Support workers can develop the skills to work with complexity in community aged care: An Australian study of training provided across aged care community services

ABSTRACT

Enhancing support workers’ (SW) role is timely given increasing demands on human and financial health care resources. This article presents outcomes of a program, delivered to 140 participants from five community aged care providers in Australia, designed to enhance knowledge, skills, and confidence of community aged care SWs, building their practical skills in understanding, recognizing, and responding to complexity. Evaluation training modules on communication, complexity, behavior change, and chronic condition self-management support involved pre/post surveys with SWs and their supervisors. SWs reported greater awareness, skills, and confidence in working with complexity, reinforcing the value of their existing practices and skills. Coordinators reported greater appreciation of SWs’ skills, and greater awareness of gaps in SWs’ support and supervision needs. Educators, policy makers, and services should account for these contributions, given growing fiscal restraint and focus on reablement and consumer-directed care.     

Peer advisers compared with specialist health professionals in delivering a training programme on self‐management to people with diabetes: a randomized controlled trial

Aims To assess the effectiveness and acceptability of peer advisers in diabetes in delivering a programme of training on self‐management for people with diabetes. Methods Adults with diabetes were randomly allocated to an education programme delivered either by trained peer advisers or by specialist health professionals. The primary outcome measure was change in knowledge tested before and at the conclusion of the four courses, each consisting of six sessions. Glycated haemoglobin and Diabetes Care Profile were assessed at baseline and at 6 months. Sessional and end‐of‐course evaluation responses were analysed, as was the attendance record. Results Eighty‐three patients were randomized. Of these, 14 failed to attend and two were excluded. Knowledge scores improved significantly in both groups, but there was no difference between the groups for any of the knowledge domains. No difference was noted in the Diabetes Care Profiles or in glycated haemoglobin. The attendance record was similar in both groups. In the post‐sessional evaluations, both groups scored highly, with the health professionals significantly more so. The post‐course questionnaire exploring patients’ understanding and confidence in self‐management of specific aspects of diabetes care revealed no difference between the groups. Conclusions Trained patients are as effective in imparting knowledge to their peers as specialist health professionals. Both are also acceptable to patients as trainers. However, lay tutors require to be given appropriate training, specific to the education programme they would be expected to deliver.     

The Pharmacy Diabetes Care Program: assessment of a community pharmacy diabetes service model in Australia.

AIM: To assess the impact of a community pharmacy diabetes service model on patient outcomes in Type 2 diabetes. METHODS: The study utilized a multisite, control vs. intervention, repeated-measures design within four states in Australia. Fifty-six community pharmacies, 28 intervention and 28 control, were randomly selected from a representative sample of urban and rural areas. Intervention pharmacies delivered a diabetes service to patients with Type 2 diabetes, which comprised an ongoing cycle of assessment, management and review, provided at regular intervals over 6 months in the pharmacy. These services included support for self monitoring of blood glucose, education, adherence support, and reminders of checks for diabetes complications. Control pharmacists assessed patients at 0 and 6 months and delivered no intervention. RESULTS: A total of 289 subjects (149 intervention and 140 control) completed the study. For the intervention subjects, the mean blood glucose level decreased over the 6-month study from 9.4 to 8.5 mmol/l (P < 0.01). Furthermore, significantly greater improvements in glycaemic control were seen in the intervention group compared with the control: the mean reduction in HbA(1c) in the intervention group was -0.97% (95% CI: -0.8, -1.14) compared with -0.27% (95% CI: -0.15, -0.39) in the control group. Improvements were also seen in blood pressure control and quality of life in the intervention group. CONCLUSION: A pharmacy diabetes service model resulted in significant improvements in clinical and humanistic outcomes. Thus, community pharmacists can contribute significantly to improving care and health outcomes for patients with Type 2 diabetes. Future research should focus on clarifying the most effective elements of the service model.     

Improving self-management in insulin-treated adults participating in diabetes education. The role of overprotection by the partner.

