Sonia Wutzke

Cohort profile: the 45 and up study.

In common with virtually all industrialized countries and many less developed nations, Australia is facing rapid population ageing. Historical patterns of fertility and migration, along with changes in life expectancy, mean that the over 65 age group is likely to increase by around 50% in the next 15–20 years. The further increase in the proportion of people in the very old age groups will result in the ‘ageing of the aged’. The challenges presented by the ageing of the population are far reaching. Discussions have tended to focus on its likely health and economic consequences; however, few aspects of society will remain unaffected by the issue. There is an urgent need for reliable evidence to inform policy to support healthy ageing. The concept of healthy ageing encompasses traditional ideas relating to freedom from disease, as well as broader considerations including independence, quality of life, management of disability, participation in society and the workforce and productivity. A wide range of factors are likely to affect health in later life, including socioeconomic, environmental and cultural variables, cigarette smoking, alcohol consumption, diet, physical activity, reproductive and hormonal factors, infections, availability of healthcare and use of pharmaceutical agents, as well as individuals’ susceptibility to disease. A comprehensive investigation of the determinants of healthy ageing must incorporate assessment of disease risk, quality of life and other indices, in relation to a very wide range of possible exposures, and with consideration of how these exposures might interact with one another. Research needs to be of a sufficient scale to provide specific information on the major diseases and health problems experienced in later life. This is because reliable assessments of risk factor–disease relationships require a substantial degree of pathological homogeneity of outcome and appropriate consideration of confounding. At the same time, research needs to be able to assess the broad risks and benefits of particular exposures, to allow meaningful conclusions to be reached about suitable public health interventions. Finally, it needs to be large and long term enough to track the impact of health interventions and policies at the population level. Australia has some unique characteristics that will impact on healthy ageing and provide particular challenges in delivering health care. For example, it has: a relatively heterogenous population with a large migrant community; an indigenous population with an average life expectancy 17 years less than for nonindigenous Australians; some remote and sparsely populated regions and a mixed health care system with responsibility shared between the national and state governments and delivery in both the public and private sectors. Excellent population-level databases relating to use of health services and medications, and registers of cancers and deaths, are available for statistical linkage with research data sets. There is therefore a need for research that addresses issues specific to the Australian population and makes use of the unique features of the Australian setting, giving the opportunity to provide insights of international relevance. The 45 and Up Study was conceived as a long-term collaborative resource to investigate healthy ageing, in response to the gaps in existing knowledge and the needs of researchers. Initial discussions among interested researchers resulted in the formation of a Scientific Steering Group in 2003 to oversee the development of the Study. The Study is auspiced by the Sax Institute, which also provided funding for its development. The Sax Institute is an independent organization with core funding from the state government of New South Wales, Australia’s most populous state. Its mission is to improve health through facilitating high-quality research and increasing the impact of this research on health policy and services; it has membership from y The Writing Committee is listed at the end of the report. For a list of the 45 and Up Study Collaborators please go to www.45andUp.org.au.

General Practitioners, Prevention and Alcohol - A powerful cocktail? Facilitators and inhibitors of practising preventive medicine in general and early intervention for alcohol in particular: A 12-nation key informant and general practitioner study

This study reports a qualitative investigation of the views of key informants (KIs) and general practitioners (GPs) on the nature and extent of preventive medicine and early alcohol intervention in general practice and the current barriers and potential facilitating factors that influence practice. Sixty-seven KIs and 126 GPs were interviewed in 12 countries. There was strong personal and professional support for GP-delivered preventive medicine in general and early intervention for alcohol problems in particular. Opinions differed on whether national health policies encouraged or discouraged GPs to do more preventive medicine. The two key areas identified for prevention were smoking and alcohol, although all but two countries thought that alcohol was the most difficult area for GPs to discuss with patients. KIs and GPs identified similar barriers and facilitating factors. The main barriers were time constraints, lack of financial reimbursement or incentives and insufficient training and education. The ma...This study reports a qualitative investigation of the views of key informants (KIs) and general practitioners (GPs) on the nature and extent of preventive medicine and early alcohol intervention in general practice and the current barriers and potential facilitating factors that influence practice. Sixty-seven KIs and 126 GPs were interviewed in 12 countries. There was strong personal and professional support for GP-delivered preventive medicine in general and early intervention for alcohol problems in particular. Opinions differed on whether national health policies encouraged or discouraged GPs to do more preventive medicine. The two key areas identified for prevention were smoking and alcohol, although all but two countries thought that alcohol was the most difficult area for GPs to discuss with patients. KIs and GPs identified similar barriers and facilitating factors. The main barriers were time constraints, lack of financial reimbursement or incentives and insufficient training and education. The main facilitating factors were more societal concern about alcohol, proactive patients, more time, financial reimbursement and supportive government policy.

