Academic literature on the topic 'Diabetes – Treatment – Australia'

Objective Little data is in existence about the most cost-effective primary treatment for Graves’ disease. We performed a cost–utility analysis comparing radioactive iodine (RAI), anti-thyroid drugs (ATD) and total thyroidectomy (TT) as first-line therapy for Graves’ disease in England and Australia. Methods We used a Markov model to compare lifetime costs and benefits (quality-adjusted life-years (QALYs)). The model included efficacy, rates of relapse and major complications associated with each treatment, and alternative second-line therapies. Model parameters were obtained from published literature. One-way sensitivity analyses were conducted. Costs were presented in 2015£ or Australian Dollars (AUD). Results RAI was the least expensive therapy in both England (£5425; QALYs 34.73) and Australia (AUD5601; 30.97 QALYs). In base case results, in both countries, ATD was a cost-effective alternative to RAI (£16 866; 35.17 QALYs; incremental cost-effectiveness ratio (ICER) £26 279 per QALY gained England; AUD8924; 31.37 QALYs; ICER AUD9687 per QALY gained Australia), while RAI dominated TT (£7115; QALYs 33.93 England; AUD15 668; 30.25 QALYs Australia). In sensitivity analysis, base case results were stable to changes in most cost, transition probabilities and health-relative quality-of-life (HRQoL) weights; however, in England, the results were sensitive to changes in the HRQoL weights of hypothyroidism and euthyroidism on ATD. Conclusions In this analysis, RAI is the least expensive choice for first-line treatment strategy for Graves’ disease. In England and Australia, ATD is likely to be a cost-effective alternative, while TT is unlikely to be cost-effective. Further research into HRQoL in Graves’ disease could improve the quality of future studies.

BACKGROUND: Australia has a low incidence of TB and has committed to eliminating the disease. Identification of risk factors associated with TB is critical to achieving this goal.METHODS: We undertook a prospective cohort study involving persons receiving TB treatment in four Australian jurisdictions. Risk factors and their association with delayed treatment completion (treatment delayed by at least 1 month) were analysed using univariate analyses and multivariate logistic regression.RESULTS: Baseline surveys were completed for 402 persons with TB. Most (86.1%) were born overseas. Exposure to a person with TB was reported by 19.4%. Diabetes mellitus (10.2%), homelessness (9.2%), cigarette smoking (8.7%), excess alcohol consumption (6.0%) and mental illness (6.2%) were other common risk factors. At follow-up, 24.8% of patients had delayed treatment completion, which was associated with adverse events (34.1%, aOR 6.67, 95% CI 3.36–13.27), excess alcohol consumption (6.0%, aOR 21.94, 95% CI 6.03–79.85) and HIV co-infection (2.7%, aOR 8.10, 95% CI 1.16–56.60).CONCLUSIONS: We identified risk factors for TB and their association with delayed treatment completion, not all of which are routinely collected for surveillance purposes. Recognition of these risk factors should facilitate patient-centred care and assist Australia in reaching TB elimination.

Melioidosis is a potentially fatal bacterial infection caused by the Gram-negative bacillus, Burkholderia pseudomallei following contact with a contaminated environmental source, normally soil or water in tropical and subtropical locations. The disease spectrum varies from rapidly progressive bacteraemic infection with or without pneumonia, to focal lesions in deep soft tissues and internal organs to superficial soft tissue infection and asymptomatic seroconversion with possible long-term dormancy. Most infections occur with a background of chronic illness such as diabetes, chronic kidney disease and alcoholic liver disease. Improvements in diagnosis, targeted antimicrobial treatment and long term follow up have improved clinical outcomes. Environmental controls following rare point source case clusters and heightened awareness of melioidosis appear to have reduced the disease burden in some parts of northern Australia. However, the impact of climate change on dispersal of environmental B. pseudomallei, and changing land use in tropical Australia is expected to change the epidemiology of melioidosis in future.

The number of people living with diabetes is expected to rise to 578 million by 2030 and to 700 million by 2045, exacting a severe socioeconomic burden on healthcare systems around the globe. This is also reflected in the increasing numbers of people with ocular complications of diabetes (namely, diabetic macular oedema (DMO) and diabetic retinopathy (DR)). In one study examining the global prevalence of DR, 35% of people with diabetes had some form of DR, 7% had PDR, 7% had DMO, and 10% were affected by these vision-threatening stages. In many regions of the world (Australia included), DR is one of the top three leading causes of vision loss amongst working age adults (20–74 years). In the management of DMO, the landmark ETDRS study demonstrated that moderate visual loss, defined as doubling of the visual angle, can be reduced by 50% or more by focal/grid laser photocoagulation. However, over the last 20 years, antivascular endothelial growth factor (VEGF) and corticosteroid therapies have emerged as alternative options for the management of DMO and provided patients with choices that have higher chances of improving vision than laser alone. In Australia, since the 2008 NHMRC guidelines, there have been significant developments in both the treatment options and treatment schedules for DMO. This working group was therefore assembled to review and address the current management options available in Australia.

