Public Health Bulletin Edition 3/2006 Chronic disease

The Prevention ofChronic Disease– the Policy ContextBruce WhitbyActing Manager, Primary Health Care and ChronicDisease Strategies,South Australian Department of HealthMichele HerriotActing Director, Health Promotion Branch,South Australian Department of HealthThe health of South Australians - their physical, mentaland social wellbeing 1 - is now being seriously threatenedby the growth of chronic disease. The impact ofchronic disease now outweighs the importance of allother conditions and, if unchecked, this will result inunsustainable demand for health care services as wellas personal hardship. For the first time in many yearsit is predicted that healthy life expectancy for today’schildren will be less than that of their parents: this isprincipally due to obesity-related chronic conditions. 2Much chronic disease can be prevented, or bettermanaged, through action, both at the population leveland in relation to the needs of individuals. This paperoutlines the national and state policy context for therequired action, as well as some of the challenges toachieving change.What is the problem?In the Australian population, over 70% of the burdenof disease and injury can be attributed to chronicconditions 3 and approximately 50% of the adultpopulation live with a chronic condition. In SouthAustralia alone it is estimated that at least 450,000people over the age of 20 have a least one preventablechronic disease, and this burden is growing. 4The South Australia Generational Health Review (GHR)Report: 2003, 5 found that the current health systemis unsustainable, and recommended a reorientationof the system from acute to primary heath care. Thisincluded a strong emphasis towards prevention andearly intervention, and a focus on consumer-centredcare rather than on institutions. There was also anemphasis on reducing inequities in health outcomes(eg diabetes), access to health services (eg preventionprograms such as healthy weight programs) and thesocial and environmental conditions which supportgood health (eg access to affordable healthy food). Thisapplies to Indigenous people in particular, as well as todisadvantaged populations generally.2What causes chronic disease?Many factors combine to impact on health andwellbeing, and on the development of chronic disease,including:• Social or upstream determinants egeducation level attained, adequacy of income,affordability and location of housing, under- andunemployment, and access to childcare.• Environmental determinants eg communityaccess to recreation facilities, public transport,nutritious safe food, as well as clean air and waterand unpolluted environments in which to live,work and play.• Psychosocial factors such as sense of control,resilience, community connections, self-esteem,and life experiences in the early years.• Behavioural determinants especially tobaccouse, inadequate physical activity, poor diet, riskyalcohol consumption and unhealthy weight.• Biological risk factors eg hypertension, highcholesterol, and metabolic syndrome.• Genetic and familial factors such as type 2diabetes, cardiovascular disease, asthma andsome cancers, these factors playing a rolethrough predisposition to disease.• Accessible and affordable health services egprograms which support prevention (screening,support and referrals) and early detection andmanagement of chronic conditions.The Organisation for Economic Co-operation andDevelopment (OECD) estimates that some 40-50% ofpremature deaths result from preventable behaviours. 6Complex problems require multiple solutionsComplex problems caused by varied determinantsrequire multi-strategy solutions, and evidence 7, 8suggests that both a stronger public health approachand a strengthened primary heath care system arerequired. Action at all stages of both the health-diseasecontinuum and the life continuum are required, withinterventions that are tailored to the needs of bothindividuals and populations (see ‘When you can’t breathe… nothing else matters’ - Dr R Ruffin, D Wilson and SAppleton). There is good evidence that chronic diseasecan be prevented from occurring in the first place andalso from progressing to become a complex problemrequiring expensive and intensive medical care. 9What is the role of the health system?Given that many of the determinants of health areoutside the direct influence of the health system, itis essential that a broad approach be taken to chronicdisease prevention. There are three complementarycomponents to action:

1. A primary prevention approach which aims to make‘the healthy choice the easy choice’ for the wholepopulation, through the creation of social andphysical environments which support good health.The health system plays a vital role in workingacross sectors to ensure, for example, that schoolpolicies support healthy eating, that work placesoffer family friendly environments, that legislationbans smoking in enclosed environments, thatpolicies control the promotion of alcohol to youngpeople, and so on. This requires strong leadershipand advocacy at a central level, supported bycomplementary local action and partnerships atall levels to underpin this approach. Because largenumbers of the population are at a moderate level ofrisk, primary prevention aims to influence this group,which contributes most to the burden of disease.2. A focus on groups at risk, to ensure thatstrategies are relevant, investment is prioritisedand inequalities are reduced. Examples includeprograms to ensure that healthy food is available andaffordable in Aboriginal communities, that women indisadvantaged areas have access to breastfeedingsupport, or that people with mental illness areassisted to quit smoking.3. Support for individuals who are at risk, or those whohave chronic disease, to ensure they have access togood treatment and management services, as wellas advice on prevention, and that they are supportedto manage their condition effectively. Better care willresult from recognising the impact of the broaderdeterminants of health on individuals as well asthe inequities faced by different groups. This formof secondary and tertiary prevention complementsthe work described above in aiming to bring aboutsignificant improvements in health, even though thismay be for fewer numbers.For health services with limited budgets, a workforcepredominantly trained in working with individuals, anda media that focuses attention on hospitals, treatmentand illness rather than on health and wellbeing, findingthe right balance across these three areas is challenging.It is clear, however, that if we are to prevent chronicdisease there needs to be a much bigger investment inpopulation-based strategies.National policy directionsA number of national bodies are responsible for a broadrange of activities in the prevention and management ofchronic disease. These include the National Public HealthPartnership (NPHP) and the National Health PriorityAction Council (NHPAC), who report to the AustralianHealth Ministers Advisory Council (AHMAC) and to theAustralian Health Ministers Conference (AHMC).NHPAC was formed to oversee the administration of theseven National Health Priority Areas (NHPA). 1031. diabetes2. heart, stroke and vascular disease3. arthritis and musculoskeletal conditions4. asthma5. cancer6. mental health7. injury preventionIn conjunction with federal, state and territorygovernments, NHPAC is developing a National ChronicDisease Strategy (NCDS) to be presented to HealthMinisters in November 2005. The NCDS aims to providean overarching framework for all non-communicablechronic diseases and a national direction for improvingchronic disease prevention and care across Australia.As an umbrella strategy for non-communicable chronicdisease, the NCDS presents a coherent approach toimproving the prevention, detection and managementof chronic disease. In the strategy, 41 key directionsdetail areas for service improvements at all levels of thehealth system. At the same time, NCDS is not intendedto be prescriptive about how the key directions are tobe implemented, nor is it designed to provide detailedcoverage on every element of prevention and care.Complementing the NCDS is the development ofNational Service Improvement Frameworks (NSIFs) 11 forarthritis and osteoporosis, asthma, cancer, diabetes, andheart, stroke and vascular disease. The NSIFs identify‘critical intervention points’ along the continuum of carewhere opportunities exist to make significant healthgains. They aim to encourage the delivery of moreperson-centred, equitable, timely, effective, affordableand cohesive health care, and to drive health serviceimprovements to achieve better health outcomesfor all Australians with these diseases, especially fordisadvantaged groups. For example, they identify theneed to address inequality by reducing variations in carethat appear across different clinician and health services,between metropolitan, regional, rural and remote areas,and in the care provided to disadvantaged groups.The National Public Health Partnership is responsiblefor identifying and developing strategic and integratedresponses to public health priorities in Australia. Inrelation to chronic disease, the primary focus hasbeen the development of the national strategies EatWell Australia, 12 the National Aboriginal and TorresStrait Islander Nutrition Strategy and Action Plan(NATSINSAP), 12 and Be Active Australia 13 (which includesa strong focus on Aboriginal and Torres Strait Islander(ATSI) populations and high need groups). Thesestrategies set out agendas for nutrition and physicalactivity action at the national level. Together with theNational Tobacco Strategy 2004-2009, 14 the proposedNational Alcohol Strategy 2005-2009, 15 and the NationalObesity Taskforce’s Healthy Weight 2008, 16 they addressthe major behavioural risk factors and provide a detailedset of prevention strategies with a major focus on

whole populations. Recently a decision has been madeto establish a Chronic Disease and Injury PreventionCommittee which will work closely with NHPAC.State policy driversThe policy environment for the prevention andmanagement of chronic disease in South Australia isbeing driven by the current health reform agenda. Thisprocess commenced with the recommendations of theGenerational Health Review and is complemented bySouth Australia’s Strategic Plan (SASP), March 2004. 17The SASP articulates key objectives for this state overthe next decade and, in particular, Objectives 2 and 6provide specific targets for the health system.Objective 2: Improving wellbeingThe SA Strategic Plan sees as a major priority the furtherimprovement of quality of life and wellbeing for thecommunity and for individual citizens. The aim is for amuch healthier population, as indicated by the followingtargets:• Increase healthy life expectancy of SouthAustralians to lead the nation within 10 years.• Reduce the percentage of young cigarettesmokers by 10% within 10 years.• Reduce the percentage of South Australians whoare overweight or obese by 10% within 10 years.• Exceed the Australian average for participation insport and physical activity within 10 years. 17Objective 6: Expanding opportunityObjective 6 makes a strong commitment to investmentin the early years and recognises that education is afundamental component. Target T6.1 particularly aims toreduce the gap between outcomes for South Australia’sAboriginal population and outcomes for the rest of SouthAustralia’s population, particularly in relation to health,life expectancy, employment, school retention rates andimprisonment.Primary health care policyImproved prevention and management of chronicdisease in South Australia requires a strong primaryhealth care system, as outlined in the SA PrimaryHealth Care Policy. 18 A requirement of the policy is theestablishment of Primary Health Care Networks; theseare not about offering ‘new’ services but about doingbusiness ‘better’ by providing linkages and coordinationbetween primary health care providers to improve19, 20population health and wellbeing.As well as health sector roles in developing integratedhealth care responses, partnerships across governmentsectors, such as health, education, justice and housing,4are increasingly being used to create synergies andbetter outcomes for individuals and families.Chronic disease frameworkIn 2004, the South Australia Department of Healthdeveloped a chronic disease framework. Chronicdisease: prevention and management opportunitiesfor South Australia 4 was the first State chronic diseaseframework to propose systematic approaches to bothprevention and management of chronic disease.The natural history of preventable chronic diseasesshows causal links to some common risk factorsfor which control and intervention is possible; theseinclude smoking, poor nutrition, physical inactivityand the risky use of alcohol. Clustering preventablechronic diseases together with their common riskfactors offers opportunities for systematic approachesin the prevention, early intervention and improvedmanagement of chronic diseases. 3 Activity in theprimary health care system permits action across thelife and disease continuum – from prevention throughto management, and across the breadth of risk factorsand chronic conditions. It has been demonstrated thatprimary health care approaches can slow the growthrate of chronic diseases. 3Four strategies were proposed in Chronic disease:prevention and management opportunities for SouthAustralia: 4Overarching strategy1. Adopt a clustered approach to chronic diseaseprevention and management.Action strategies2. Increase system coordination and integration.3. Increase the availability of a system for selfmanagement.4. Increase primary health care capacity forprevention, early detection, early intervention, andchronic disease management.How does this work in practice?South Australia is now in the fortunate position of havingclear policy directions, at state and national levels, whichsupport the improved prevention and management ofchronic disease. Increasingly, regions are developingcomplementary strategies, and over the next few yearswe can expect to see increasing strategic action at alllevels.There are already examples of well-integratedapproaches, such as in the important area of increasingthe consumption of fruit and vegetables to prevent anumber of chronic conditions and to promote healthyeating. The development of the National Fruit andVegetable Coalition brings together public, private