AIMS: To examine the role of overprotection by the partner--i.e. excessive protection, unnecessary help, excessive praise for accomplishments, or attempts to restrict activities as a consequence of underestimating the patient's capabilities--in changes in patient self-management in the context of diabetes education. METHODS: Sixty-seven insulin-treated patients with a partner completed questionnaires on admission to a Multidisciplinary Intensive Education Programme (MIEP) and 3 months after completing the core module of MIEP. Factors assessed were overprotection by their partner and three aspects of diabetes self-management, namely internal locus of control, diabetes-related distress and HbA1c. Regression analyses were used to test the independent associations of patient sex, baseline overprotection and the interaction between sex and overprotection with diabetes self-management at the follow-up stage, controlling for the baseline value of the dependent variable. RESULTS: The increase in internal locus of control and decrease in HbA1c were both significantly less for female patients who perceived their partner to be rather overprotective than for female patients who did not perceive their partner to be overprotective. The more patients, both male and female, perceived their partner to be overprotective, the less their diabetes-related distress decreased. CONCLUSIONS: Overprotection by the partner showed a negative association with improvement in diabetes self-management, especially for female patients. Thus, an intervention programme with the aim of reducing overprotection by the partner, or the perception of this, may enhance self-management in patients participating in diabetes education.     

Direct observation of treatment for tuberculosis: a randomized controlled trial of community health workers versus family members

We implemented community-based direct observation of treatment, short course (DOTS), including a randomized controlled trial of direct observation either by community health workers (CHWs) or family members, under operational conditions in a region of Swaziland. There was a high death rate of 15%, due to the high HIV rates in the region. There was no significant difference in the cure and completion rate between direct observation of treatment by CHWs and family members [2% difference (95% CI -3% to 7%), exact P = 0.52]. A before-and-after comparison of outcomes demonstrated that the cure and treatment completion rate improved from a baseline of 27-67% following implementation of community-based DOTS. We conclude that community-based tuberculosis DOTS can improve successful outcomes of treatment. However, direct observation can be undertaken effectively using either daily family or CHW supervision. The choice of treatment supporter should be based on access, patient preference and availability of CHW resource.     

Community-based validation of assessment of newborn illnesses by trained community health workers in Sylhet district of Bangladesh

Objectives  To validate trained community health workers' recognition of signs and symptoms of newborn illnesses and classification of illnesses using a clinical algorithm during routine home visits in rural Bangladesh.
Methods  Between August 2005 and May 2006, 288 newborns were assessed independently by a community health worker and a study physician. Based on a 20-sign algorithm, sick neonates were classified as having very severe disease, possible very severe disease or no disease. The physician's assessment was considered as the gold standard.
Results  Community health workers correctly classified very severe disease in newborns with a sensitivity of 91%, specificity of 95% and kappa value of 0.85 ( P  < 0.001). Community health workers' recognition showed a sensitivity of more than 60% and a specificity of 97–100% for almost all signs and symptoms.
Conclusion  Community health workers with minimal training can use a diagnostic algorithm to identify severely ill newborns with high validity.     

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at‐risk patient about appropriate foot self‐care and treat any pre‐ulcerative sign on the foot. Instruct moderate‐to‐high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non‐surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high‐risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer‐free days, and to reduce the patient and health care burden of diabetic foot disease.     

Evaluation of the WHO Haemoglobin Colour Scale for diagnosis of anaemia in children and pregnant women as used by primary health care nurses and community health workers in western Kenya

OBJECTIVES: To evaluate the diagnostic accuracy of the WHO Haemoglobin Colour Scale (HCS) for anaemia in three groups of children aged 2 months to 2 years (sick children, those visiting an immunization clinic and a community-based random sample of children) and a sample of pregnant women. METHODS: Finger-prick blood samples were taken from all consenting participants. Haemoglobin (Hb) levels from the HCS were compared with results from a HemoCue portable haemoglobinometer. Sensitivity, specificity and positive and negative predictive values for the HCS were calculated. RESULTS: A total of 457 sick children, 336 children visiting immunization clinics, 454 children from the community at large and 643 pregnant women participated. The prevalence of anaemia (Hb<11 g/dl) in these groups was 87%, 79%, 74% and 52%, respectively. The prevalence of severe anaemia (Hb<7 g/dl) was 24%, 11%, 10% and 2%, respectively. The sensitivity of the HCS for anaemia ranged from 60% to 79% and specificity from 59% to 94%. The sensitivity of the HCS for severe anaemia ranged from 24% to 63% and the specificity from 97% to 100%. Through use of the HCS, the proportion of sick, anaemic children visiting peripheral health facilities diagnosed and treated for anaemia would increase from 3% to 65%. CONCLUSIONS: In an area with high prevalence of anaemia among sick children, use of the HCS has the potential to significantly increase the proportion of sick, anaemic children who are diagnosed with anaemia and given appropriate treatment. Further evaluations of the effect of the use of the HCS on treatment practices at the health facility level are required.     