The validity of an Australian modification of the AUDIT questionnaire

The Alcohol Use Disorders Identification Test (AUDIT) has been used widely and is reported to be superior to conventional questionnaires in detection of current hazardous and harmful alcohol use. We assessed the validity of an Australian modification of the AUDIT (the AusAUDIT), which has been employed widely in Australian and New Zealand early intervention programmes. We used a cross-sectional study of 370 subjects from the follow-up phase of a randomized controlled trial of early intervention to reduce hazardous alcohol consumption. Scores on the AusAUDIT were compared against 12-month ICD-10 diagnoses of harmful alcohol use and dependence, as determined by the Composite International Diagnostic Interview, and against self-report of alcohol consumption exceeding Australian National Health and Medical Research Council (NH&MRC) recommended limits. AusAUDIT had good internal consistency and discriminated significantly between persons meeting criteria for ICD-10 alcohol use disorders, and drinkers who did not. At currently recommended cut-off scores, AusAUDIT detected more than 85% of people meeting criteria for ICD-10 alcohol use disorders, or drinking over NH&MRC recommended limits, but its specificity was limited (29% in men, and 58% in women for drinking over NH&MRC limits). No subset of questions performed as well as the full AusAUDIT in detection of drinking problems, but the alcohol consumption items provided a reasonable screen for drinking over NH&MRC limits. We conclude that AusAUDIT is effective in detecting problematic drinking, but positive cases should be confirmed by clinical assessment. The findings illustrate the need for validation of questionnaire modifications, and the difficulty in increasing test sensitivity without reducing specificity.

Longitudinal research: Methods for maximizing subject follow-up

Early intervention for hazardous alcohol use has been shown repeatedly to be effective in reducing alcohol consumption, limiting alcohol-related problems and improving biochemical parameters. However, in most studies the follow-up period has been 2 years or less. The current paper presents progress on a 10-year follow-up of a randomized controlled trial of early intervention. Methods used for tracing subjects and ensuring minimal refusals are detailed. The intensity of effort required to locate subjects is documented and recommendations for ensuring good follow-up rates are made. At completion of follow-up, 72.5% of the sample reviewed here and 78.2% of the total cohort had been traced. Our experiences demonstrate that long-term follow-up is feasible, given sufficient planning and persistence.

An ongoing national programme to reduce antibiotic prescription and use

High levels of antibiotic use have been associated with higher levels of antimicrobial resistance. The National Prescribing Service (NPS) has been running national programs to reduce prescription and use of antibiotics in Australia since 1999. These programs have used a range of strategies to influence general practitioners, community pharmacists and consumers. Over time, there have been modest changes in consumer attitudes towards antibiotics and antibiotic prescription rates continue to decline.

Beyond fun runs and fruit bowls: an evaluation of the meso-level processes that shaped the Australian Healthy Workers Initiative.

Issue addressed The Australian National Partnership Agreement on Preventive Health (NPAPH) charged states and territories with the development and implementation of the Healthy Workers Initiative (HWI) to improve workplace health promotion. Most evaluation efforts focus on the setting (micro) level. In the present study the HWI at the meso-level (state program development) was examined to understand how jurisdictions navigated theoretical, practical, and political priorities to develop their programs, and the programmatic choices that support or hinder perceived success. Methods Interviews with HWI program coordinators and managers across seven Australian jurisdictions explored decision-making processes related to developing and implementing the HWI and the impact of defunding. Interviews were audio-recorded, transcribed and analysed using thematic analysis. Results Despite taking a variety of approaches to the HWI, jurisdictions had common goals, namely achieving sustainability and capacity for meaningful change. These goals transcended the performance indicators set out by the NPAPH, which were considered unachievable in the given timeframe. Four ways jurisdictions sought to achieve their goals were identified, these were: 1) taking an embedded approach to workplace health promotion; 2) ensuring relevance of the HWI to businesses; 3) engaging in collaborative partnerships with agencies responsible for implementation; and 4) cultivating evolution of the HWI. Conclusions This meso-level evaluation has provided valuable insights into how health promotion program coordinators translate broad, national-level initiatives into state-specific programs and how they define program success. The study findings also highlight how broader, contextual factors, such as jurisdiction size, political imperatives and funding decisions impact on the implementation and success of a national health promotion initiative. So what? When evaluating the translation of complex initiatives, a meso-level analysis can reveal valuable principles for informing program effectiveness and sustainability. It can also identify alignment between macro- and meso-level goals and where macro-level specifications may hinder or assist those goals.

The Australian Prevention Partnership Centre: systems thinking to prevent lifestyle-related chronic illness

Chronic diseases are the major cause of death in Australia and the biggest contributor to premature death and disability. Although prevention of chronic disease can be effective and cost-effective, it has proven difficult to systematically implement interventions that target important lifestyle-related risk factors for chronic disease such as poor nutrition, physical inactivity and harmful alcohol use. Prevention efforts targeting these lifestyle-related risk factors have had mixed success due to issues around designing and implementing effective interventions that address the complexity of risk factors, and incorporating evidence and implementing interventions at a scale, duration, intensity and quality required to achieve population effects. There is increasing recognition that multilevel, multisector approaches are required for the effective and sustained prevention of complex chronic disease. The Australian Prevention Partnership Centre, one of two National Health and Medical Research Council Partnership Centres established in 2013, is researching and developing systems perspectives to prevent lifestyle-related chronic disease in Australia. The Centres collaborative approach is providing opportunities for researchers to work with policy makers and practitioners to develop research questions, conduct research, and analyse, interpret and disseminate the findings. As such, it is the model of interaction that is being tested as much as the specific projects. With its funding partners, the Centre has developed plans for more than 30 projects. It has also established four capacity units that will improve the gathering, sharing and use of evidence to build a prevention system in Australia. The Centre is exploring new ways to advance prevention by bringing together researchers, policy makers and practitioners to determine the information and actions needed for an effective prevention system for Australia.