and non-government sectors to undertake nationalactivities such as the development of a business casefor investment, public relations activities on the benefitsof increasing the consumption of fruit and vegetables,and national research. At the state level, the Coalition isimplementing a coordinated state campaign to promotefruit and vegetables, integrating fruit and vegetables intoschool guidelines, distributing resources, and providinga mechanism to share experience and expertise. In thearea of monitoring, comprehensive data is collectedwhich can also be made available at the regional levelto track progress. Complementing this campaign arelocal activities such as supporting markets or stores inremote areas to provide affordable fruit and vegetables,working with local schools and childcare services toprovide healthy food choices, and working with highneed groups such as young mothers to introduce fruitand vegetables appropriately to their babies.ConclusionIn order to prevent and better manage chronic diseasein South Australia, both primary prevention and ‘highrisk’ approaches are important and complementary. Apopulation approach aims to create the best physical,social and policy environments for supporting peopleto be healthy. This requires good treatment andmanagement services, easily accessible through theprimary health care system by those with establisheddiseases. Similarly, the need to treat individuals atrisk will never reduce unless it is complemented by aprimary prevention approach that recognises the broaddeterminants of health and ensures that impediments tomaking healthy choices are minimised.Social, behavioural and environmental healthdeterminants may be considered by some healthworkers as outside their realm of influence, or that ofthe health system. But to think in this way decreasesour chances of impacting on chronic disease and ouropportunities for advocacy and leadership for action.While health workers and health services on their owncannot solve poverty or unemployment, they are in anideal position, through their work with individuals andcommunities, to identify where health inequalities arecontributing to poor health outcomes.The challenge for the health system and for individualworkers is to find the right balance: working withindividuals at risk whilst increasing our efforts tomove the whole population to a lower level of risk.The national, state and regional policy contexts areincreasingly focussed on preventing and managingchronic disease. However, in order to support andembrace the changes that are foreshadowed in thisarticle, a re-orientation of health workforce skills,knowledge and understanding will be required. To betteralign the health system to the needs and priorities ofthe community as a whole, a positive view of thesechanges is required, such that a broader social view of5individual and population wellbeing becomes routine inhealthy system planning, as well as in individual healthencounters.References1. World Health Organization. Preamble to theconstitution. As adopted by the International HealthConference, New York, June 19-22, 1946. SignedJuly 22, 1946 by representatives of 61 States andentered into force on 7 April 1948.Geneva: WHO,1946/7/8.2. Author A. Title of article. N Engl J Med 2005;352(11): 1138.3. National Public Health Partnership. Preventingchronic disease: a strategic framework backgroundpaper. Melbourne: Department of Health andAgeing, 2001.4. South Australian Department of Human Services.Chronic disease: prevention and managementopportunities for South Australia. Adelaide:Department of Human Services, January 2004.5. South Australian Department of Human Services.Generational health review discussion paper:overview. Adelaide: Department of HumanServices, 2002.6. Organisation for Economic Co-operation andDevelopment (OECD). Health data in VicHealthLetter 2004. Accessed winter 2005 at www.vichealth.vic.gov.au.7. Draft National Chronic Disease Strategy, August 222005.8. National Public Health Partnership Group, AMandate for Action on Chronic Disease Prevention,Melbourne: National Public Health Partnership,November 2004.9. Centres for Disease Control and Prevention.Promising practices in chronic disease preventionand control: a public health framework for action.Atlanta: Department of Health and Human Services,2003.10. National Health Priority Area Initiative. AccessedOctober 2005 at http://www.aihw.gov.au/nhpa.11. National Health Priority Action Council. The nationalservice improvement framework for cancer.Adelaide: Department of Health and Ageing, July2004.12. The Strategic Inter-Governmental Nutrition Allianceof the National Public Health Partnership. Eat wellAustralia, 2001. Including the National Aboriginal andTorres Strait Islander Nutrition Strategy and ActionPlan. Accessed October 2005 at http://www.nphp.gov.au/workprog/signal/index.htm

13. National Public Health Partnership. Be activeAustralia: a framework for health sector action forphysical activity. Melbourne: NPHP, 2005. AccessedOctober 2005 at www.nphp.gov.au.14. Ministerial Council on Drug Strategy. Nationaltobacco strategy 2004-2009.The Strategy, 2004.Accessed October 2005 Date of access at http://www.nationaldrugstrategy.gov.au.15. Ministerial Council on Drug Strategy. 2005.Accessed October 2005 at http://www.alcohol.gov.au/strategy.htm.16. Healthy weight 2008 - Australia’s future: the nationalaction agenda for children and young people andtheir families. Report of the National Obesity TaskForce, Nov 2003. Accessed October 2005 at http://www.healthyactive.gov.au/docs/healthy_weight08.pdf17. South Australia’s strategic plan: creating opportunity.Volume 1. Adelaide: Government of South Australia,March 2004.18. Primary Health Care Branch, Department of HumanServices. Primary health care policy statement2003-2007. Adelaide: Government of SouthAustralia, 2003.19. Starfield B, Shi L. Policy relevant determinants ofhealth: an international perspective. Health Policy2002; 60 (3): 201-218.20. South Australian Department of Human Services.Better choices better health. Final report of theSouth Australian Generational Health Review.Adelaide: Government of South Australia, 2003.Chronic DiseaseSurveillance in SouthAustraliaAnne TaylorPopulation Research and Outcome Studies UnitSouth Australian Department of HealthIntroductionChronic diseases are the most prevalent, costly andpreventable of all health problems. 1 The contributionof chronic diseases in the total burden of diseaseshas risen considerably in recent decades to replacecommunicable diseases as the leading cause ofmorbidity and mortality in developed countries. 2 Theburden placed upon the individual, the health systemand the community is also expected to increase as thepopulation ages in future decades.Chronic diseases are defined as non-communicablediseases that have complex causes, multiple risk factors,a long latency period, and a long illness period whichultimately results in some limitation of daily living. 3 Thechronic diseases are generally regarded as cardiovasculardiseases (CVD), diabetes, chronic lung disease, arthritis,musculoskeletal diseases and cancer. Conditions, suchas incontinence, mental health conditions and dementiarelateddisorders, are often included in this definition.Many chronic diseases share common risk and protectivefactors. The risk factors include the modifiable aspectsassociated with smoking, diet, physical activity andalcohol consumption. These risk factors are modifiableon a population basis – either by changing personalbehaviours or by enforcing policy and legislative changes.While low levels of physical activity and high levels ofalcohol consumption are risk factors for ill-health, theconverse (ie higher levels of physical activity and lowerlevels of alcohol) are seen as protective factors. Otherbiomedical risk factors (such as hypertension and elevatedcholesterol) are also important risk factors for ill-health andare commonly related to more than one chronic disease(eg diabetes and CVD).Increasing emphasis is also being placed upon therelationship between chronic disease/conditions, risk andprotective factors, and the range of social inequalitiesthat occur across the life course. 4 In addition, endeavoursto replace the use of single focused or a ‘silos’ approachas a means to describe each disease is gradually beingreplaced by larger, more contextual and inclusive lifestyleapproaches. 1South Australia (SA) is served comprehensively by theSA Cancer Registry which oversees the collection andanalysis of all cases of invasive cancer diagnosed inSA. 5 The surveillance, monitoring and epidemiological6

assessment of the other non-communicable chronicdiseases, the associated risk and protective factors, andthe related social and inequality measures, is primarilyundertaken in SA, on a population-wide basis, by thePopulation Research and Outcome Studies (PROS) Unitin the Department of Health. This includes diabetes,asthma (and other respiratory conditions such as ChronicObstructive Pulmonary Disease (COPD)), arthritis andmusculoskeletal conditions, incontinence and aspectsassociated with mental health (eg psychological distressand depression). The risk factors covered by the Unitinclude body mass index (BMI), alcohol, smoking, physicalactivity, nutrition (food consumption and food insecurity),high blood pressure (HBP) and high cholesterol. Relevantindictors of socioeconomic inequality include householdincome, housing status, marital status, family structureand education level.The assessment of these diseases and associatedfactors is undertaken on a high level indicator basis– policy, planning and health service management isundertaken by the relevant non-government agenciesor other Department of Health specialised policy andplanning areas. The Unit undertakes descriptive analysisto explain and predict trends in chronic diseases andassociated factors, so as to inform population-wide earlydetection, preventive and service management efforts.Data collection for the surveillance and monitoring of nonregistrybased chronic diseases and associated factorsare commonly undertaken by the use of population-basedsurveys. This is because the conditions are managed inthe community (until complications necessitate moreinvasive treatment) and are not ‘counted’ by other existingsystems.MethodsFollowing are details on the methodology and resultsfrom two systems designed to collect data on chronicdisease and associated factors in SA.The South Australian Monitoring andSurveillance SystemThe South Australian Monitoring and SurveillanceSystem (SAMSS) 6 is a telephone monitoring systemdesigned to systematically monitor the trends of chronicdiseases, health related problems, associated factorsand other health services issues for all ages, over time,for the South Australian health system. SAMSS is ableto provide representative and timely estimates of keyindicators associated with chronic diseases and riskfactors for the state overall, and for each health region,by a range of social and demographic variables. Box 1highlights the methodology associated with SAMSS.North West Adelaide Health StudyTo monitor the change in individuals and to evaluatethe change along the disease continuum from nodisease to disease with complications and ultimate7Box 1The South Australian Monitoring and Surveillance System(SAMSS) methodology• 600+ randomly selected people (of all ages) areinterviewed each month.• Respondents aged less than 16 years have surrogateinterviews.• All households in SA with a telephone connected and thetelephone number listed in the Electronic White Pages(EWP) are eligible for selection in the sample.• A letter introducing the survey is sent to all selectedhouseholds.• The person with the most recent birthday is chosen forinterview. There is no replacement for non-respondents.• Up to ten call backs are made to the household tointerview the selected person.• A CATI (Computer Assisted Telephone Interviewing)system is utilised to conduct the interviews.• The data are weighted by area (metropolitan/rural), age,gender and probability of selection in the household tothe most recent SA population data so that the results arerepresentative of the SA population.death, the PROS Unit is involved with the North WestAdelaide Health Study (NWAHS). 7 NWAHS is providinginformation about chronic diseases, including diabetes,chronic lung disease, arthritis and musculoskeletalconditions, enabling more effective targeting andstrategic interventions to improve health outcomes. 8,9In addition, NWAHS is able to report clinical assessedestimates rather than self-reported estimates obtainedfrom the population surveillance systems. Box 2highlights the NWAHS methodology.Box 2North West Adelaide Health Study methodology• This was a biomedical cohort study of 4000+representative adults, randomly selected from Glenelg toGawler.• All households with a telephone connected and thetelephone number listed in the EWP were eligible forselection in the study.• The sample was stratified into the two health regions:western Adelaide and northern Adelaide.• A letter introducing the study and an informationbrochure were sent to the household of each selectedtelephone number.• Within each household, the person who had their birthdaylast, and was 18 years or older, was selected for interviewand invited to attend the clinic.• Appointments were made for participants in one of thetwo hospital-based clinics (The Queen Elizabeth Hospitaland Lyell McEwen Health Service). Participants weresent an information folder that included a questionnairewith questions on chronic disease, alcohol consumption,physical activity levels, quality of life and socio-economicdetails (including highest education level, marital status,work status, country of birth and household income level).• Age, sex, smoking status, height, weight, and whetherthey had ever been told they had high blood pressure orhigh cholesterol were asked in the recruitment telephoneinterview.• At the clinic a range of assessments were made includingtaking blood (to test fasting plasma glucose, lipids,HbA1c), skin prick tests to common allergens, bloodpressure, height and weight (to determine BMI), andspirometry lung function tests.