Significant gaps remain between recommendations of evidence-based guidelines and primary health care practice in Australia. This paper aims to evaluate factors associated with the use of guidelines reported by Australian GPs. Secondary analysis was performed on a survey of primary care practitioners which was conducted by the Commonwealth Fund in 2009: 1016 general practitioners responded in Australia (response rate 52%). Two-thirds of Australian GPs reported that they routinely used evidence-based treatment guidelines for the management of four conditions: diabetes, depression, asthma or chronic obstructive pulmonary disease and hypertension – a higher proportion than in most other countries. Having non-medical staff educating patients about self-management, and a system of GP reminders to provide patients with test results or guideline-based intervention or screening tests, were associated with a higher probability of guidelines use. Older GP age was associated with lower probability of guideline usage. The negative association with age of the doctor may reflect a tendency to rely on experience rather than evidence-based guidelines. The association with greater use of reminders and self-management is consistent with the chronic illness model.

Abstract Context: The Australian Institute of Health and Welfare (AIHW) health survey in 2018 demonstrated that mortality rates from diabetes in remote and very remote areas were twice as high compared to those in the urban regions. Moreover, diabetic patients in the lowest socioeconomic areas were more than twice as likely to die from the disease and its associated complications than those living in the highest socioeconomic areas (77 and 33 per 10,000 respectively) [1]. These health disparities prompted a closer look into the quality of local inpatient diabetes management in order to identify the changes required to improve diabetes care in a rural community. Methods: A retrospective audit assessing all adult patients (aged over 18) with diabetes between August and October 2019 who attended treatment in one rural health centre in Queensland, Australia was conducted. Information was obtained from paper based patient records, especially the state-wide insulin subcutaneous order and blood glucose chart. Results: There were 122 diabetic inpatients during the study period. 9 were excluded due to poor documentation on the details of diabetes or insulin management. Men comprised 62% (n = 75) of the patients and the chronicity of diabetes in the majority of the patients was either unknown or undocumented (n = 90). Type 2 diabetes represented 87% (n = 106) of the hospitalisations. There were 64 hospitalisations with diabetes or diabetic related complications as the principal diagnoses. Among these, 7% (n = 8) were due to diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) or severe hyperglycaemia with ketosis, while 2 patients (1.7%) presented with hypoglycaemia. The majority (32%, n = 36) of the diabetic related complications were due to an underlying infection. Throughout inpatient stay, half (50.4%, n = 57) of the patients experienced one or more hyperglycaemic episodes and 14% (n = 16) experienced at least one hypoglycaemic events. The prevalence of inappropriate management of hyperglycaemia during this period was observed to be 21%. This was due to prescription errors i.e. usual insulin not prescribed (n = 7), erroneous insulin type (n = 3) and unsigned order (n = 4). Persistent hyperglycaemia, defined locally by blood glucose level (BGL) > 12 mmol/L was not managed ideally in 10 patients due to either lack of communication between staffs and physicians or failure to make changes when notifications were relayed. Patients were followed up until the discharge phase. Nearly half (41.8%, n = 51) of the patients were found to have no clearly documented follow up plans albeit the limitations of paper based clinical records should be taken into account. Conclusion: The management of diabetes in the rural communities can be challenging. Communication between the different layers of healthcare providers is imperative to ensure hyperglycaemia among hospitalised patients is not mismanaged. Clear documentation of insulin doses and BGL levels on paper records as well as regular education and shared clinical experience on insulin titration in response to abnormal BGL levels by clinicians are strategies to improve diabetes care. Reference: 1. Australian Institute of Health and Welfare. 2021. Diabetes, Type 2 Diabetes - Australian Institute Of Health And Welfare. [online] Available at: <https://www.aihw.gov.au/reports/diabetes/diabetes/contents/hospital-care-for-diabetes/type-2-diabetes> [Accessed 6 January 2021].

Objective. To examine the effect of diabetes treatment on change of measures of specific cognitive domains over 4 years.Research Design and Methods. The sample was drawn from a population-based cohort study in Australia (the PATH Through Life Study) and comprised 1814 individuals aged 65–69 years at first measurement, of whom 211 were diagnosed with diabetes. Cognitive function was measured using 10 neuropsychological tests. The effect of type of diabetes treatment (diet, oral hypoglycemic agents, and insulin) on measures of specific cognitive domains was assessed using Generalized Linear Models adjusted for age, sex, education, smoking, physical activity level, BMI, and hypertension.Results. Comparison of cognitive function between diabetes treatment groups showed no significant effect of type of pharmacological treatment on cognitive function compared to diet only group or no diabetes group. Of those on oral hypoglycaemic treatment only, participants who used metformin alone had better cognitive function at baseline for the domains of verbal learning, working memory, and executive function compared to participants on other forms of diabetic treatment.Conclusion. This study did not observe significant effect from type of pharmacological treatment for diabetes on cognitive function except that participants who only used metformin showed significant protective effect from metformin on domain of verbal learning, working memory, and executive function.