Self‐management education for persons with arthritis: Managing comorbidity and eliminating health disparities

Objective

To compare short‐term and long‐term effectiveness of the Arthritis Self‐Help Course (ASHC) and the Chronic Disease Self‐Management Program (CDSMP) for persons with arthritis concerning health care use, health‐related quality of life, health behaviors, and arthritis self‐efficacy.

Methods

Forty‐eight workshops were randomized to the ASHC (n = 26) or CDSMP (n = 22). A total of 416 individuals, including 365 African Americans, participated. The mean age for each group was 64 years, mean years of education was 11.7, mean number of chronic conditions was 4, and 75–80% of participants in each group were female. Multivariate statistical tests were used to assess effectiveness within and between programs for all workshop participants and African Americans.

Results

At 4 months all ASHC participants including African Americans, had significant improvements (P ≤ 0.05) in self‐efficacy, stretching and strengthening exercises, aerobic exercises, and general health. All CDSMP participants had statistically significant improvements in self‐efficacy, disability, pain, and general health. African American CDSMP participants showed statistically significant improvements in general health. Trends toward improvement (P = 0.051–0.100) were shown in 5 variables among African American CDSMP participants and in 4 variables among all CDSMP participants. Statistically significant differences between the 2 programs at 4 months were seen in pain and disability in both groups. The CDSMP produced stronger results. Significant results at 1 year within and between programs were minimal for both groups.

Conclusion

When populations with arthritis and multiple comorbid conditions are targeted, the CDSMP may be most cost effective.     

Effects of self-management training in Type 2 diabetes: a randomized, prospective trial.

AIMS: The efficacy of three education programmes for Type 2 diabetic patients was tested in a randomized trial. A didactic-oriented training programme (treatment A) was compared with a self-management-oriented programme delivered in group sessions (treatment B). The latter programme was compared with a more individualized approach (treatment C). METHODS: One hundred and eighty-one Type 2 diabetic patients (age 55.6 +/- 6.3 years, diabetes duration 6.6 +/- 6.2 years, HbA(1c) 7.8 +/- 1.6%, female 49.7%) took part. Efficacy was assessed 3 months (t1) after baseline (t0) and at a follow-up 15 months (t2) after baseline. RESULTS: The fall in HbA(1c) in treatment B at t1 was sustained at t2 (t0 8.1 +/- 1.8%, t1 7.3 +/- 1.7%, t2 7.4 +/- 1.9%). In treatment A, HbA(1c) was unchanged throughout (t0 7.6 +/- 1.5%, t1 7.5 +/- 1.3%, t2 7.7 +/- 1.7%; treatment A vs. treatment B; P < 0.05). With the more individualized approach of treatment C, there was a fall in HbA(1c) at t1, but this was not sustained at t2 (t0 7.8 +/- 1.6%, t1 7.1 +/- 1.3%, t2 7.6 +/- 1.6%; treatment B vs. treatment C; P = 0.73). There were also significant benefits in treatment B subjects compared with treatment A in further medical (body mass index and fasting blood glucose), psychological (control, irritability and hunger dependency of eating behaviour, and trait anxiety) and behavioural (exercise) variables. There were no significant benefits of the more individualized treatment C compared with group treatment B. No significant differences were found regarding triglyceride levels, high-density lipoprotein, diabetes-related knowledge, negative well-being, urine or blood glucose levels or foot care. CONCLUSION: Self-management training had a significantly higher medium-term efficacy than didactic diabetes education. The group sessions were more effective than a more individualized approach.     