ResultsTable 1 highlights the prevalence of self reported chronicdiseases (from SAMSS) with estimates ranging from4.2% for self-reported doctor-diagnosed osteoporosisto 22.1% for arthritis. Table 1 also highlights theprevalence of diabetes, asthma and COPD whenclinical assessments were made in the NWAHS. Theprevalence of diabetes (determined from fasting bloodglucose levels) was 6.6% with an additional 13.8%of the participants having impaired fasting glucose(a pre-diabetes state). The prevalence of asthma (asdetermined by lung function tests) was 12.3% withnearly a quarter of people with asthma not previouslyhaving the condition diagnosed.Figure 1: Proportion of population with no risk factors by SEIFAIndex, aged 18 years and overTable 1. Prevalence of chronic disease/conditions in SouthAustralia, ages 18 years and overSEIFA 2001 Index of Relative Socio-Economic Disadvantage Quintiles(postcode level)Source: SAMSS (July 2002 to December 2004)obesity, current smoker, high long term alcohol riskand insufficient fruit and vegetable intake). Figure 1highlights the proportion of people with no risk factorsby Index of Relative Socio-Economic DisadvantageQuintile (SEIFA) and shows notable differences betweenhigh and low SEIFA categories.Table 2 highlights risk factor prevalence rates. Withinthe NWAHS cohort population, the measured ratesof obesity were significantly higher, as was theprevalence of hypertension and elevated cholesterol.Within the SAMSS data-base, 59.7% of adults in SA(18+ years) have at least one risk factor (assessed byself-reported HBP, high cholesterol, no physical activity,Table 2. Prevalence of risk factors in South Australia,ages 18 years and overDiscussionAvailability of the chronic disease information fromSAMSS and NWAHS is aimed at promoting evidencebaseddecision making, providing information about theimpact of chronic conditions on quality of life, identifyingappropriate points of intervention, and improving theplanning and delivery of services to improve the healthand wellbeing of people with, and at risk of, chronicdisease. While the risk factor epidemiology paradigm isseen to place decreased emphasis on other influencesof health, such as wealth distribution, work status andhousing ownership, and other economic and sociopoliticaldimensions of life, all need to be consideredso that prevention, early detection and managementprograms are implemented to limit the occurrence andprogression of chronic diseases in South Australia.8

References1 National Public Health Partnership. Preventingchronic disease: a strategic framework. Melbourne:NPHP, 2001.2 McQueen, DV. A world behaving badly: the globalchallenge for behavioral surveillance. Am J PublicHealth 1999; 89(9): 1312-4.3 World Health Organization. Global strategy forthe prevention and control of non-communicablediseases. Report by the Director-General. Geneva:WHO, 2000.4 Kuh D, Ben-Shlomo Y. A life course approach tochronic disease epidemiology. New York: OxfordUniversity Press, 1977.5 Clapton W. Cancer epidemiological surveillanceservices – The South Australian Cancer Registry.Public Health Bulletin SA 2004; 1: 13-15.6 The South Australian Monitoring and SurveillanceSystem (SAMSS) Brief Report. 2002–20.Department of Health, South Australia. http://www.dh.sa.gov.au/pehs/PROS/brief-reports-pros.html/brsamss02-20.pdf7 Population Research and Outcome Studies. NorthWest Adelaide Health Study. Brief report 2002-07. [accessed: May 2005] http://www.dh.sa.gov.au/pehs/PROS/brief-reports-pros.html/br-nwahsstudy02-07.pdf8 Grant JF, Chittleborough CR, Taylor AW, et al. TheNorth West Adelaide Health Study: methodologyand baseline segmentation of a cohort alonga chronic disease continuum. EpidemiologicPerspectives & Innovations. In press.9 Taylor A, Dal Grande E, Chittleborough C, et al. Keybiomedical findings, policy implications and researchrecommendations. Adelaide: SA Department ofHealth, 2002.The PreventionTerminologyMichele HerriotA/Director, Health Promotion Branch,South Australian Department of HealthThis paper draws heavily from a paper prepared byColin Sindall (Department of Health and Ageing) andJudy Stratton (formerly Department of Health andAgeing). 1My thanks to them.‘Primary prevention’, ‘population health’, ‘primaryhealth care’, ‘universal approaches’, ‘early intervention’– the terminology used at present in the health sectorfrequently causes confusion and misunderstanding.If we are to increase our efforts in the prevention ofdisease, especially chronic diseases as outlined inthe Department of Health Strategic Directions, 2 itwould be useful to have a common framework. Thispaper provides some definitions for a few of the morefrequently used terms.Stratton and Sindall 1 identify four different ways ofcategorising preventive measures:1. Stage in the natural history of a disease at whichthey are introduced.2. Determinants of a disease which are beingaddressed.3. Target groups to which they are applied.4. Setting or level of delivery of preventive measures.1. Stages of DiseaseFor chronic, non-communicable disease there is acontinuum from a disease-free state, to asymptomaticbiological change, to clinical illness, impairment anddisability, development of complications, and, formany conditions, ultimately death. This is illustrated inthe following diagram (Figure 1). At every point alongthe continuum there are opportunities for preventionof the disease itself, its progression, or associatedcomplications.Figure 1: The natural history of chronic disease9

Preventive interventions are frequently conceptualised interms of primary, secondary and tertiary prevention. 3Primary preventionPrimary prevention is defined as theprotection of health by measureswhich eliminate or reduce causes anddeterminants of departures from goodhealth and control exposure to risk.Primary prevention decreases the numberof new cases of a disorder or illness.Causes and determinants include social, environmentaland economic factors which contribute to disease orconversely are protective, for example, encouragingadequate housing, clean air, education and incomeas well as actions to promote and support healthybehaviours such as tobacco control legislation andaccess to and information about healthy food. Primaryprevention seeks to reduce or eliminate risk factors andencourage health-promoting factors, thus preventingdisease occurring in the first place.In this (stage of disease) context primary preventionis usually directed at the whole population but is alsorelevant to sub-groups, eg older people, and in one-tooneclinical settings, eg providing information on howto stay healthy, or supporting people to get involved incommunity activities.Secondary preventionSecondary prevention refers to themeasures available to individuals andpopulations for the early detection ofdepartures from good health and promptand effective intervention to correct them.Secondary prevention is therefore aimed at earlydetection of biological abnormalities (eg high bloodpressure or cholesterol) and their prompt treatmentand management (including medication and risk factormodification), to reduce morbidity and mortality.Cancer screening (eg breast, cervix and bowel) isalso a secondary prevention measure as it attemptsto detect cancers early. Secondary (and tertiary)prevention includes clinical, pharmacological and surgicaltreatments as well as the management of behaviouralrisk factors eg supporting those who have diabetes tobe active and eat a healthy diet.The terminology becomes more complicated in relationto cardiovascular disease where secondary preventionis used to describe interventions (such as reduction ofbehavioural risk factors) in people who have experienceda cardiovascular event (eg heart attack or stroke) and aretherefore at risk of another event. 4Using the more descriptive term early detection, ratherthan secondary prevention might help to overcomethese problems.Tertiary preventionTertiary prevention consists of themeasures available to reduce or eliminatelong-term impairments, disabilities andcomplications from established disease,and to minimise suffering caused byexisting departures from good health.Tertiary prevention seeks to minimise the impactof established disease and uses many of the samemethodologies as above. In practice, of course, the linesbetween different forms of prevention are somewhatblurred.2. Determinants of health and diseaseFigure 1 identifies a range of determinants of health andillness which include social and environmental factors,often called upstream determinants, as well as thosewhich relate to the individual, eg behaviour, psychosocialfactors such as resilience and self esteem (midstreamor host factors). This latter group of factors are stronglyinfluenced by the upstream determinants. For example,it is hard to make a decision to quit smoking if you areunemployed, homeless or feel you have little controlover your life; it is difficult to comply with medications ifthere is no fridge in which to keep antibiotics.Measures aimed at upstream determinants correspondbroadly to primary prevention measures in the earlierterminology. Policies directed at social, environmental,psychological and behavioural determinants benefitthose who are well as well as those with disease.Detection and management of the biological,psychological and behavioural risk factors or diseaseprecursors corresponds to secondary prevention, whilethe effective management of established disease(preventing complications and restoring health andfunction to the maximum extent possible) correspondsto tertiary prevention.3. Target groupsDiscussion about prevention often centres aroundidentifying appropriate target groups. Interventionsmight focus on the whole population (eg promotionof consumption of 2 fruit and 5 veg), at-risk groups orindividuals (eg smokers or Aboriginal and Torres StraitIslander community) or individuals with establisheddisease (eg people with diabetes or those who areobese). Prevention approaches apply to all target groups.Figure 2: Target groups for preventive activities 510

It should be noted that the mental health field uses theterms ‘universal’ (for the whole population), ‘selective’(for individuals and groups with higher risk) and‘indicated’ (for those with early signs and symptoms).See Promotion, Prevention and Early Intervention forMental Health – A Monograph. 6Universal and Targeted approachesA ‘whole of population’ or ‘universal’ approach aims todevelop interventions that are targeted to the entirepopulation without individual selection. The aim is toreduce the level of risk (risk factors) and to move theentire risk factor distribution to a lower level. This needsto be complemented by a high risk or targeted approachwhere individuals considered to be at high risk for aparticular disease will be identified and their conditionsaddressed.• The unique requirements of those populationgroups with special health needs are to be takeninto account when determining priorities for action.• Health services are considered in a whole ofgovernment context.• Communities are an integral part of achievinghealth objectives.• Enhancing health status requires intersectoralcollaboration and partnership.• Policy and program implementation should beevidence based.These themes complement those described above.Other commonly used frameworks are Health Promotionand Public Health. These will be further explored infuture editions of the Public Health Bulletin.4. Level of delivery of preventive measuresThe fourth category describes where preventivemeasures are delivered. Primary prevention tends tooccur at the level of the whole population or subgroups,eg school canteen policies or through public policyaround food regulations or safe alcohol use guidelines.Social and economic determinants are perhaps betteraddressed at the level of the population or particularsubgroups rather than with individuals, though effectivepractitioners recognise the context within which theirclient lives and works and the impact of this on theirprognosis. However, as identified above, clinical settingsin both primary health care services and acute careand aged care services also have a role in primaryprevention.Behavioural risk factors can be addressed at the wholeof population level, eg working with local governmentto create ‘walkable’ neighbourhoods; influencing stateplanning policy for open space measures; or supportingindividuals though, eg, nicotine replacement therapyprovision. Early detection or secondary preventionusually takes place through a clinical setting or throughwork with at-risk groups through primary health careservices or screening programs.Primary health care services play a vital role inpromoting health and preventing and managing illness.Population Health ApproachAlso common now is use of the term ‘population healthapproach’. The Department of Health is finalising aPopulation Health Policy which draws on the Canadianexperience and outlines the key elements as:• Population health strategy development andimplementation is based on the determinants ofhealth.ConclusionGiven the confusion around overlapping terminology,it may be helpful if clear descriptions are provided asto the focus of the relevant work. This should includewhether target clients do or do not have chronicconditions, and whether the interventions are primarilyfocussed on individuals, groups at risk, or the populationas a whole.References1. Stratton J, Sindall C. Perspectives on preventionterminology. Unpublished paper for the SNAP(Smoking, Nutrition, Alcohol and Physical activity)Implementation Group Meeting, Canberra: June 2,2003.2. South Australian Department of Health. Strategicdirections 2004-2006. Adelaide, 2004.3. Brownson R, Remington P, Davis J, eds. Chronicdisease epidemiology and control. 2 nd ed. WashingtonDC: American Public Health Association, 1998.4. Commonwealth Department of Health and AgedCare and Australian Institute of Health and Welfare.National health priority areas report: cardiovascularhealth 1998. AIHW Cat no PHE 9. Canberra: Healthand AIHW, 1999.5. National Heart Foundation of Australia. Futuredirections (2003-2007). Melbourne: National HeartFoundation, 2003.6. Commonwealth Department of Health and AgedCare. Promotion, prevention and early interventionfor mental health – a monograph. Canberra:Commonwealth Department of Health and AgedCare, 2000.11

The Impact of EarlyLife on the SubsequentDevelopment ofChronic DiseaseA/Prof Peter BaghurstPublic Health Research Unit,Women’s and Children’s HospitalChildren Youth and Women’s Health ServiceIf one were asked to nominate the major influenceson our thinking about the determinants of health overthe last quarter of the twentieth century, it would beimperative to include the growing understanding of(1) how strongly social factors can influence the riskof disease, either directly, or indirectly by encouragingspecific behaviour patterns; and (2) the importance ofthe early years in establishing health outcomes in laterlife.The aetiology of cardiovascular disease (CVD) is richwith examples of how both biological factors andsocially determined behaviours in the early years canlead to an undesirable health outcome in adult life.But our definition of ‘early life’ needs to encompasslife in utero, given the growing acceptance of Barker’sFetal Origins Theory of Adult Disease. 1 Using old parishbirth records in the UK, Barker observed that low birthweightbabies were at much greater risk of CVD in laterlife than heavier babies; this is a strong epidemiologicassociation which has been demonstrated in severaldifferent settings subsequently. Given that fetal undernutritioncan produce acute physiologic changes, suchas redistribution of blood flow to protect the brain, alowered metabolic rate to reduce the use of substrates,and a slowing of growth to reduce demand for thosesubstrates, Barker argued that such adaptations leavea permanent biological ‘memory’ of under-nutrition – aprocess increasingly referred to today as ‘programming’and now implicated, albeit controversially, in otherlong-term outcomes such as kidney disease andosteoporosis.Animal studies which demonstrate higher bloodpressure in the progeny of mothers fed proteinrestricteddiets also support the notion that maternalpre-pregnancy nutrition may influence programming.And, while these findings would appear to confirm theimportance of good maternal nutrition both prior toand during a pregnancy, the situation with respect topossible interventions which might ‘remedy’ low birthweightthrough postnatal ‘catch-up’ is controversial.In fact there is disturbing evidence that acceleratedpostnatal growth may be positively associatedwith blood pressure. Long-term studies and goodrecord linkage facilities are needed to resolve thesecontroversies.12In addition to the direct biologic determinants of CVDthere are, of course, a host of behavioural factorswhich are probably more important from a publichealth perspective. Obesity in children leads to obesityin adulthood, insulin resistance, heart disease, andpossibly cancer. It currently looms larger than anythingelse on the public health radar screen. The vast majorityof children who have a problem have simply got theirenergy intake and expenditure out of balance. We knowwhat’s required – more physical activity, and maybe alittle less to eat. But we know remarkably little abouthow to achieve these remedies. Issues such as thesafety of children on our busy roads, on bikes or justwalking the streets; the sedentary lifestyle encouragedby the instant gratification of all forms of electronicentertainment; and factors affecting food choices, areall important – but they are very difficult to control orinfluence.Smoking may still be the biggest risk factor for CVD– but the short-term fiscal consequences of controllingthis behaviour have frightened governments awayfrom the most obvious legislative means of reducingsmoking. While some might still try to argue thatthe decision to smoke is purely personal, there ismounting interest in the highly repeatable observationthat children and young people with emotional andbehavioural problems are more likely to resort torecreational drugs of all kinds than their less troubledpeers. Given the importance of the relationship betweenchildren and their carers in terms of their cognitive,linguistic, emotional, social and moral development, it isnow generally accepted that children who do not enjoyrelationships with their carers that are warm, nurturing,individualised, and responsive in a contingent andreciprocal manner, will be at risk of adopting behaviourswhich are directly damaging to health. Since the abilityof caregivers to attend to the individualised needsof young children is influenced by both their internalresources (eg emotional health, social competence,intelligence, educational achievement, personal familyhistory) and the external circumstances of their lives(eg family environment, social networks, employmentstatus, economic security), it is not difficult to see howthe choice of risky behaviours may be heavily influencedby the social context in which such choices are made.The public health importance of finding new and betterways to support children with developmental problemsthat are secondary to the influences of adversecaregiving environments characterised by poverty, familyviolence, and parental mental illness cannot be overemphasised.With around a quarter of all deaths resulting fromcancers, one might well ask whether there aremeasures we can take in the early years to preventcancer in adult life. Many cancers of the lung,oesophagus, nasopharynx, pancreas and bladder couldbe prevented by refraining from smoking, a contextsensitivebehaviour already discussed in the context