There is evidence that complementary and alternative medicine (CAM) use is common among people with diabetes. The role of CAM in the treatment or management of diabetes is an emerging health issue given the potential side effects and benefits associated with the use of this kind of medicine. This paper examined patterns and determinants of CAM practitioner use in Queensland, Australia, using a large population-based sample of people with type 1 and type 2 diabetes. The study found that within a 12-month period, 7.7% of people with diabetes used the services of CAM practitioners alongside or as a complement to conventional health care service. Younger age, female gender, a higher education, having private health insurance, and engagement in preventive health behaviours are significant predictors of individuals who are more likely to visit a CAM practitioner. There was no significant difference in CAM practitioner use between people with type 1, type 2 insulin requiring, or type 2 noninsulin requiring diabetes. The findings highlight the need for further research on the role of CAM in the prevention and management of diabetes.

OBJECTIVES: In Australia, diabetes causes significant morbidity and mortality. Whilst the need to prevent diabetes and its complications has been widely recognised, the capacity of health care systems - which organise diabetes care - to facilitate prevention has not been fully established. METHODS: A series of seven population-based case-control studies were used to examine the effectiveness of the Australian health care system and its capacity to manage diabetes. Six of the studies compared the patterns of care of patients who had developed advanced diabetes complications in 2000 (cases), to similar patients who remained free of the condition (controls) across Australia and for various risk groups. A secondary study investigated the role of treating GPs in the development of the outcome. RESULTS: A strong relationship between the patterns of care and the development of advanced diabetes complications was found and is described in Chapter 4. In Chapter 5, this same relationship was investigated for each Australian state and territory, and similar findings were made. The study in Chapter 6 investigated whether late diagnosis or the patterns of care was the stronger risk factor for advanced diabetes complications, finding that the greatest risk was associated with the latter. In Chapter 7 the influence of medical care during the pre-diagnosis period was explored, and a strong relationship between care obtained in this period and the development of advanced complications was found. In Chapter 8, which investigated the role of socio-economic status in the development of advanced complications, found that the risk of advanced diabetes complications was higher in low socio-economic groups. Chapter 9 investigated geographic isolation and the development of advanced diabetes complications and found that the risk of advanced complications was higher in geographically isolated populations. Finally, Chapter 10, which utilised a provider database, found that some GP characteristics were associated with the development of advanced diabetes complications in patients. CONCLUSION: A number of major risk factors for the development of advanced complications in Australia was found. These related to poorer diabetes management, later diagnosis, low socioeconomic status and geographic isolation. Strategies must be devised to promote effective diabetes management and the early diagnosis of diabetes across the Australian population.

Master of Public Health
OBJECTIVES: In Australia, diabetes causes significant morbidity and mortality. Whilst the need to prevent diabetes and its complications has been widely recognised, the capacity of health care systems - which organise diabetes care - to facilitate prevention has not been fully established. METHODS: A series of seven population-based case-control studies were used to examine the effectiveness of the Australian health care system and its capacity to manage diabetes. Six of the studies compared the patterns of care of patients who had developed advanced diabetes complications in 2000 (cases), to similar patients who remained free of the condition (controls) across Australia and for various risk groups. A secondary study investigated the role of treating GPs in the development of the outcome. RESULTS: A strong relationship between the patterns of care and the development of advanced diabetes complications was found and is described in Chapter 4. In Chapter 5, this same relationship was investigated for each Australian state and territory, and similar findings were made. The study in Chapter 6 investigated whether late diagnosis or the patterns of care was the stronger risk factor for advanced diabetes complications, finding that the greatest risk was associated with the latter. In Chapter 7 the influence of medical care during the pre-diagnosis period was explored, and a strong relationship between care obtained in this period and the development of advanced complications was found. In Chapter 8, which investigated the role of socio-economic status in the development of advanced complications, found that the risk of advanced diabetes complications was higher in low socio-economic groups. Chapter 9 investigated geographic isolation and the development of advanced diabetes complications and found that the risk of advanced complications was higher in geographically isolated populations. Finally, Chapter 10, which utilised a provider database, found that some GP characteristics were associated with the development of advanced diabetes complications in patients. CONCLUSION: A number of major risk factors for the development of advanced complications in Australia was found. These related to poorer diabetes management, later diagnosis, low socioeconomic status and geographic isolation. Strategies must be devised to promote effective diabetes management and the early diagnosis of diabetes across the Australian population.

