Oct4A was evaluated by generating stable knockdown (KD) of Oct4A clones in an established ovarian cancer cell line HEY using shRNA-mediated silencing. The expression of integrins in cell lines was evaluated by flow cytometry. Spheroid forming ability, adhesion and the activities of matrix metalloproteinases 9/2 (MMP-9/2) was measured by in vitro functional assays and gelatin zymography. These observations were further validated in in vivo mouse models using Balb/c nu/nu mice. RESULTS: We report significantly elevated expression of Oct4A in high-grade serous ovarian tumors compared to normal ovarian tissues. The expression of Oct4A in ovarian cancer cell lines correlated with their CSC-related sphere forming abilities. The suppression of Oct4A in HEY cells resulted in a significant diminution of integrin β1 expression and associated α5 and α2 subunits compared to vector control cells. This was associated with a reduced adhesive ability on collagen and fibronectin and decreased secretion of pro-MMP2 in Oct4A KD cells compared to vector control cells. In vivo, Oct4A knock down (KD) cells produced tumors which were significantly smaller in size and weight compared to tumors derived from vector control cells. Immunohistochemical analyses of Oct4A KD tumor xenografts demonstrated a significant loss of cytokeratin 7 (CK7), Glut-1 as well as CD34 and CD31 compared to vector control cell-derived xenografts. CONCLUSION: The expression of Oct4A may be crucial to promote and sustain integrin-mediated extracellular matrix (ECM) remodeling requisite for tumor metastasis in ovarian cancer patients.

The purpose here is to establish the incidence of respiratory tract colonization with Candida (RT Candida) among ICU patients receiving mechanical ventilation within studies in the literature. Also of interest is its relationship with candidemia and the relative importance of topical antibiotic (TA) use as within studies of selective digestive decontamination (SDD) versus other candidate risk factors towards it. The incidence of RT Candida was extracted from component (control and intervention) groups decanted from studies of various TA and non-TA ICU infection prevention methods with summary estimates derived using random effects. A benchmark RT Candida incidence to provide overarching calibration was derived using (observational) groups from studies without any prevention method under study. A multi-level regression model of group level data was undertaken using generalized estimating equation (GEE) methods. RT Candida data were sourced from 113 studies. The benchmark RT Candida incidence is 1.3; 0.9-1.8 % (mean and 95 % confidence intervals). Membership of a concurrent control group of a study of SDD (p = 0.02), the group-wide presence of candidemia risk factors (p < 0.001), and proportion of trauma admissions (p = 0.004), but neither the year of study publication, nor membership of any other component group, nor the mode of respiratory sampling are predictive of the RT Candida incidence. RT Candida and candidemia incidences are correlated. RT Candida incidence can serve as a basis for benchmarking. Several relationships have been identified. The increased incidence among concurrent control groups of SDD studies cannot be appreciated in any single study examined in isolation.

PURPOSE: To estimate the direct and indirect (contextual) effects of the factorized constituents of selective digestive decontamination and selective oropharyngeal decontamination (SDD/SOD), being topical antibiotic (TA) and protocolized antifungal prophylaxis (PAFP), on ICU-acquired candidemia. METHODS: A broad range of ICU candidemia incidence studies were sourced to serve as points of reference. The candidemia incidence was extracted from component (control and intervention) groups decanted from studies of various designs (concurrent or non-concurrent) and whether investigating SDD/SOD versus non-TA methods of ICU infection prevention. The candidemia incidences were summarized in regression models using generalized estimating equation (GEE) methods. Groups derived from observational studies (no prevention method under study) provided an overarching external benchmark candidemia incidence for calibration. RESULTS: Within studies investigating SDD/SOD, the mean (and 95% confidence interval) candidemia incidence among concurrent component groups (40 control; 2.4%; 1.7-3.2% and 43 intervention groups; 2.4%; 1.6-3.1%), but not non-concurrent control groups (11 groups; 1.6%; 0.1-2.7%), is higher than that of the benchmark candidemia incidence derived from 54 observational groups (1.5%; 1.2-1.9%). The TA constituent within SDD/SOD has significant direct and indirect (contextual) effects in GEE models even after adjusting for the publication year and the group-wide presence of either candidemia risk factors or PAFP use. CONCLUSION: The TA constituent of SDD/SOD is associated with a contextual effect on candidemia incidence which is similar in magnitude to that of the conventional candidemia risk factors and against which PAFP partially attenuates. This increase is inapparent within individual SDD/SOD studies examined in isolation.

BACKGROUND: Medical termination of pregnancy (MToP) is a safe and acceptable abortion option. Depending on country context, MToP can be administered by general practitioners and mid-level healthcare providers in the first and second trimesters of pregnancy. Like other high-income countries, a range of social and structural barriers to MToP service provision exist in Australia. To counter some of these barriers, geographic decentralization of MToP was undertaken in rural Victoria, Australia, through training service providers about MToP to increase service delivery opportunities. The aim of this study was to investigate the factors that enabled and challenged the decentralization process. METHODS: Face-to-face and telephone interviews were undertaken between April and June 2016 with a purposeful sample of six training providers and 13 general practitioners (GP) and nurse training participants. Study participants were asked about their perceptions of motivations, enablers and challenges to MToP provision. A published conceptual framework of synergies between decentralization and service delivery was used to analyse the study findings. RESULTS: Three key themes emerged from the study findings. First, the effort to decentralize MToP was primarily supported by motivations related to making service access more equitable as well as the willingness of training providers to devolve their informal power, in the form of MToP medical expertise, to training participants. Next, the enablers for MToP decentralization included changes in the regulatory environment relating to decriminalization of abortion and availability of required medication, formation of partnerships to deliver training, provision of MToP clinical resources and local collegial support. Finally, challenges to MToP decentralization were few but significant. These included a lack of a state-wide strategy for service provision, provider concerns about coping with service demand, and provider stigma in the form of perceived negative community or collegial attitudes. These were significant enough to create caution for GPs and nurses considering service provision. CONCLUSIONS: Decentralization concepts offer an innovative way for reframing and tackling issues associated with improving MToP service delivery. There is scope for more research about MToP decentralization in other country contexts. These findings are important for informing future rural MToP service expansion efforts that improve equity in service access.