of CVD. Melanoma and other skin cancers caused byexposure to ultraviolet light are preventable throughsimple behavioural changes – some enforceable at earlyages – but peer pressure to acquire a particular bodyimageis a strong influence against the adoption of sunsmartpractices.Over the past 25 years we have seen estimates of therisk of cancers attributable to dietary habits steadilywhittled away by epidemiologic research. Despitethe identification of a host of plausible mechanismsby which various foods and food components mightpossibly influence carcinogenesis, evidence for thepublic health relevance of these mechanisms remainsunconvincing. Getting the energy balance right appearsto be our best hope at the moment, with obesity andlack of physical activity being consistently cited as riskfactors for several common cancers. Finding enjoyableways for our children to be active now – and to want tostay active in later life – must surely deserve its statusas a high public health priority.The danger in emphasising too heavily the role of theearly childhood years on adult outcomes is that onecreates an image of a health trajectory too closelyakin to the trajectory of a rocket. Nothing can alter itscourse after the motor is extinguished following a brieffiring at the launch. This would, of course be extremelydisheartening to those trying to improve the lives ofadolescents and adults. Perhaps the analogy is not sopoor, however, if we allow our rocket to be fitted withsmall course-adjusting ‘retro’-rockets.References1. Barker DJP (ed) Mothers, babies, and disease inlater life. London: BMJ Publishing Group, 1994.Further readingCommittee on Integrating the Science of EarlyChildhood Development, Board on Children, Youth, andFamilies. From neurons to neighborhoods: the scienceof early childhood development. Shonkoff JP, Phillips DA,eds.Washington D.C.: National Academies Press, 2000.Khan IY, Lakasing L, Posto L, Nicolaides KH. Fetalprogramming for adult disease: where next? J MaternFetal Neonatal Med 2003; 13: 292-9.Cooper C, Javaid MK, Taylor P, Walker-Bone K, DennisonE, Arden N. The fetal origins of osteoporotic fracture.Calcif Tissue Int 2002; 70: 391-4.When you can’tBreathe … NothingElse Matters*RE RuffinD WilsonS AppletonOn Behalf of the North West Adelaide Health (Cohort)Study Team.(Department of Medicine & Health Observatory,University of Adelaide, Queen Elizabeth and LyellMcEwin Hospital campuses)*Australian Lung Foundation – Trade MarkBackgroundChronic Obstructive Pulmonary Disease (COPD) is aslowly progressive disease of the airways, characterisedby gradual loss of lung function. It includes emphysemachronic bronchitis and chronic obstructive bronchitisand is one of the most common respiratory conditionsof adults. The exact prevalence of COPD is difficultto establish because of the problem of definition anddiagnosis. Sometimes it is difficult to differentiatebetween COPD and chronic asthma, and in older ageit may be difficult to differentiate from other problemsof ageing. A working definition may be given as a‘disease state characterised by the presence of airflowlimitation due to chronic bronchitis or emphysema;the airflow obstruction is generally progressive, maybe accompanied by airway hyperactivity, and may bepartially reversible’. 1 The physiological definition is aFEV 1/FVC ratio (forced expiratory volume to forcedvital capacity) equal to or greater than two standarddefinitions from the predicted.COPD poses a considerable and increasing future threatto the health care system and to society in terms ofdirect costs of health care services and indirect coststhrough loss of productive life. Worldwide, it is expectedto become the fifth leading cause of disability adjustedlife years (DALYs) by 2020. 2 In Australia it is currentlythe third leading cause of disease burden and thesixth leading cause of disability. 3 COPD also leads to asignificant deterioration in quality of life, especially asthe disease progresses. Smoking is the dominant riskfactor for development and progression of the disease.A recent South Australian study has identified the riskof COPD attributable to smoking alone to be 40% forcurrent smokers and 78% for current smokers and exsmokerstogether. 4This paper argues that a great deal can be done toimprove COPD morbidity and mortality by means of anintegrated public health campaign comprising primaryand secondary prevention components. Emphasis isplaced on the importance of three initiatives:13

• establishing a public health agenda for COPD whichdeals with the primary risk factor of smoking.• improving early detection of COPD in general practice.• developing resources for smoking cessation in generalpractice for both the general practitioner and thepatient.The North West Adelaide Health (Cohort) Study(NWAHS)The NWAHS is a representative population study inwhich biographical and biomedical information onCOPD has been obtained from an ongoing populationsurveillance program of chronic disease and associatedrisk factors. Methods employed in the study havebeen documented previously. 4 The data presented inthis paper were obtained from the baseline study of asample population n=4010 who completed spirometryand answered questionnaires. Biographical data wereobtained by interview and from the self-completionquestionnaires. Airway obstruction was measuredusing spirometry, conducted according to AmericanThoracic Society (ATS) 5 criteria. Each subject performedat least three reproducible forced vital capacity (FVC)manoeuvres. Obstruction was determined using forcedexpiratory volume (FEV 1) in one second (ie the amountthat can be forcefully exhaled in the first second from afull inspiration), expressed as a percentage of the forcedvital capacity (FVC), that is, the volume change betweena full expiration and residual volume after expiration.People who demonstrated post bronchodilator airwayobstruction according to the criteria of Quanjer, (FEV 1/FVC equal to or less than two standard deviations belowthat predicted for age and gender) were classifiedas having COPD. 6 All identified cases were furtherclassified according to severity, based on FEV 1asa percent of predicted volume for an individual of aspecific age and gender, as specified by ATS criteria.COPD prevalence (%)Figure 1. Age- and gender-specific prevalence of COPDResultsThe NWAHS study showed that 3.5% of the populationhave COPD (Figure 1) but this reaches 11% in malesaged 60+ years of age. Of the total number with COPD,85.6% were previously undiagnosed. Table 2 showsthat, while more than half of the undiagnosed group hadmild COPD, 10% had severe disease, which is causefor concern. The prevalence of smoking in the NWAHSpopulation without COPD was 16.6%, compared to30.4% in the COPD sub-population aged 40 years orolder (Table 3). However, smoking prevalence is higherthan this in some COPD groups and declines withincreasing severity of disease. The greater the severityof disease the more likely people are to have alreadyquit smoking (Table 2).Table 2: Severity of COPD overall and according to diagnostic status*Table 1: Age specific COPD prevalence according to diagnosticstatus** Based on % predicted post- bronchodilator FEV 11Airway obstruction demonstrated in the clinic and self-reporteddoctor confirmed emphysema2Airway obstruction demonstrated in the clinic in the absence ofself-reported doctor confirmed emphysemaTable 3: Age specific smoking prevalence in COPD* Based on % predicted post- bronchodilator FEV 11Airway obstruction demonstrated in the clinic and self-reporteddoctor confirmed emphysema2Airway obstruction demonstrated in the clinic in the absence ofself-reported doctor confirmed emphysema14

In logistic regression analyses the variables that bestjointly described those people with COPD were malegender, older age, low income and lower educationlevel.DiscussionThe increasing burden and impact of COPD can bemodified if a comprehensive public health plan isdeveloped to address key aspects of the problem.In terms of primary prevention, the major initiativemust be directed to smoking prevention programs,given that up to 50% of all smokers are likely to beaffected. 7 At present, COPD detection rates may beunderestimating this figure by almost 90%. 7 To dateno major public health promotion agenda dedicated toCOPD has addressed the COPD/smoking relationship,or its consequences and preventability, with the SouthAustralian public. Establishing this agenda is a necessarystarting point for progress. It will be necessary, giventhe benefits of earliest possible cessation, to targetsmokers at an age when they are prepared to listen tothe COPD message. This will mean further qualitativeresearch for the development of communications. Thedevelopment of COPD smoking cessation programsmust be distinguished from generalised smokingcessation programs. COPD specific programs need tobe targeted more specifically, especially towards malesmokers living on lower income and of lower educationlevels with whom the largest smoking problem exists.The Quit Line and community based cessation programshave a role to play with this target group and as part ofthe overall public health plan.Primary care has a major role to play in reducing theburden of COPD through earliest possible detectionand intervention. This is essential, given the largeundiagnosed group with COPD. It should, however, bepointed out that the general practitioner’s task in relationto COPD is not simple, and COPD can be difficult todiagnose, especially in the older person where it is mostcommon. Before a general practitioner can diagnose apatient with asthma or COPD they must first have thesymptoms presented to them. An important factor inunder-diagnosis is that many patients do not presenttheir symptoms to a doctor: this is a feature of all chronicdiseases, including COPD. This issue underscores theimportance of appropriately establishing a COPD agendawith the South Australian population, as mentioned,and of promoting the need for, and advantages of,early presentation of respiratory symptoms. 8 Another,complementary, approach to the problem of identifyingCOPD cases would be the use of smoking history totrigger measurement of lung function.There is also a great deal that can be done to improvethe likelihood of early COPD diagnosis and interventionin primary care. The general practitioner is well placedto make a difference, given a planned public healthapproach. A number of international guidelines havebeen developed for COPD, which agree on the role of15spirometry in its diagnosis. Establishing lung functionmeasures is essential to the diagnosis of COPD, butthe use of spirometry in general practice is limitedand of variable quality. This leaves us with two choicesfor improvement: either we need to improve generalpractitioner or in-practice nursing skills in relation tospirometry, or we need to provide enough specialistspirometry services to which general practitionerscan refer. As lung function is basic information for thediagnosis and management of COPD, improvementin the practice and quality of spirometry is essential.Spirometry is to dyspnoea as the electrocardiogram is tochest pain. 9 Improving the situation in general practiceis an infrastructure and training problem that requiresfunding.International COPD guidelines also agree on theimportance of smoking cessation. However, generalpractitioners need to be supported in the effectiveimplementation of smoking cessation initiatives.We know that simple advice from a doctor givingthe reasons for quitting can be effective with somepatients. 10 The Lung Health Study 11 showed that doctorswho are adequately prepared and supported canachieve high smoking cessation rates, and these canbe sustained over the long term, resulting in significantbenefits. This was an aggressive smoking cessationprogram in which the doctor played a pivotal role,strongly recommending cessation and then referringparticipants to groups guided by a health educator.Given the Australian burden of disease study mentionedearlier 3 showed that smoking is the number one riskfactor contributing to disease outcomes in Australia, anaggressive approach to smoking is warranted as partof well planned public health program within which thegeneral practitioner can focus on patient specific issuesand communication.The Lung Health Study also showed that smokers withCOPD were more likely to be male, of lower educationalstatus and on lower incomes. 11 Their circumstances maymean that access to nicotine replacement therapy isfinancially out of reach. In such cases it is necessary toconsider the addition of nicotine replacement therapyto the Pharmaceutical Benefits Scheme, as removingbarriers to smoking cessation must be a part ofpreventive COPD policy.Increased detection of COPD cases will also lead toother preventive benefits. Earlier detection of COPDwill produce milder cases where, as already shown,there is a higher concentration of smokers who willbenefit from intervention. It will also lead to earlierdevelopment of management plans and improvedmanagement of COPD exacerbation, annual influenzaand periodic pneumococcal vaccinations. All of theseimportant additional management initiatives will improvequality of life for those with COPD and, theoretically,reduce the prevalence of late diagnosis when treatmentand management of the disease have become morecomplex and requires increased use of health resources.