In Australia, type 2 diabetes mellitus (T2DM) is a leading cause of morbidity and mortality with approximately 1.2 million people affected. Australia has a large number of migrants: as of June 2019, 7.5 million (29.7%) Australians were born overseas, and the Indian migrant population is 660,000 (2.6% of the total population). Evidence suggests that there is a very high prevalence of diabetes among Indian migrants (14.8%) compared to the Australian-born population (7.1%) along with a high rate of diabetes-related hospitalisation and complications. Indians are traditionally known for high use of ayurvedic medicines (AM), a component of complementary and alternative medicines (CAMs). Diabetes management's primary goal is to reduce symptoms, avoid the associated harms and improve quality of life. The patient can achieve these goals by adhering to treatment and lifestyle modifications. However, maintaining a normal blood sugar level can be challenging for Indian migrants because of several factors, such as an unhealthy diet, inadequate physical activity, poor adherence to medicines, religious factors, poor understanding of the health system, treatment costs, migration-related stress, seeking a job and other family-related issues. Ethno-racial and socio-cultural characteristics affect not only the susceptibility of individuals to diabetes, but also the day-to-day management of diabetes. While it is understood that Indian migrants are generally more at risk of developing diabetes than local Australians, the impact of Indian ethno-cultural traditions and religious and social norms on diabetes management is not well understood. The socio-cultural structure, traditions and ideologies of Indian migrants are complex and unique, and their impact on diabetes needs to be explored for a comprehensive understanding of, and interventions to improve, diabetes management for Indian migrants. Overall, this research aimed to gain an understanding of the factors that influence decision-making about medications and medication adherence in Indian migrants with type 2 diabetes (T2D), living in Australia. The research consisted of two stages: in-depth qualitative interviews and on-line survey using discreet choice experiments. The specific qualitative study objectives were: • To investigate Indian migrants’ awareness and understanding of, and access to, the healthcare system; how they feel it compares with their experience in India; and how they perceive this access influences their diabetes care. • To investigate Indian migrants’ medication-taking behaviour (with conventional medicines for diabetes) and factors that influence adherence at its three phases. • To explore the beliefs, decision-making process and experiences of patients with type 2 diabetes mellitus (T2DM) using AM, with a specific focus on the AM use pattern and disclosure to doctors, sources of information about AM and where AM is purchased. • To explore how Indian migrants cope with T2DM through religion and spirituality, and the impact of religion and fasting on insulin use. The specific discrete choice experiment (DCE) study objectives were: • To determine the preferences for conventional vs AM in Indian migrants with T2DM. • To identify the factors that may influence the preferences. Methods Qualitative study A qualitative study was designed consisting of face-to-face interviews. The study included Indian-born migrants (Australian citizen/permanent resident) aged 18 years or over; with T2DM; using at least one anti-diabetic medication; living in Greater Sydney or its surrounding suburbs, responsible for their own medications and fluent in English and/or Hindi. Twenty-three participants were interviewed; data saturation was reached after the 18th interview. The interview protocol was prepared after an extensive literature review, and comprised open-ended questions to enable participants to speak freely. The 40–45-minute interviews were audio recorded, transcribed verbatim and thematically analysed using a framework and an inductive approach to thematic analysis. Data analysis was performed manually using Microsoft Word. The consolidated criteria for reporting qualitative research (COREQ) was used to provide transparency in data reporting to improve the rigor, comprehensiveness and trustworthiness of the study. DCE research methods Participants completed an online survey with eight choice tasks and answered demographics questions. In the choice tasks, they chose their preferred medicine (conventional vs AM) or a 'no medicine' option. Paid and unpaid strategies were employed to recruit the participants, using Facebook and email. A D-efficient design was used to balance the attribute levels and to select a subset of the medication profiles. A total of 32 choice tasks were generated; however, to improve feasibility, the survey was blocked in 4 iterations, with each respondent completing 8 chosen tasks. Attributes and attribute-levels for the DCE were chosen systematically following a literature review and the qualitative research findings. Eight attributes (glycated haemoglobin, side effects, number of times medicine is taken (frequency), formulation, instructions to take with food, hypoglycemic events, weight change and cost of the medications) were selected. The levels chosen were widely spaced to encourage participants to maximise trade-off and increase the reliability of parameter estimates. Descriptive statistics (standard deviation, mean and frequency) for the socio-demographic characteristics of the sample and other parameters were reported. The DCE responses were analysed; a mixed multinomial logit (MMNL) model was used as it relaxes the assumption of identical distribution and accounts for heterogeneity in preferences between individuals. In DCE, parameter (β) estimates refer to the importance given by patients to an individual attribute-level, where a higher value indicates higher utility. The computer programme NLogit 6 was used for data analysis. Results Qualitative study Twenty-three participants were interviewed. The majority of participants were male (n=18) and followed Hinduism (n=17). Twelve participants had used AM at least once since they had been diagnosed with diabetes, and the remaining 11 had never used AM for diabetes (5 used AM for other conditions). Once diagnosed with T2DM, Indian migrants reported mixed emotions. Participants contemplated the need to restrict their diet, change their lifestyle and use lifelong medicines, and raised several issues related to their physical and mental health, which they felt were deteriorating. Consequently, they felt that they had to take further action to manage their diabetes: to maintain a normal blood sugar level, and to maintain well-being and inner or spiritual comfort. Controlling diabetes and associated health problems, such as co-morbid conditions and diabetes-related health issues, through the use of medications (either conventional or ayurvedic) was regarded as an important strategy. The findings show a limited knowledge of the healthcare system, and the use of informal sources (e.g., family, friends, social media) to learn about the healthcare system and the available services. Several barriers to decision-making in accessing health services were identified, such as socio-cultural beliefs, social impacts, preference for Indian healthcare professionals and the high cost of medications; these ultimately influenced diabetes management, which could lead to poor diabetes control. The study also identified some enablers encouraging people to improve their diabetes care, such as Health Cards (Medicare and NDDS card), which enable access to free GP consultations and laboratory tests and other diabetes products at a subsidised price. The findings suggest that religious beliefs influence diabetes management in this group. Participants believed that prayers gave them inner strength to manage their diabetes, and that prayers/blessings from religious leaders could help them manage their health conditions, including