What will it take to improve prevention of chronic diseases in Australia? A case study of two national approaches

Objective Despite being a healthy country by international standards, Australia has a growing and serious burden from chronic diseases. There have been several national efforts to tackle this problem, but despite some important advances much more needs to be done. From the viewpoint of diverse stakeholders, the present study examined two approaches to controlling chronic disease in Australia: (1) the 2005 National Chronic Disease Strategy (NCDS); and (2) the 2008 National Partnership Agreement on Preventive Health (NPAPH). Methods Individual and small group semistructured interviews were undertaken with 29 leaders across Australia, reflecting a diverse cross-section of senior public health managers and program implementation staff from state and territory health departments, as well as academics, thought leaders and public health advocates. A grounded theory approach was used to generate themes relevant to the research. Results There is general support for national approaches to the prevention of chronic disease. The NCDS was viewed as necessary and useful for national coordination, setting a common agenda and serving as an anchor to align jurisdictional priorities and action. However, without funding or other infrastructure commitments or implementation plans, any expectations as to what could be meaningfully achieved were limited. In contrast, although jurisdictions welcomed the NPAPH, its associated funding and the opportunity to tailor strategy to their unique needs and populations, there were calls for greater national leadership as well as guidance on the evidence base to inform decision making. Key aspects of successful national action were strong Australian Government leadership and coordination, setting a common agenda, national alignment on priorities, evidence-informed implementation strategies, partnerships within and across governments, as well as with other sectors, and funding and infrastructure to support implementation. Conclusions Both the NCDS and NPAPH were seen to have overlapping strengths and weaknesses. A key need identified was for future approaches to focus on generating more sustainable, system-wide change. What is known about the topic? Despite some important advances, chronic diseases remain Australias greatest health challenge. In efforts to tackle this increasing burden from chronic diseases, several large-scale, national initiatives have been released in Australia over recent years, including the 2005 NCDS and the 2008 NPAPH. What does this paper add? From the viewpoint of practitioners, policy makers, advocates, researchers and public health thought leaders, this paper examines the usefulness and significance of the NCDS and NPAPH as national initiatives for achieving improvements to the prevention of chronic disease. What are the implications for practitioners? By better understanding how previous countrywide chronic disease initiatives were viewed and used at national, state and local levels, this research is well placed to inform current, planned and future large-scale, population-level health initiatives.

Systems approaches for chronic disease prevention: sound logic and empirical evidence, but is this view shared outside of academia?

INTRODUCTION There is a need and desire to improve chronic disease prevention efforts across Australia. Increasingly, scientists are urging the use of systems thinking and its methods to significantly shift the way we think about, and intervene in, chronic diseases. This research aimed to examine the convergence between the systems science literature and the views of those working in and advocating for prevention, in relation to the value of systems thinking and its methods for the prevention of chronic diseases. METHODS Individual and small-group semistructured interviews were undertaken with 29 individuals across Australia. The interviewees reflected a diverse cross-section of senior public health managers and program implementation staff from state and territory health departments, and senior thought leaders and public health advocates. Interviews were audio recorded and coded into key themes. RESULTS AND DISCUSSION Feedback from informants illustrated that, among those working in and advocating for prevention, there is a mix of support for systems thinking for chronic disease prevention, and some healthy scepticism. The lack of consistent confluence between those promoting the value of systems science, and those responsible for working in and advocating for prevention indicates a level of confusion about language and definitions. It also reflects a desire for published evidence about systems methods that have proven effectiveness. CONCLUSION Systems thinking and its methods have a promising and important role to play in creating a robust, effective and sustainable strategy for prevention of chronic diseases throughout Australia. However, the method requires further development and refinement, and promotion of case studies of effectiveness. We also need to heed lessons learnt overseas.

Partnering to prevent chronic disease: reflections and achievements from The Australian Prevention Partnership Centre

OBJECTIVES To accelerate the use of evidence in policy and practice through cross-sectoral, multidisciplinary partnership research, founded on shared governance and coproduction. Type of program or service: A National Health and Medical Research Council (NHMRC) Partnership Centre for Better Health. METHODS We present our views and experiences based on the first 5 years of operation of The Australian Prevention Partnership Centre. RESULTS We have undertaken an ambitious and complex 5-year program of work taking a systems approach to prevention research, and have grown the size and reach of the collaboration to become a focus for prevention research in Australia. We have progressed towards reaching our objectives. However, there have been challenges including trust building between stakeholders, the complexities of incorporating coproduction into every research project, and the production of research that is implementable within different policy environments. LESSONS LEARNT Working within the partnership model has provided the time, resources and flexibility to coproduce policy-relevant, timely research.