References1. American Thoracic Society. Standards for the diagnosisand care of patients with chronic obstructivepulmonary diseases. Am J Respir Crit Care Med1995; 152: S77-S121.2. Lopez AD, Murray CC. The global burden of disease.1990-2020. Nat Med 1998; 4: 1241-43.3. Mathers CD, Vos ET, Stevenson CE, et al. The burdenof disease and injury in Australia. Bull WHO 2001; 79:1076-84.4. Wilson D, Adams RJ, Appleton S, Ruffin RE.Difficulties identifying and targeting COPD andpopulation attributable risk of smoking for COPD.Chest. In press. Accepted July 2005.5. American Thoracic Society. Standardisation ofspirometry: 1987 update. Am Rev Respir Dis 1987;136: 1285-98.6. Quanjer P. Lung volumes and forced ventilatory flows.Eur Respir J 1993; 6(SIR): 5-40.7. Lundback B, Lindberg A, Lindstrom, et al. Not 15 but50% of smokers develop COPD? – Report fromthe Obstructive Lung Disease in Northern SwedenStudies. Respir Med 2003; 97(2): 115-22.8. van Weel C. Underdiagnosis of asthma and COPD:is the general practitioner to blame? Monaldi ArchChest Dis 2002; 57: 65.9. Petty Tl. Benefits and barriers to the widespread useof spirometry. Curr Opin Pulm Med 2005; 11: 115-20.10. Wilson DH, Wakefield MA, Steven ID, et al. ‘Sick ofSmoking’: evaluation of a targeted minimal smokingcessation intervention in general practice. Med JAust 1990; 152: 518-21.11. Anthonisen NR, Connett JE, Kiley JP, et al. Effectsof smoking intervention and the use of an inhaledanticholinergic bronchdilator on the rate of decline ofFEV1: the Lung Health Study. JAMA 1994; 272: 1497-1505.16Focussing on New Ideasfor Dying HabitsDella RowleyManager, Tobacco Control UnitDrug and Alcohol Services South AustraliaThe article When you can’t breathe … nothing elsematters, by authors Ruffin, Wilson and Appleton(see page 13 in this issue) concludes that smokingis the number one risk factor contributing to ChronicObstructive Pulmonary Disease (COPD) in Australia.Smokers with COPD are more likely to be males oflower educational status and on lower incomes. Theauthors consider that an ‘aggressive approach tosmoking cessation is warranted’.The British Lung Foundation’s recent survey of 1,200women 1 revealed that only 1% of women said thatCOPD was their main worry. Yet rates of the disease aresoaring and it may soon be the fourth biggest killer ofwomen. Male rates of COPD have reached a plateau,but there appears to be little understanding of how thedisease can be prevented and managed effectively. Thesurvey’s authors concluded that a measurable increasein awareness about COPD is needed, along withincreased diagnosis and a reduction in the prevalence ofsmoking in affected people.Since the 1970s there have been large-scale publicawareness anti-smoking campaigns in Australia. Despitea general awareness that tobacco kills 19,000 2 people inAustralia each year, and millions worldwide, it appearsthat some population groups are still not aware thatCOPD is one of the major consequences of smoking.Currently playing on South Australian television andradio, the advertising campaign Bubblewrap 3 linksemphysema and smoking and is the first public healthcampaign in South Australia to make the link betweensmoking and COPD. Early evaluation of this campaignshowed that those with lower levels of education wereaffected by the campaign; it made them feel concernedabout their smoking. 4However, public health campaign approaches totobacco control are not sufficient to make significantprogress with the most disadvantaged, high prevalencegroups. 5 There is a well documented relationshipbetween smoking and socio-economic status. Smokingprevalence is highest among males of 30-44 years, andhigher still among unemployed people, those who leftschool at the age of 15, and those who have gained nofurther qualifications or have a trade qualification. 6We cannot continue to ignore smoking rates of over50% in these priority populations. New and innovativestrategies are needed while maintaining the currentpopulation-wide approach. South Australia’s Tobacco

Control Strategy 2005-2010 7 is concentrating effort onthree priority groups: Aboriginal people, those with amental illness and young people. The prevalence ofsmoking in each of these population groups is far higherthan that of the general population and they make up alarge proportion of the remaining group of smokers.Working closely with all three groups in a collaborativeway is essential, and this means the concerted effortof many health professionals supporting each other’swork. We know that the desire to make a ‘quit’ attemptis very similar across all socio-economic status groups,but people who live in lower socio-economic statusareas have less confidence about quitting. 6 This lack ofconfidence relates to the degree of addiction as well asto the length of time a person has smoked, how manycigarettes they smoke, and also to the environment andthe influence of other people with whom they live, workand socialise. 6Increasing the capacity of doctors and other healthworkers to give ‘quit’ advice, especially in disadvantagedcommunities, is an important component of tobaccocontrol. It is true that inattention, or pessimism,has prevented health workers from persisting withhigh prevalence smoking groups. There have beenmany rationalisations for not working on smokingcessation programs with these priority groups. It isunderstandable, though not a sustainable argument, toconcede that the pressures of other more critical issuessuch as petrol sniffing deaths, or severe mental illness,tend to discount the consequences of smoking in suchgroups.We are beginning to see some success withinnovative projects around the state, working withpeople with a mental illness and working in areasof multiple disadvantage. Interventions by cliniciansand counsellors, and the use of pharmacotherapy,significantly increase the likelihood of smokers quitting,and efforts are needed to increase the use of thesestrategies in disadvantaged communities. 8 Broadercommunity approaches are also needed, and theseprojects must involve the community in the design andimplementation of interventions. They need to supportpositive identity formation rather than just focussing onnot smoking, and preferably they should be entertaining,supportive and interactive. 9People who still remain smokers, in the face of thestrong evidence of health risks, are going to need arange of services that address their life circumstanceswhile providing the extra encouragement to give uptheir habit. Pressure on its own is not enough incentive.Legislation to make all work places, including hotelsand clubs, smoke-free by November 2007 will break thesocial nexus between smoking and alcohol and gamblingand remove one very powerful arena for inducingyoung people to initiate smoking. With these combinedstrategies we hope to further reduce smoking-relateddeaths and ensure that smoking really is a dying habit.References1. British Lung Foundation. Femme fatality: the riseand rise of COPD in women. London, British lungFoundation, August 20052. Ridolfo B, Stevenson C. The quantification of drugcausedmortality and morbidity in Australia, 1998.AIHW cat. no. PHE 29. Canberra: AIHW (DrugStatistics series no.7), 2001.3. History of quit commercials. The Bubblewrapemphysema ad is listed under 2005 televisionadvertisements. Accessed on 12th September 2005at www.quit.org.au and follow the links to ‘aboutquit’.4. Durkin S, Wakefield M. Responses to the‘Bubblewrap emphysema’ campaign. CBRCResearch paper series no. 15. Melbourne: Centre forBehavioural Research in Cancer, The Cancer CouncilVictoria, July 2005.5. Woodward A, Kawachi I. Tobacco control in Australia.Tob Control 2003; Vol 12: Supplement 11, ii1.6. Hickling J, Quinn S, Miller C, Kriven S. Smokingand social inequalities in South Australia. Adelaide,Tobacco Control Research & Evaluation, April 2004.7. South Australian Department of Health, Draft SouthAustralian Tobacco Control Strategy 2005-2010,October 2005.8. Schroeder S. What to do with a patient who smokes.JAMA July 2005; 294(4): 482-4879. Remafedi G, Carol H. Preventing tobacco use amonglesbian, gay, bisexual, and transgender youths.Nicotine and Tobacco Research; April 2005,7(2): 249-256.17

The Go for 2&5 ®Campaign- example of a Public HealthNutrition Early InterventionStrategyChristina PollardNational Public Health Partnership Fruit & VegetableProject OfficerDepartment of Health in Western Australia.BackgroundIt has been suggested that eating more fruit andvegetables may be the single most important dietarychange needed to reduce the risk of major chronicdiseases. 1Increasing fruit and vegetable consumption is a globalnutrition priority. The ‘Global Strategy on Diet, PhysicalActivity and Health’, endorsed by the World HealthAssembly, encourages countries ‘to take steps toincrease the consumption of fruit and vegetables’ andemphasises that governments play a primary steeringand stewardship role in strategy development, ensuringimplementation, and monitoring long-term impact. 2In Australia, the National Public Health Partnership(NPHP) is responsible for identifying and developingstrategic and integrated responses to public healthpriorities. 3 In 2004, the NPHP supported its nutritionadvisory sub-committee Strategic Inter-governmentalNutrition Alliance (SIGNAL) to form a nationallycoordinated approach to increasing fruit and vegetableconsumption.A year later, in May 2005, the national Go for 2&5 ®campaign was launched, with its goal over five yearsto increase fruit and vegetable consumption by at leastone serve per day. The success of the Go for 2&5 ®campaign, which was developed by the Departmentof Health in Western Australia, has led to it becomingAustralia’s national fruit and vegetable campaign. It isnow an Australian state and territory government healthinitiative, supported by industry and other organisationswith an interest in promoting good health.Why promote fruit and vegetables?The main reasons why health authorities promoteincreasing fruit and vegetable consumption include thefollowing:• There is growing evidence of the health protectiveeffects of an adequate dietary intake of fruit andvegetables.• Intakes of fruit and vegetables are significantly belowrecommended levels, and this is true for most age andgender groups.• Most people think their intake is adequate despite itbeing low (particularly for vegetables).18• Many people are not aware of the recommendedintakes of fruit and vegetables (particularly vegetables).• There is a lack of media promotion of fruit andvegetables to compete with heavily promotedunhealthy foods.Health benefits of increasing fruit and vegetable intakeEating adequate amounts of fruit and vegetables mayhelp in the prevention and management of conditionsincluding: cardiovascular disease; stroke; hypertension;some cancers (including cancer of the mouth, pharynx,oesophagus, stomach, colon, rectum, lung and possiblycancer of the breast, ovaries, cervix, endometrium,thyroid, liver, prostate and kidney); some vitamindeficiency diseases (including Vitamin A deficiency,Vitamin C deficiency and scurvy, Folic acid deficiencyand megaloblastic anaemia); and some bowel disorders(including constipation, Crohn’s disease, diverticulardisease); obesity; diabetes and hypercholesterolemia. 4,5How fruit and vegetables help to protect us fromdiseaseFruit and vegetables contain a wide range ofmicronutrients, antioxidants and phytochemicals, withno single nutrient providing all the protection againstpreventable chronic diseases. The recommendation isto eat a wide variety of fruit and vegetables, to promotegrowth and development and to protect against chronicdiseases.Additionally, fruit and vegetables are low in fat andenergy. Eating more of them leaves less room for lessnutritious foods and may contribute to lower risks ofobesity, hypertension, diabetes, circulatory diseases andsome cancers.Fruit and vegetable recommendations - how much ofwhich types should we eat?The total amount of fruit and vegetables recommendeddepends on age, appetite and activity levels, and isincreased with pregnancy and breast-feeding. Childrenare encouraged to Go for 2&5 ® : however, the amountof food that children need for healthy growth anddevelopment depends on age, activity and body size(see Table 1).VegetablesIt is recommended that adults and adolescents eat atleast five serves of vegetables (including legumes) perday. One serve of vegetables is about 75 grams: aroundhalf a cup of cooked vegetables (including legumes),one cup of salad vegetables or one medium potato.A wide variety of vegetables should be eaten everyday, particularly the dark-green, orange/yellow andcruciferous varieties. This should include some raw andcooked vegetables.