diabetes. Participants who held stronger religious beliefs were not in favour of using insulin or other medication derived from animal sources, and believed that fasting was an important religious obligation which could not be skipped due to diabetes. In contrast, some participants believed that animal-based medicines were permissible to consume and fasting could be skipped as it was detrimental to the health and well-being of people with diabetes. For the 12 participants that used AM, the decision-making process included evaluating AM benefits vs harms, and the positive opinions of others who used AM. Most participants expressed positive beliefs about AM (no side effects, can cure the condition and are effective), which influenced their decision to initiate AM. The decision to initiate AM was also influenced by other factors such as personals beliefs, social influence, and others’ experiences of using AM. They sought information from various sources such as family members, friends, multimedia, and from healthcare professionals in India. Participants believed that AM does not have side effects because it is obtained from a natural source (herbals), is effective and can cure diabetes. The use of AM was discontinued within months of initiation if there were no benefits. Participants used both ayurvedic and conventional medicines together as they believed that the combination of both medicines could better control blood sugar with no harmful effects. Most participants discontinued taking AM if they felt it was ineffective. Negative beliefs about AM centered on lack of scientific evidence to show effectiveness, and formulations. The majority of participants were initially prescribed oral antidiabetic medication and only two were started on insulin. From the time of diagnosis, patients made daily decisions about their diabetes disease control. The medication-taking behaviour among the participants changed at the three different phases of medication-taking (initiation, implementation, and discontinuation). Several factors influenced adherence at these three phases of adherence. At the initiation phase, most of the patients started conventional medication as soon as prescribed by GPs, while some postponed treatment initiation. The decision to initiate and continue the use of medications (adherence) was based on a balance between patient concerns and needs. The key motive was the desire to improve the diabetes outcome (control blood glucose level), and some participants were motivated to initiate treatment by advice/recommendations from GPs and the information they received about the medication. Fear of side effects delayed treatment initiation with conventional medications. Most participants reported taking their medication as prescribed. However, some reported forgetting their medication, especially when they were in a hurry for work or were out for family dinners or a party. In the implementation phase, patient benefits in (blood glucose levels) influenced people to adhere to conventional medications. Negative factors such as stigma and fear of side effects and drug dependence were identified barriers to adherence during the implementation phase. A few participants discontinued taking conventional medications once they started getting benefits and moved to AM; however, they restarted conventional medications if the desired results were not achieved with the ayurvedic medication. A few participants discontinued taking their medication due to fear of side effects. Overall, findings showed that negative beliefs and concerns about medications, such as fear of side effects, the stigma of diabetes and medications and fear of drug dependence, are common factors that influenced the initiation of medication. Decision to initiate the process was influenced by the balance between the desire to improve blood sugar levels and Hba1c outcomes (necessity beliefs) and negative medication beliefs (concerns). If the benefits were greater than the concerns, participants were more likely to initiate medications (either conventional or ayurvedic). DCE research The survey was completed by 141 participants. The average age was 49.7 years; most were male (n=92, 65.2%). The majority followed Hinduism (n=75, 53.2%). Many (n=80, 56.7%) respondents had co-morbid conditions, mainly cardiovascular disease. The majority (n=114, 80%) of participants used prescribed oral conventional medicine and 31.2% (n=44) used AM alone or with conventional medicines for their diabetes. Overall, the preference of respondents to initiate a medicine was negative for both medicines (conventional (β=−2.33164, p<0.001) and AM (β=−3.12181, p<0.001)); however, significant heterogenicity was noted in participants’ preferences (SD: 2.33122, p<0.001). Six attributes were identified to be a significant influence on medicine preferences: occurrence of hypoglycaemic events (relative importance, RI= 24.33%) was the most important, followed by weight change (RI=20.00%), effectiveness of the medicine (RI= 17.91%), instructions to take with food (RI= 17.05%), medicine side effects (RI=13.20%) and medicine formulation (RI= 7.49%). Another important finding was that participants expressed a desire to initiate a medicine despite the medicine having side effects, with the preference for initiation being higher with mild side effects compared with moderate to severe side effects. Conclusions This is the first qualitative study of Indian migrants with T2DM to explore their understanding of the Australian healthcare system; their medication-taking behaviour; and the impact of religious, cultural and other factors on diabetes management. The qualitative study revealed that Indian migrants had limited knowledge about the Australian healthcare system and relied on informal sources for information. Sociocultural beliefs, social influences, preferences for healthcare professionals, and high cost of medicine were barriers to accessing healthcare, while healthcare cards (Medicare and NDSS) were the main enablers. Religious beliefs play an important role in the self-management of diabetes among Indian migrants living in Australia. However, both positive and negative beliefs were identified regarding praying, using animal-based medicines, and the impact of fasting on the management of diabetes. Participants had a limited understanding of the rulings and teachings of their religion within the context of diabetes. Overall, Indian migrants usually use AM alone or with conventional medicine for diabetes self-management. Most took conventional medicines, though there were delays in initiation of the prescribed medicines. Side effects was a significant factor influencing medication adherence at all phases, whilst motivation to manage diabetes effectively was the key facilitator of medication taking. The quantitative findings demonstrated negative preferences for both conventional and ayurvedic medications; that is, Indian migrants were more likely to not start either conventional or ayurvedic medication to manage diabetes. Overall, if choosing between medications, they were more likely not to take ayurvedic medication compared to conventional medication. Preferences for conventional and ayurvedic medication were heterogenous and influenced by several factors. Experiencing hypoglycemic events was the most influential factor, followed by weight change, glycated haemoglobin, instructions for taking with food, side effects and formulation of medications. However, Indian migrants with T2DM indicated willingness to initiate medication to gain benefits despite mild and moderate side effects. This research has highlighted the importance of AM as a treatment option for T2D in Indian migrants living in Australia, and the range of factors influencing medication taking. The study findings point to the importance of healthcare professionals, particularly prescribers, to consider the range of factors that can impact medication taking when monitoring adherence, from initiation to persistence and discontinuation of therapy