建筑工地外来务工人员艾滋病健康教育干预效果分析

目的分析比较建筑工地外来务工人员几种常见艾滋病(AIDS)宣传干预措施的效果。方法整群抽取8个建筑工地共560名外来务工人员,分成4个组,1个组为对照组,3个组为干预组。干预组分别采取传统健康教育方式(A组)、互动方式(B组)和老乡带教方式(C组)进行干预,比较各干预组干预前后及组间干预的效果。结果干预后,3个干预组艾滋病一般知识、预防措施相关知识的知晓率均有显著改善,传播途径相关知识中,除共用注射器和母婴传播仅干预C组有显著改善外,其他传播途径3个干预组均有显著改善,相关知识干预总体效果C组>B组>A组。艾滋病相关态度行为3个干预组的总体干预效果不明显,仅共用剃须刀在C组、愿坚持使用安全套预防艾滋病在B组和C组有显著改善,干预效果C组要好于B组和A组,但差异无统计学意义。结论进行流动人口艾滋病宣教干预,老乡带教方式的效果要优于互动方式和传统健康教育方式,在态度行为方面更为明显。     

Support workers as agents for health behavior change: An Australian study of the perceptions of clients with complex needs,support workers,and care coordinators

ABSTRACT

An expanding aging population has placed increased demands on health care resources in many countries. Enhancing community aged care support workers’ role to support greater client self-management and reablement is therefore timely. This article presents perceptions of the impact of an Australian practice change initiative designed to enhance knowledge, skills, and confidence of support workers to support behavior change in clients with complex health care needs. A comprehensive training program was delivered in 2013. Methods included thematic analysis of interviews with clients, focus groups with support workers and coordinators, and collection of case studies of client/support worker behavior change interactions. Client, support worker, and coordinator responses were highly positive, reporting improvement in the quality of interactions with clients, client health outcomes, care coordination, communication, and teamwork. Mental health literacy remained the biggest knowledge gap. This research showed that support workers are ideally placed to be more actively involved in motivating clients to achieve behavior change goals.     

The impact of cognitive impairment in dementia on self‐care domains in diabetes: A systematic search and narrative review

Self‐management is integral to effective chronic disease management. Cognitive impairments (CogImp) associated with dementia have not previously been reviewed in diabetes mellitus (DM) self‐care. The aims of this study are to know (1) whether CogImp associated with dementia impact self‐care and (2) whether specific CogImp affects key DM self‐care processes. A systematic literature search with a narrative review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. This review examined studies published from January, 2000 to February, 2016 describing the relationship between cognition and DM self‐care domains in community dwelling older adults with dementia/CogImp. Eight studies met inclusion criteria. Decrements in all self‐care domains were associated with CogImp. Problem solving was related to reduced disease knowledge (OR 0.87, 95% CI = 0.49‐1.55), resulting in poorer glycemic control. Decision‐making impairments manifested as difficulties in adjusting insulin doses, leading to more hospital admissions. People without CogImp were better able to find/utilize resources by adhering to recommended management (OR 1.03, 95% CI = 1.02‐1.05). A lack of interaction with health care providers was demonstrated through reduced receipt of important routine investigation including eye examinations (ARR = 0.85, 95% CI = 0.85‐0.86), HbA1c testing (ARR = 0.96, 95% CI = 0.96‐0.97), and LDL‐C testing (ARR = 0.91, 95% CI = 0.901‐0.914). People without CogImp had better clinic attendance (OR 2.17, 95% CI = 1.30‐3.70). Action taking deficits were apparent through less self‐testing of blood sugar levels (20.2% vs 24.4%, P = 0.1) resulting in poorer glycemic control, self‐care, and more frequent micro/macrovascular complications. Persons with diabetes and CogImp, particularly in domains of learning, memory and executive function, were significantly impaired in all self‐care tasks.     