FruitIt is recommended that adults and adolescents eat atleast two average-sized pieces of fruit per day. A widevariety of fruits should be eaten each week, particularlyorange or yellow varieties, which are high in vitaminsA and/or C. One serve of fruit is about 150 grams: oneaverage-sized piece of fruit, two smaller pieces (egapricots) or one cup of chopped or canned fruit.Table 1: Recommended daily intake of fruit and vegetablesSource: The Australian Guide to Healthy Eating 6Current fruit and vegetable intakeThe 1995 National Nutrition Survey 7 provides validand reliable food intake data; however, many peopleoverestimate their fruit and vegetable intake during suchsurveys, which suggests that consumption levels areactually lower than those reported. The results showthat most Australians are consuming well below therecommended intakes of fruit and vegetables, in manycases half of what is recommended.Background to the Go for 2&5 ® campaignDeveloped by the Western Australia Department ofHealth, the Go for 2&5 ® campaign is a social marketingcampaign aiming to increase awareness of the needto eat more fruit and vegetables and to encourageincreased consumption. Since its launch in 2002, adultsin WA have been eating more fruit and vegetables.Prior to the campaign, most WA adults were aware ofthe benefits of fruit and vegetables, agreeing that ‘theyare healthy’, as a positive aspect of including fruit andvegetables in their diet. Even so, while more adults feltthey should eat more fruit, only half thought they shouldeat more vegetables.The strategyThe West Australian Go for 2&5 ® campaign has taken an‘encouragement’ approach. Initially, the single-mindedadvertising proposition was ‘It’s easy to get an extraserve of vegies into your day’. This was followed by themore specific ‘How many serves of vegies are you reallyeating today?’.The Go for 2&5 ® campaign included paid advertising(television, radio, print), public relations, a website(www.gofor2and5.com.au), publications, sports and artsevents, sponsorships and point-of-sale promotions. The30-second television commercials featured animatedfruit and vegetable characters informing viewers thattheir vegetable intake was low, encouraging them to‘fit a few more vegies in your day’, and promoting acookbook with healthy fruit and vegetable recipes.Although schoolchildren were not the primary targetgroup for the campaign, they do take informationhome to their parents. The annual Schools Fruit‘n’VegWeek provides an opportunity for the whole schoolcommunity to focus on the health aspects of eatingfruit and vegetables. Their website is at: http://www.fruitnvegweek.health.wa.gov.au/home/index.aspCampaign ResultsPrior to the campaign, most adults knew that fruit andvegetables are good for them, however the barriers toincreasing consumption were reported as already eatingenough and that they are difficult to prepare. In 2004,a tracking telephone survey 8 (n=780) showed higherawareness (66% spontaneous, 87% prompted) andmore people thought they should eat more vegetables(34% in 2002 increased to 43% in 2004).As shown in the accompanying graphs, in WA as aresult of the Go for 2&5 ® campaign, there have beensignificant improvements in attitudes, knowledge andbeliefs towards fruit and vegetable consumption (Figure1) and self-reported intake (Figure 2).Figure 1: Attitudes, knowledge and beliefs towards consumptionThe campaign targets the meal preparer and shopperin the household, the person who has the greatestinfluence on the family diet. Its objectives are to:• Encourage awareness of the need to eat more fruitand vegetables, particularly vegetables.• Improve perceptions of the ease of preparing andeating vegetables.• Increase awareness of the recommended number ofserves of fruit and vegetables.The campaign uses a comprehensive range ofstrategies, including mass media advertising (television,radio and press), as the overarching focus for publicrelations activities, publications, point-of-sale activities,website, school-based activities, liaison with foodindustry groups, and community activities.19Source: Nutrition and Physical Activity Branch, NutritionMonitoring Survey 1995, 1998, 2001, 2004, consumption trends,Western Australian Department of Health, unpublished report.

Figure 2: Consumption trendsFigure 4: SIGNAL logoReferences:Source: Nutrition and Physical Activity Branch, NutritionMonitoring Survey 1995, 1998, 2001, 2004, consumption trends,Western Australian Department of Health, unpublished report.Similarly, there has been an overall average dailyincrease of 0.8 serves of fruit and vegetables acrossthe adult population since the commencement of thecampaign (Figure 3). Fruit consumption has increasedfrom 1.6 serves to 2.1 serves per day and vegetableconsumption from 2.6 serves to 2.9 serves per day.Figure 3: WA Adult fruit and vegetableconsumption (mean)1. World Health Organization. Global strategy on diet,physical activity and health. 2004. Accessed August2005 at http://www.who.int/dietphysicalactivity/en/2. National Public Health Partnership. An interventionportfolio to promote fruit and vegetable consumption.Part 1: The process and the portfolio. 2001. AccessedAugust 2005 at http://www.dhs.vic.gov.au/nphp/publications/signal/intfv1.pdf3. National Public Health Partnership. Strategicintergovernmental nutrition alliance. 2003. AccessedAugust 2005 at http://hna.ffh.vic.gov.au/nphp/workprog/signal/index.htm4. National Health & Medical Research Council. Foodfor health: dietary guidelines for Australian adults – aguide to healthy eating. 2003. Accessed August 2005at http://www7.health.gov.au/nhmrc/publications/synopses/dietsyn.htm5. National Health & Medical Research Council.Food for health: dietary guidelines for children andadolescents in Australia – a guide to healthy eating.2003. Accessed August 2005 at http://www7.health.gov.au/nhmrc/publications/synopses/dietsyn.htm6. Commonwealth of Australia. The Australian guide tohealthy eating. Canberra: Australia, 1998.Source: Health Information Centre, Western Australian Departmentof Health, Health and Wellbeing Surveillance System, December2003, Western Australian Department of Health, unpublishedreport.ConclusionThe national Go for 2&5 ® campaign was launched inSouth Australia in 2005, with the goal over five years toincrease fruit and vegetable consumption by one serveper day.7. Australian Bureau of Statistics. National nutritionsurvey: selected highlights, Australia 1995. Canberra:Australian Bureau of Statistics and Department ofHealth and Family Services, 1997.8. Nutrition and Physical Activity Branch, HealthDepartment of Western Australia, Go for 2&5 ®campaign Tracking Survey 2004, unpublished report.Western Australia’s Go for 2&5 ® campaign hasdemonstrated much success, of increasing fruit andvegetable consumption by almost one serve in threeyears, which has led to other Australian states andterritories taking part in the national campaign.Increasing fruit and vegetable consumption is a nationalnutrition priority where all states and territories areworking together to follow the successful exampleshown by Western Australia.20

Diabetes Mellitus – theLife-style DiseaseDr Mitra GuhaDirector, Post-graduate Education& Clinical Associate Dean,Royal Adelaide HospitalOf all diseases prevalent worldwide, diabetes mellitusbears a peculiar association with increasing affluence.It is almost as if diabetes and its partner-in-crime,cardiovascular disease, are the just penalties forimproving a nation’s socio-economic status! Why isthis so? In simple (and perhaps simplistic) terms,improvement in socio-economic status goes hand inhand with increased access to high fat and refinedcarbohydrate diets, and with a sedentary lifestyle.Affluence means motorised transport, supermarkets andfast food chains rather than walking and a subsistencediet. It is estimated 1 that approximately 60% of theAustralian population can currently be classified aseither obese or overweight, and this represents an18% increase in the prevalence of obesity since 1980.With obesity comes insulin resistance, one of thetwin defects leading to diabetes (the other is a relativedeficiency in insulin production). It is therefore notsurprising that by the year 2010 there are likely to beapproximately 1 million people with Type 2 diabetes inAustralia, one of the highest prevalence rates for thisdisease in the developed world. 1 Basically, this meansthat one cannot have one’s cake and eat it too! (At least,not without putting some effort into working it off!)While no one would wish to turn the clock back to ahunter-gatherer lifestyle, the affluent world needs totake a serious look at its comfortable and overindulgentexistence in order to avoid the penalties that accrue.A number of studies have clearly demonstrated thatmodification to lifestyle can significantly alter the onsetof diabetes mellitus. The Finnish Diabetes PreventionStudy 2 demonstrated that, in a group of people at highrisk for diabetes, the risk could be reduced by as muchas 58% through altering dietary intake and increasingthe level of physical activity. The Nurses Health study 3from the United States showed a much lower rate ofonset of diabetes mellitus in the group of women theystratified as low risk, based on body mass index, dietaryhabits and level of physical activity. While individualchoice and responsibility towards maintaining a healthylifestyle remain the cornerstone in reducing individualrisk of developing this chronic disease, governmentand health policy initiatives are essential in reducingcommunity risk.The AusDiab survey 1 of the prevalence of diabetes inAustralia estimates that for every person with knownType 2 diabetes there is another who has yet to bediagnosed. Type 2 diabetes is an insidious disease,21often with very vague symptoms which may not beimmediately recognised by patients or their doctors. Itis not uncommon for the first presentation of diabetesto be with one of its chronic complications. Studiesestimate that around 5% of patients admitted tocoronary care units with acute myocardial infarction willbe diagnosed for the first time with diabetes, suggestingthat they may have already had the condition for anumber of years without realising it. 4 More dramatically,patients have been known to present with sudden onsetof blindness which on investigation revealed diabeticretinopathy as the cause; yet they had not known theyhad diabetes. There is therefore a strong imperativeto screen actively for diabetes in populations knownto be at high risk, so as to allow early detection andappropriate treatment. The earlier the detection, themore effective the strategies will be to reduce therisk of chronic complications. Current guidelines 5 haveidentified at-risk populations such as those with a firstdegree relative with diabetes, specific ethnic groups(Aboriginal and Torres Strait Islanders, Polynesians,people from the Indian subcontinent, or from parts ofSouth East Asia, China etc), obese subjects and certainother groups. Members of these groups have beendesignated for regular screening from a recommendedage. For more specific details on whom, when andhow to screen, readers are referred to the guidelines,Managing Type 2 Diabetes in South Australia. 5 Screeningcan be simply done by measuring fasting plasma bloodglucose. A fasting blood glucose level greater than 7mmol/L on two occasions, or a random blood glucoselevel of 11 mmol/L or more in a symptomatic patient, willconfirm the diagnosis. An oral glucose tolerance test isoccasionally needed in ambiguous cases.Impaired glucose tolerance (IGT) is defined in apatient who has a blood glucose level of between7.8 and 11 mmol/L after a two-hour glucose load. Thiscondition is important to recognise for two reasons– the individual is at a higher risk of developing Type 2diabetes and, significantly, even without the evolutionto full-blown diabetes, impaired glucose toleranceconfers a higher risk for developing cardiovasculardisease. Hence, patients with this condition needaggressive management of cardiovascular risk factorsas well as advice on lifestyle alterations to reducethe risk of progression to diabetes. Another groupof patients is identified as having impaired fastingglucose (fasting glucose levels of between 5.6 and6.9 mmol/L). The significance of this condition withregard to cardiovascular disease is not as clear as withIGT. Nevertheless both groups are at higher risk ofdeveloping Type 2 diabetes and are part of the at-riskpopulation that should be screened regularly.If the acute metabolic disturbances associated withdiabetes were the only concern, then its managementwould be relatively straightforward. It is not difficult toobtain a fair level of metabolic control that minimisessymptoms, eradicates thirst and frequent urination,