Understanding the relationships between culture, associated health beliefs and lifestyle, and ethnic disparities in health is of particular importance in Australia, where one in four people was born overseas. Vietnam-born Australians (N=159,849 at the 2006 Census) are among the top five overseas-born population groups. Most arrived as refugees (50%, 1977-1986) and family reunion immigrants (42%, 1987-1996), thus many have poorer socio-economic status than other population groups. Vietnam-born Australians also share a distinct Oriental culture and traditional health beliefs that largely differ from Western biomedicine perspectives. Changes in diet among new immigrants have been reported but the impact of acculturation on various lifestyle factors and, importantly, health status of Vietnam-born Australians has not been examined extensively. Research evidence shows that people of Vietnamese ethnicity are at higher risk of diabetes. However, there is little existing information about diabetes among Vietnam-born Australians. Therefore, this thesis aimed to investigate two interrelated aspects of health in this population: the impact of acculturation on health-related behaviours and health status; and the prevalence of type 2 diabetes, its risk factors and hospitalisation and mortality outcomes. Baseline questionnaire data (2006 to 2008) from the 45 and Up Study, a cohort study of more than 266,000 residents of New South Wales (NSW), Australia aged 45 years and over, were used to investigate relationships between acculturation (duration of residence, age at immigration, density of Vietnam-born population in residential areas, and social interactions) and lifestyle, health status, and prevalence of and risk factors for type 2 diabetes. Analytic techniques included descriptive statistics, direct age-standardisation and logistic regression modelling. Among 797 Vietnam-born participants in the Study (390 men and 407 women), higher levels of acculturation were associated with increased consumption of red meat, white meat and seafood, higher levels of physical activities, and lower prevalence of overweight and obesity, and type 2 diabetes. Likelihood of smoking was lower among Vietnam-born men living in areas with low proportion of Vietnam-born population (< 2%). The age standardised prevalence of self-reported type 2 diabetes was 11.2% (crude prevalence 12.9%), which was 1.6 times (95%CI=1.31-1.90) higher than in Australia-born participants. Strong risk factors for type 2 diabetes in Vietnam-born participants included family history of diabetes (adjusted odds ratio [OR]=7.07, 95%CI=4.14-12.07) and older age (OR≥2.49, p< 0.001). Overweight or obesity based on body mass index (≥23.0 kg/m2) was not a strong predictor (OR=1.64, 95%CI=0.99-2.74). Vietnam-born people with type 2 diabetes were more likely to have a health care concession card, high blood pressure, heart disease, and poorer self-rated general health and quality of life. The NSW Admitted Patient Data Collection (APDC, 1/7/2000 to 31/12/2008), an administrative database of all hospital stays in NSW, was linked to NSW death registrations (1/7/2000 to 30/12/2009) and Australian Bureau of Statistics mortality data (1/7/2000 to 30/12/2007) to investigate diabetes-related hospitalisation and mortality. One hundred and fifty-two Vietnam-born patients admitted between 1/7/2000 and 31/12/2008 for treatment of type 2 diabetes were followed prospectively for readmissions and mortality. Statistical techniques included Poisson and Cox proportional hazard regression modelling. Vietnam-born patients had lower rates of readmission for diabetes and comorbidities (450.7, 95%CI=394.4-515.0 per 1,000 person-years) than Australia-born counterparts (528.5, 95%CI=522.2-535.0) but the difference was not statistically significant (adjusted rate ratio [RR]=0.81, 95%CI=0.64-1.03). However, Vietnam-born patients had significantly higher risk of death from all causes (adjusted hazard ratio [HR]=1.42, 95%CI=1.07-1.88) and for diabetes-related causes (HR=1.58, 95%CI=1.05-2.38). The prevalence of hypertension, chronic kidney disease, and other comorbidities was significantly higher in Vietnam-born than in Australia-born patients. The findings of this thesis have implications for education about healthy lifestyle and for proactive management of diabetes in this population. Early diagnosis and optimal control of diabetes and comorbid conditions are important for Vietnam-born Australians given their high risk of diabetes. Family members’ participation in patient-centred management of people with diabetes could provide additional positive outcomes. This research has demonstrated the value of record linkage of already available, population-based health administrative data for investigating diabetes management and associated health outcomes among overseas-born Australians.