Individual and contextual factors associated with follow‐up use of diabetes self‐management education programmes: a multisite prospective analysis

Aims Although a considerable body of research supports the efficacy of diabetes self‐management education (DSME), these programmes are often challenged by high attrition rates. Little is known about factors influencing follow‐up use of DSME services, thus the aim of this study was to identify these factors. Methods In this multisite prospective analysis, adults with Type 2 diabetes (n = 268) who attended one of two diabetes management centres (DMCs) were followed over a 1‐year period from their initial visit. The influence of individual and contextual factors on the number of contacts with DMC providers was examined. Data were analysed within the context of the Health Behavioral Model of Health Services Utilization. Results In a multivariable negative binomial regression model, the number of contacts over 1 year was greater for those who were female, non‐smokers, unemployed, self‐referred to the DMC, lived closer to the DMC, had a lower body mass index, or had a longer known duration of diabetes. Follow‐up use of services differed significantly between the two sites. Provider contacts were greater at the centre that offered flexible hours of services and a variety of optional educational modules. Conclusions Healthcare professionals need to encourage ongoing use of DSME, particularly for individuals prone to lower follow‐up use of these services. Providing services that are accessible, convenient, and can easily fit into patients’ schedules may increase follow‐up use. Further exploration into how operations and delivery of these services influence utilization patterns is strongly recommended.     

The global challenge of type 2 diabetes and the strategies for response in ethnic minority groups

Ethnic minorities living in high‐income countries usually exhibit a greater risk of developing diabetes along with higher morbidity and mortality rates. We evaluated the effectiveness of interventions to improve glycaemic control in ethnic minority groups. Results of major controlled trials, systematic reviews and meta‐analyses were included in the review. Only 1/47 studies addressing diet and exercise interventions reported details on the ethnicity of the studied population. Self‐management education was successful if associated with increased self‐efficacy; delivered over a longer period; of high intensity; culturally tailored; and when using community educators. Strategies adopted in community‐gathering places, family‐based, multifaceted, and those tackling the social context were likely to be more effective. A positive relationship was found between social support and self‐management behaviour as well as quality of life, but there is little evidence about the impact of organizational changes within health‐care services on diabetes control. More research is needed to strengthen the evidence on effective strategies for response to diabetes in ethnic minorities. Also, there is a need to take into account diabetes beliefs and communication difficulties, as well as potential protective factors. Globally, many health‐care systems are inadequately equipped to improve diabetes prevention and disease outcomes in these communities. Copyright © 2010 John Wiley & Sons, Ltd.     

Factors associated with establishment-based female sex workers accessing health care services in Shanghai

Female sex workers are a priority population for HIV prevention and health promotion in China. This paper examines the patterns of and factors associated with the utilisation of HIV-related and general health services by establishment-based sex workers in Hongkou District, Shanghai. Participants were recruited through a three-stage sampling strategy and invited to self-complete a brief survey in 2012. The median age of the 400 participants included in the analyses was 33 years (range = 18–52 years old), with over three-quarters being married at the time of the survey. Participants were mostly internal migrants, more than half had lived in Shanghai for six months or longer and nearly two-thirds were working in an establishment with a total of less than five female sex workers. Routine physical examination and HIV testing were the most commonly accessed health services in the previous 12 months. Altogether, 347 women (86.8%) had actively sought, including 157 women had obtained, free health services mainly from local Community Health Service Centres (CHSCs) in the previous 12 months. The active seeking of free, largely CHSC-provided health services was associated with a longer duration of residence in Shanghai (adjusted odds ratio [AOR] = 2.55, 95% CI = 1.32–4.93; p < 0.01) and having tested for HIV in the previous 12 months (AOR = 3.68, 95% CI = 1.84–7.38; p < 0.001). Conversely, a higher annual income (AOR = 0.41, 95% CI = 0.21–0.80; p < 0.01), working in a larger establishment (AOR = 0.40, 95% CI = 0.20–0.79; p < 0.01) and knowing that HIV can be transmitted through blood transfusion with unscreened blood (AOR = 0.21, 95% CI = 0.05–0.91; p < 0.05) were associated with not actively seeking such services. Free, community-based health services are highly demanded by establishment-based female sex workers in Shanghai. Scaling-up of free and integrated health services provided by community-based health service providers in metropolitan areas in China and beyond holds promise for promoting health and well-being of female sex workers.