improves energy levels and reduces drowsiness. It isthe prevention of the draconian chronic complicationsof this disease that is the major challenge. Recentlyan eminent diabetologist ruefully observed that theproblem posed by the possible bird ‘flu epidemic, for allits potentially devastating outcome, is nowhere near asoverwhelming as the catastrophic burden on patientsand the health care system that is being predictedfor the diabetes epidemic. After all, the effects of bird‘flu are likely to sweep through communities over afew months and then pass. The massive burden ofdiabetes complications such as renal failure, blindness,limited mobility from amputations etc include longtermdisabilities for patients and an ongoing drain oncommunity and health care resources over decades.On the positive side, however, is the highly convincingdata from several major trials in the last decade, whichclearly demonstrate that this burden can be significantlyreduced for both patients and the community. TheDiabetes Control and Complications Trial on Type 1diabetes 6 and the United Kingdom Prospective DiabetesStudy for Type 2 diabetes 7 showed a marked reductionin microvascular complications such as eye and kidneydisease, and nerve damage, with tight glycaemiccontrol. Not only could the onset of these complicationsbe retarded but, encouragingly, the progressionof established complications could be slowed byimproving blood glucose levels. The target marker forgood glycaemic control, an HbA1c level of 7%, is notin the normoglycaemic range but is an achievable goalfor most patients with diabetes. With the exceptionof the very young and the very old, this should bethe goal for all patients with diabetes and their healthcare providers. The downside of good control is theincreased frequency of hypoglycaemia, which is dreadedby patients and can sometimes be a disincentive toachieving optimal control. The advent of new types ofinsulin and delivery systems will aid in this area.Macrovascular diseases make up the other major groupof diabetes complications – heart attacks, strokes, andblocked arteries to the legs leading to claudication andgangrene. Blood glucose control alone is not sufficientto reduce the risks of these events. However, severaltrials on blood pressure and cholesterol treatment havedemonstrated a substantial reduction of these lifethreateningcomplications in the diabetic population. 8For patients with diabetes, the target levels for bloodpressure and cholesterol are more stringent than forthose of the general population. Indeed the goals ina diabetic person with no previous history of a heartattack are equivalent to the levels aimed for in patientswho have already had a heart attack and are aiming toprevent a second one (secondary intervention goals).The cessation of smoking is a given.While these goals are easy to identify, the actualachievement is much more challenging. It requires ahealth care system that has the capacity to support andmonitor patients, health professionals who are familiar22with the targets that need to be achieved, and patientswho are actively engaged in their own management.References1. Cameron AJ, Welborn TA, Zimmet PZ, et al.Overweight and obesity in Australia: the 1999-2000Australian Diabetes, Obesity and Lifestyle Study(AusDiab). Med J Aust. 2003; 178(9): 427-432.2. Tuomilehto J, LindstromJ, Eriksson JG, et al.Prevention of Type 2 diabetes mellitus by changesto lifestyle among subjects with impaired glucosetolerance. For the Finnish Diabetes Prevention Group.N Engl J Med 2001, May3; 344(18): 1343-50.3. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyleand the risk of Type 2 diabetes mellitus in women. NEngl J Med 2001, Sep 13; 345(11): 790-97.4. Dunstan DW, Zimmet PZ, Welborn TA, et al. TheAustralian Diabetes, Obesity and Lifestyle Study(AusDiab) – methods and response rates. DiabetesRes Clin Pract 2002, Aug; 57(2): 119-29.5. Dept of Human Services. Managing Type 2diabetes in South Australia – screening, diagnosis& management in general practice. Currently beingupdated. Adelaide: Department of Human Services,May 2002.6. Diabetes Control and Complication Trial ResearchGroup. The effect of intensive treatment of diabeteson the development and progression of long-termcomplications in insulin-dependent diabetes mellitus.N Engl J Med 1993, Sep 30; 329(14): 977-86.7. UK Prospective Diabetes Study (UKPDS) Group.Intensive blood-glucose control with sulphonylureasor insulin compared with conventional treatment andrisk of complications in patients with type 2 diabetes.Lancet 1998, Sep 12; 352(9131): 837-53.8. Kemp TM, Barr EL, Zimmet PZ (et al. Glucose,lipid and blood pressure control in Australian adultswith type 2 diabetes. For the AusDiab SteeringCommittee. Diabetes Care 2005, Jun; 28(6): 1490.

Self-Management ofChronic Conditions:Everybody’s BusinessSharon LawnResearcherFlinders Human Behaviour & Health Research UnitEmail: sharon.lawn@flinders.edu.auMalcolm W BattersbyDirectorFlinders Human Behaviour & Health Research UnitEmail: malcolm.battersby@flinders.edu.auRene G PolsDeputy DirectorFlinders Human Behaviour & Health Research UnitEmail: rene.pols@flinders.edu.auIntroductionThe National Chronic Disease Strategy (NCDS) 1 is duefor release in October 2005 after being presented tofederal, state and territory health ministers within theAustralian Health Ministers’ Advisory Council (AHMAC).The strategy comprises four action areas, one of whichis self-management, and this is integrally linked withthe other action areas of prevention, early detection,and integration and coordination. This paper provides adefinition of chronic condition self-management (CCSM)as it applies to the individual, the clinician and the healthsystem. It also discusses the role of GPs and otherhealth workers in using a population health approachto provide self-management support for people withan established chronic condition and people at risk ofdeveloping chronic conditions.Self-management is viewed as a key element in theprevention and early intervention of chronic conditions,and can be applied to individuals, families, communitiesand populations. It fits well with public health modelsof prevention and the population approach. It alsoacknowledges that social determinants of health have apowerful influence on lifestyle behaviours and perceivedchoices, so that attempts to prevent and minimise theimpact of chronic conditions must focus not only onindividuals but also on the social determinants of healthwhich influence their behaviours. This is everybody’sbusiness, and particularly that of the health servicesystems, which often shape and influence how a personresponds to and manages their chronic condition.Rationale for self-management as part of a publichealth approachThe leading chronic conditions (cardiovascular disease,cancer, chronic lung disease, and diabetes) share severalkey risk factors (tobacco use, poor diet, lack of physicalactivity, and alcohol use) and are strongly influencedby social determinants of health such as poverty,education, mental health and unemployment. Selfmanagementprograms offer a key strategy that can beused to prevent and better manage the range of chronicconditions and their risk factors, as well as takinginto account the underlying determinants of health.Hence, population health strategies that shift towardsprimary intervention are crucial for the prevention andmanagement of chronic conditions. 2However, existing health care systems tend to provideepisodic care services in response to patient demand,often in association with acute health events, and donot necessarily encourage self-management. Currently,attempts to address many of the risk factors notedabove occur within administrative and bureaucraticsilos, with each developing its own strategy in isolation.A person must usually seek help from a single healthprofessional, or else be forced to navigate a labyrinthof services provided by health professionals withina fragmented and disjointed system. Diverse anddivergent structures and cultures offer few clearlyestablished communication pathways that enableinformation to be shared. This often leads to duplicationand waste, and ignores the possibility of a holisticapproach to the person’s health and wellbeing, or to therealities of their psychosocial environment.The current system of health care focuses heavily ontreating individual chronic conditions and deliveringspecialised disease management programs throughspecialist clinics. Under these circumstances offragmented patient care, health professionals mayunder-treat or overlook other related (or unrelated)disorders, with deleterious consequences for theperson’s morbidity and mortality. 3 The person withthe chronic condition is also more likely to feeldisempowered within such a system, and less likelyto learn effective self-management. Evidence fromresearch on compliance and adherence supports theidea that health professionals need to change theway they interact with consumers of health services. 4Such research has found that 30-50% of people do notcomply with their treatment (medical or behaviourallifestyle changes) irrespective of disease, prognosis orsetting. This suggests that health professionals needto consider and understand the person’s viewpoint andpotential barriers to managing their health, rather thansimply dictating the treatment and expecting the personto follow it largely without question. 423

The person’s perspectiveWhen a person develops a chronic illness and is firstgiven a formal diagnosis, this constitutes a criticallife event for them. Such a crisis has well definedcharacteristics. 5,6 Put simply, it is a time of emotionaldisequilibrium, and one that needs resolution throughthe learning of new skills to cope with the challenge thatis presented. Once the challenge is confronted, dealtwith and overcome, the person can achieve a sense ofmastery, and self efficacy can grow. 7 This is the first stepin developing an effective self-management approach toany clinical condition. The person’s experience of chronicillness is subjective, interpersonal and social.Self-management tasks involve an understanding of,and the ability to distinguish between, the experienceof illness, levels of distress, perceived loss of wellbeing,illness behaviour, and the impaired functioningobserved by others. They serve to reduce the effectsof the condition or disease on the person, such associal stigma and exclusion, and decreased levelsof participation in family and community, and aim topromote full personal and social wellbeing.Similarly, the perspective of a chronically ill person’scarer is unique. Caring for someone with chronic illnesshas a significant impact on the carer’s role, and on theirinterpersonal relationships with the person and withothers, as well as causing inevitable changes in theirown careers and lives. 8A cognitive behavioural (CBT) approach to CCSM,as used in the Flinders model, enables the healthprofessional to use a motivational approach in supportof self-efficacy and change, as part of their interactionwith a chronically ill person. It is linked with a crisisintervention model which recognises that crisis offersa unique opportunity for the person to make positivechanges. 9 It also involves an important personal,emotional, social and psychological adjustment,progressing towards self-management beyond the limitsof bio-psychosocial understanding, 10,11 and is thereforemore meaningful for the person with the chroniccondition.Medical practitioners and allied health workers arecritical partners for people faced with the diagnosisof any chronic condition. At this time, the person,their carers and family, doctors and health workersmust join together as “partners in health” to developcomplementary roles in the total management of thecondition. Central to this is agreeing on what CCSMmeans and how responsibility for self-management andself-management support is shared.Definitions of self-managementPeople with chronic conditions need (and want) to liveeffective lives in spite of their symptoms and limitations,if they are to make the most of their lives with theleast possible disability and optimum health outcomes.24Central to this is good mental health and wellbeing tofoster positive coping skills and independence ratherthan dependence. Together with these goals, anydefinition of CCSM needs to encompass the broadspectrum of chronic conditions and to support a genericfocus for action. It needs to recognise that personal riskfactors for health, CCSM and health promotion are partof the same strategy.CCSM is about how the person, the health workersand the system share knowledge and responsibility andwork together to support the achievement of betterhealth and wellbeing, as defined by the person, not bythe professional. It acknowledges social, psychological,and biological impacts on self-management ability, andsets all this within a cultural context that recognises andrespects the beliefs and values of the person.Self-management is therefore a set of attributes of theindividual who:• has knowledge of their condition and treatment• follows a treatment plan (care plan) agreed andnegotiated with their health professionals, carers/family and other supports• actively shares in decision-making with healthprofessionals, carers/family and other supports• monitors and manages signs and symptoms of theircondition• manages the impact of the condition on theirphysical, emotional and social life and has goodmental health and wellbeing as a result• adopts a lifestyle that addresses risk factors andpromotes health by focusing on prevention and earlyintervention• has confidence in their ability to use supportservicesThis occurs within a health system that provides readyaccess to appropriate systems of self-managementsupport which are:• evidence-based• adequately resourced• endowed with staff who are adequately trained,culturally sensitive to the person’s needs and whosupport the belief in the person’s ability to learn selfmanagementskillsHence, for definitional purposes, self-management iswhat the person with a chronic condition (or at risk of achronic condition) does, and self-management supportis what the health professional and the health systemdo to support the person in achieving optimal selfmanagement.The professional assists the person with a range oftasks that promote effective self-management, based onthe person’s goals, wishes and capacities, by addressingand encouraging the person’s participation in the key

skills of knowledge-building, problem-solving, decisionmaking,and confidence-building. This is achieved byaddressing central tasks regarding role, emotionalmanagement, and medically related tasks, using a clientcentred,holistic approach that builds on the person’scapacity, strengths, resilience and dignity. CCSMinvolves the identification of issues, setting of goals, andcommitment to action components. Hence, progressand outcomes are measurable via action plans that canbe reviewed over time for process and impact by theperson, helping professionals and other supports. Weargue that a self-management care plan must be clientownedand client-driven in order to be effective.We also suggest that this care plan can be incorporatedinto current GP chronic disease care planningarrangements, 1 as the means of promoting collaborationand partnership between the person, their GP and otherhealth professionals, and alleviating the fragmentationof services and communication between these selfmanagementsupport providers.ConclusionFor chronic condition self-management to become anaccepted and established part of health care in Australia,a range of support structures and relationships needto be developed or enhanced. Fundamentally, this alsorequires a shift towards building self-managementcapacity in the individual with the chronic condition, andplacing them at the centre of action and knowledge. Thisinvolves a significant change in the behaviour of healthprofessionals who have traditionally viewed themselvesas experts. Increasing the capacity of the primary (aswell as secondary and tertiary) and acute health caresectors to provide timely, coordinated and integratedchronic disease management support is essential.Promoting a partnership approach to self-managementcare planning is needed, with the person as an equalpartner with each and all of those providing support.It also involves raising awareness in the communityabout managing, promoting and maintaining healthand wellness, and minimising health risks as part of apopulation-wide approach.References1. Australian Government Department of Healthand Ageing. New Medicare chronic diseasemanagement items replace enhanced primarycare (EPC). Care planning items from 1 July 2005.Canberra: Australian Government Department ofHealth and Ageing, 2005.2. World Health Organisation. Innovative care forchronic conditions: building blocks for action. Globalreport. Geneva: World Health Organisation, 2002.3. McAlister FA, Lawson FME, Teo KK, Armstrong PW.A systematic review of randomised trials of diseasemanagement programs in heart failure. Am J Med2001; 110: 378-384.4. Vermeire E, Hearnshaw H, Van Royen P, DenekensJ. Patient adherence to treatment: three decadesof research. A comprehensive review. J Clin PharmTher 2001; 26: 331-342.5. Caplan G. Principles of preventative psychiatry. NewYork: Basic Books Inc, 1964: 38-54.6. Gunderson E, Rahe RE. Life events and illness.Springfield Illinois: Thomas, 1974.7. Bandura A. Self-efficacy: toward a unifying theory ofbehavioral change. Psychol Rev 1977; 84: 191-215.8. Australian Bureau of Statistics. Disability, ageingand carers, Australia: summary of findings. Cat. no.4430.0. Canberra: ABS, 2003.9. Golan N. Crisis theory. In: Turner F, ed. Social worktreatment: interlocking theoretical approaches. NewYork: Free Press, 1974.10. Drew L. Beyond the disease concept of addiction:towards integration of the moral and scientificperspectives. Aust Drug Alcohol Rev 1987; 6: 45-48.11. Miller W. Spirituality: the silent dimension inaddiction research. The 1990 Leonard Ball oration.Drug Alcohol Rev 1990; 9: 259-266.15.25