The number of young adults diagnosed with type 1 diabetes is increasing globally and is the most common childhood non-communicable disease after asthma. Type 1 diabetes is a complex condition which requires 24- hour vigilance of blood glucose levels, insulin administration, and food and exercise. Individuals need to be well informed in self-management skills to prevent or respond to acute diabetes crises. In Australia, transition from paediatric to adult health care occurs at the end of schooling or between 16-18 years of age. Given the large numbers in paediatric care, young adults with type 1 diabetes have featured significantly in the transition literature; however, there are limited reports of successful interventions in adult health care. The aim of this multi-method study is to evaluate the feasibility, acceptability, effectiveness and sustainability of a structured intervention (WDTS) model in improving diabetes health outcomes and sick-day management tailored for YWD following their transition from paediatric to adult health care. The thesis aims to contribute to the knowledge on the effects of sustainable interventions through evaluating the key components of the Westmead Diabetes Transition Service model. This model is aligned with the Care Transition Framework that provided the theoretical underpinnings for the study. This comprehensive and long-term evaluation of the Westmead Diabetes Transition Service model of care provided evidence that age-appropriate interventions can improve the health outcomes of young adults with type 1 diabetes following transition to adult care. More importantly, glycaemic control alone was an imperfect measure, as it failed to ‘‘tell the whole story” of day-to-day diabetes self-care and the value of continued engagement with a multidisciplinary transition service to prevent deterioration in diabetes management following transition. The importance of developing trusting relationships between adult providers and young adults with type 1 diabetes is critical to prevent loss to medical follow-up and reduce the risk of acute diabetes crises. The utilisation of phone support promoted self-efficacy in selfmanagement of sick days for young adults with type 1 diabetes; hence, development of transition strategies should take into account changing technology and the use of telematics among young adults. Diabetes control following transition can be maintained with regular attendance at followup. However, if young adults with type 1 diabetes are to meet the recommended levels of glycaemic control, further research into psychological and behavioural interventions to promote self-efficacy and address diabetes-related distress earlier in adolescence and prior to transition are likely to be required to improve diabetes control at entry to adult services.

Cultural competence is a relatively recent term describing appropriate ways of working with increasingly diverse cultures in society. By interviewing diabetes practitioners, this study sought to investigate the interaction between scientific knowledge and the practice of diabetes healthcare with patients from non-Western cultural groups.

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Title page, contents and abstract only. The complete thesis in print form is available from the University Library.
Examines goal setting in people with diabetes as part of chronic disease management in a rural setting. The studies were performed in Eyre Peninsula with a significant (10-20%) Aboriginal population.
Thesis (M.D.)--University of Adelaide, Dept. of General Practice, 2005

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Includes bibliographical references (leaves 210-242)
242 leaves
Examines goal setting in people with diabetes as part of chronic disease management in a rural setting. The studies were performed in Eyre Peninsula with a significant (10-20%) Aboriginal population.
Thesis (M.D.) -- University of Adelaide, Dept. of General Practice, 2005

Diabetes in Indigenous Australians occurs at a younger age and at almost four times the rate of non-Indigenous Australians. While the cause for this health disparity is multi-factorial, recent studies suggest that nutrition, and particularly magnesium intake, may play a role in onset of diabetes and related pathologies. No study has ever examined whether there is any relationship between diabetes and magnesium intake in Indigenous Australians, and the present study therefore sought to establish whether any such interrelationship existed. As part of this study, dietary magnesium intake was estimated in an urban cohort of Aboriginal and Torres Strait Islander subjects and compared to the average Australian dietary intake. An ecological study then explored environmental correlates, and specifically the magnesium level in drinking water, to diabetes mortality. Finally, total and free serum magnesium concentrations were determined to identify any differences in magnesium status between diabetic and non-diabetic Indigenous and non-Indigenous Australians, and also to compare which of the two parameters was a more sensitive measure of magnesium status and diabetic risk. All Aboriginal and Torres Strait Islander people that were recruited for this study were patients of the Townsville Aboriginal and Islander Health Services, Townsville, North Queensland, who presented for health monitoring and subsequently required fasting blood tests as part of that routine care. Additional non-Indigenous people were recruited from five GP practices in the Townsville area. Inclusion criteria included persons over the age of 15 (Tanner Stage 5) who had lived in the Townsville area for at least ten days. Exclusion criteria included chronic diarrhoea, alcoholism or binge drinking in the past two weeks, use of diuretics, consumption of magnesium supplements, reduced renal function (urinary albumin to creatinine ratio exceeding > 2.5 mg/mmol in men and > 3.5 mg/mmol in women), severe mental illness, pregnancy, or breastfeeding. Our results indicated that 60% of the Indigenous people assessed in this study had a dietary intake of magnesium that was below the estimated average magnesium requirement for half the national population. Additionally, the average magnesium intake in Indigenous Australians was significantly less than the intake of non-Indigenous Australians (p<0 .001). A significant negative correlation was found between the incidence of diabetes related mortality and the concentration of magnesium in drinking water in Queensland, confirming previous reports from the USA that drinking water magnesium may be an important factor in development of diabetes. The needs assessment study confirmed that diabetes in both Indigenous and non-Indigenous Australians was associated with reduced levels of total serum magnesium, and more importantly, that total serum magnesium was lower in Indigenous Australians who did not have diabetes compared with their non-Indigenous counterparts (p=<0.001). In the absence of diabetes, the prevalence of hypomagnesaemia was 17.2% for the non-Indigenous but 36.9% for the Indigenous subjects. Finally, the ionic serum magnesium analysis confirmed the results of the total serum magnesium study, and demonstrated that ionic magnesium was strongly correlated to the total magnesium concentration (r: 0.75. p < 0.001), with the relationship being apparent irrespective of either diabetic (r: 0.66 to 0.81. p<0.001) or ethnicity (r = 0.71 to 0.81. p<0.001)." We conclude that although not causal, the evidence suggests that magnesium may be a significant contributing factor to diabetes in Australia, especially for Aboriginal and Torres Strait Islander peoples, and that further investigation of the potential relationship between magnesium and diabetes in the Australian Indigenous populations, and possible corrective interventions, is highly warranted.
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Thesis (Ph.D.) - University of Adelaide, School of Medical Sciences, 2008

There is a growing body of research examining psychosocial aspects of diabetes. Relatively few studies, however, have investigated a theoretical framework to help integrate empirical knowledge. This study tested the utility of an expanded health belief model for explaining regimen adherence among Type II Diabetes patients. Furthermore, the study examined differences between Maltese Australian people and Anglo-Saxon Australian people. A paper and pencil questionnaire was administered to 147 people with Type II Diabetes who attended Diabetes Australia in Sunshine, Western Metropolitan Melbourne. The questionnaire measured adherence to diabetes medication, dietary treatment adherence, adherence to home blood glucose monitoring, 'perceived susceptibility and severity of diabetes and its complications', 'perceived benefits and barriers to carrying out treatment', 'health locus of control', 'attitudes toward doctors', 'beliefs about food', and demographic factors. Health beliefs predicted dietary treatment adherence. There were predictive relationships found between health beliefs and ethnic differences were evident. A new 'Diabetes Dietary Adherence Model' emerged from the findings, which may assist in re-directing patient education programs.

Melioidosis is a serious infection caused by the soil-dwelling Gram-negative bacillus Burkholderia pseudomallei. It is most commonly reported in north-east Thailand and northern Australia, but is increasingly recognized around the world. Infection is predominantly acquired through bacterial inoculation, often related to occupation, and mostly affects adults between the fourth and sixth decade who have risk factors such as diabetes mellitus and renal impairment. Clinical features are very varied, ranging from a septicaemic illness (the most common presentation), often associated with concomitant pneumonia (50%) and other features including hepatic and splenic abscesses, to a chronic illness characterized by fever, weight loss, and wasting. Aside from supportive care and drainage of collections of pus, treatment requires prolonged antimicrobial therapy, with a parenteral phase of 10 to 14 days (ceftazidime or a carbapenem) followed by oral therapy for 12 to 20 weeks (trimethoprim-sulfamethoxazole).