Improving HealthOutcomes: Self-Management of ChronicDiseasePauline KellyStanford T-TrainerEducation Services ManagerArthritis SA‘Patients with chronic conditions make day-to-day decisions about– self-managing – their illnesses. This reality introduces a newchronic disease paradigm: the patient-professional partnership,involving collaborative care and self-management education.Self-management education complements traditional patienteducation in supporting patients to live the best possible qualityof life with their chronic condition. Whereas traditional patienteducation offers information and technical skills, self-managementeducation teaches problem-solving skills. A central concept inself-management is self-efficacy – the confidence to carry outa behavior necessary to reach a desired goal. Self-efficacy isenhanced when patients succeed in solving patient-identifiedproblems. Evidence from controlled clinical trials suggeststhat (1) programs teaching self-management skills are moreeffective than information-only patient education in improvingclinical outcomes; (2) in some circumstances, self-managementeducation improves outcomes and can reduce costs for arthritisand probably for adult asthma patients; and (3) in initial studies, aself-management education program bringing together patientswith a variety of chronic conditions may improve outcomes andreduce costs. Self-management education for chronic illnessmay soon become an integral part of high-quality primary care.’ 1JAMA 2002; 288: 2469-2475In its report on innovative care for people with chronicconditions, the World Health Organisation presentshealth self-management as a key strategy to respond tothe increasing global burden of chronic diseases. 2The term ‘self-management’ is used to describe thehealth activities undertaken by individuals with achronic illness to manage their condition, including dailysymptom management, behaviour and role adaptation,and management of the psychosocial aspects of livingwith a chronic illness. 3 People with chronic conditionsneed education and support to help them accomplishthese tasks.While the reason behind the success of selfmanagementeducation programs is unclear, and there4, 5, 6, 7are methodological limitations to some studies,increased perception of personal control appears to bepositively associated with changes in health behaviourand health status. 8 An Australian longitudinal studyreported that positive effects on clinical and functionaloutcomes are sustained following attendance at aregistered arthritis self-management course. 9In the United Kingdom, the ‘Expert Patient Program’,developed to improve the management of people withchronic conditions, provides accredited, local selfmanagementeducation programs. 10 Preliminary resultsof this approach show a need to raise awareness ofthe education program among health professionalsand the public, and a need to target these programsto population sub-groups, particularly marginalisedgroups. 11Self-management was a major focus of the AustralianGovernment Sharing Health Care Initiative (SHCI),which aimed to improve the quality of life of peoplewith chronic conditions. The Initiative compriseddemonstration projects testing a range of chroniccondition self-management models, includingIndigenous-specific projects, education and trainingof health professionals and people participating inthe projects. 12 The results of a national evaluation ofthe SHCI demonstrated that the people participatingreported improved health outcomes, a better qualityof life and reduced service utilisation. This trend wasobserved across all eight demonstration projects,including those with Indigenous and Culturally andLinguistically Diverse client groups.The issues around living with a chronic condition aremany and various. An example of a highly successfulself-management program is the Stanford ChronicDisease Self-Management Program (CDSMP). Thisprogram is the basis of the Expert Patient Program inthe UK. Building on the experience and evaluation ofthe Arthritis Self-Management Program, the StanfordCentre for Research in Patient Education and KaiserPermanente began, in 1990, to develop the CDSMP.The program content concentrates on patients’ selfdefinedneeds and self-management options forcommon problems and symptoms such as pain, fatigue,fear and frustration. Patients participating in the programalso learn how to manage emotional and other changesbrought about by illness, including anger, depression,uncertainty about the future, changed expectationsand goals, and isolation. The program is based on theself-efficacy theory and incorporates skill mastery,reinterpretation of symptoms, modeling, and socialpersuasion, to enhance patients’ sense of personalefficacy. 13The Stanford CDSMP has been demonstrated toimprove healthful behaviours and health status at 6months. It also resulted in fewer hospitalisations anddays of hospitalisation. 14 These changes were sustainedat 2 year follow up. 1326

It is our responsibility to our profession and to ourpatients to recognise the role of self-management ofchronic disease and to establish it as an integral part ofhigh quality primary care. A beginning step for SouthAustralia has been the recent acquisition of a licensefor the Stanford CDSMP that covers all Department ofHealth funded health portfolio entities.References1. Bodenheimer T, Wagner EH, Grumbach K. Improvingprimary care for patients with chronic illness. JAMA2002; 288: 2469-2475.2. World Health Organization. Innovative care for chronicconditions: building blocks for action. Geneva: WHO,2002. http://www.who.int/chronic_conditions/en/icccglobalreport.pdf3. Lorig K, Holman H. Self-management education:history, definition, outcomes, and mechanisms.Annals Behav Med 2003; 26(1): 1-7.4. Niedermann K, Fransen J, Knols R et al. Gap betweenshort- and long-term effects of patient education inrheumatoid arthritis patients: a systematic review.Arthritis Care Res 2004; 51(3): 388-398.5. Walker C, Swerissen H, Belfrage J. Selfmanagement:its place in the management of chronicillnesses. Aust Health Rev 2003; 26(2): 34-42.6. Riemsma R, Kirwan J, Taal E et al. Patient educationfor adults with rheumatoid arthritis (CochraneReview). In: The Cochrane Library, Issue 1.Chichester: John Wiley & Sons, 2004.7. Warsi A, La Valley M, Wang P et al. Arthritis selfmanagementeducation programs: a meta-analysisof the effect on pain and disability. Arthritis Rheum2003; 48(8): 2207-2213.8. Lorig K, Seleznick M, Lubeck D et al. The beneficialoutcomes of the Arthritis Self-Management Courseare not adequately explained by behaviour change.Arthritis Rheum 1989; 32: 91-95.9. Osborne R, Wilson G, McColl G. Does selfmanagementlead to a meaningful and sustainablechange? Two year follow up of 452 Australians.Proceedings of the Commonwealth Department ofHealth and Ageing Sharing Health Care Initiative EarlyWins Workshop, Hobart, Dec 9-10, 2002. http://www.chronic-disease.health.gov.au/proceedings.10. National Health Service (NHS). The expert patient: anew approach to chronic disease management forthe 21st Century. London: National Health Service,2001.11. Gupta S. The Expert Patient Programme and primarycare: a challenge and an opportunity. AustralianGovernment Department of Health and AgeingNational Chronic Condition Self-ManagementConference, Melbourne, November 2003.12. Health Inequalities Research Collaboration, PrimaryHealth Care Network (HIRC PHC Network). Actionon health inequalities: early intervention and chroniccondition self-management. Sydney: University ofNew South Wales Centre for Health Equity, Training,Research and Evaluation, 2004.13. Sobel D, Lorig K, Hobbs M. Chronic DiseaseSelf-Management Program: from developmentto dissemination. The Permanente Journal 2002;6(2):11-18.14. Lorig K, Sobel D, Stewart A et al. Evidencesuggesting that a chronic disease self-managementprogram can improve health status while reducinghospitalization: a randomized trial. Med Care 1999;Jan 37(1): 5-14.27

The Heart FoundationCardiovascular HealthCourse for AboriginalHealth WorkersWendy KeechManager, Program Development,Cardiovascular Health Team,National Heart Foundation (NHF) SA DivisionKatrina BaroniaProject Officer, Cardiovascular Health Team,NHF SA DivisionGraham WilliamsCoordinator, Centre of Health Education and Training,Aboriginal Health Council of South AustraliaIntroductionThe National Heart Foundation Australia (NHFA) isstriving to support the prevention and managementof chronic disease for all Australians, particularlyCardiovascular Disease (CVD), and with a special focuson those at greatest risk. As an important component ofthis strategy, the NHFA is supporting appropriate trainingfor Aboriginal Health Workers (AHW) in CardiovascularHealth (CVH).Since late 2003, in an effort to make a positive impacton the health status of Aboriginal people and TorresStraight Islanders, the National Heart Foundation SouthAustralian Division (NHFSA) has been working todevelop a specific training program in South Australia.A collaborative partnership has been established forthis project with Nunkuwarrin Yunti, Pika Wiya and theAboriginal Health Council of South Australia (AHCSA).Whilst the training course has a clear preventionfocus, the management of CVD is included, due to theprevalence and early onset of CVD among Aboriginalpeople. Financial support for the program been receivedfrom the SA Department of Human Services (now theDepartment of Health, Aboriginal Health Division) andthe Commonwealth Office of Aboriginal and Torres StraitIslander Health (OATSIH).The National Heart Foundation and Aboriginal andTorres Straight IslandersThe NHFA 1 describes its strategic direction as aiming todecrease the incidence of heart, stroke and blood vesseldisease in the Australian population. This will meanincreasing the use of proven treatments and promotinglifestyles that improve cardiovascular health. Itsefforts are focused on those people who are currentlydiagnosed with and those at greatest risk of heart,stroke and blood vessel disease. Such cardiovascularconditions contribute significantly to the level of ill healthexperienced by Aboriginal and Torres Straight Islanders.The NHFA has developed a Platform for Action withAboriginal people and Torres Strait Islanders which workstowards addressing the level of CVD in this population.The key components of this platform include:• support of national, state and territory cardiovasculardisease training programs• support for the provision of cardiac rehabilitationprograms for all eligible Aboriginal & Torres StraitIslander patients.• support for the implementation of a nationallymanaged program for the secondary prevention andmanagement of rheumatic fever and rheumatic heartdisease.• development and implementation of a secure fundingbase for the Aboriginal and Torres Strait Islandercardiovascular programs.The NHFA has strategically decided to develop trainingstrategies with Aboriginal and Torres Straight Islanderhealth workers. This was the key recommendationidentified by the conference Heart Disease andAboriginal Health – What will make a Difference? Theconference was held in 1997 in Perth in partnershipbetween the NHFA, the Australia Medical Association,and Derbarl Yerrigan Health Services (WA).Why train Aboriginal and Torres Straight Islanderhealth workers?In Australia, Aboriginal and Torres Strait Islander healthworkers have a range of roles including:• providing information to assist community membersand clients to make informed decisions about theirhealth and treatment options• assisting and supporting planning programs, includingthe development of a community profile to assist inidentifying health problems• ensuring cultural sensitivity and maintainingtraditional health philosophies• providing health education and promotion,management and controlAboriginal Health Workers (AHWs) play a critical rolein improving and maintaining the health of Aboriginalpeople, as it is thought that no other health professionalis as well placed or better able to provide culturallyappropriate health care and education to Aboriginalpeople within their own communities. It is recognisedthat living locally in communities and understandingcommunity issues at first hand gives AHWs anenormous advantage in treating and preventingAboriginal ill health.28

Cardiovascular health training for Aboriginal andTorres Straight Islander health workersFollowing the conference Heart Disease and AboriginalHealth – What will make a Difference? the NHFA, theAustralia Medical Association and Derbarl YerriganHealth Services developed the ‘Heart Health Manual’training package. It was designed specifically for AHWs,to assist them in reducing the high prevalence of heartdisease among Aboriginal people. The training packageis registered as a Certificate in Cardiovascular Health forAboriginal Health Workers (NTIS: 51023) and graduatesfrom this course receive an Accredited Skills Formation(ASF) Level 5 certificate.The training course is run over 60 hours and includestraining in a number of chronic disease risk factors, withseveral case studies to demonstrate how health workerscan facilitate healthy behaviour change with their clients.The modules covered in the course include:• Aboriginal Health• Cardiovascular Health• Role of the Aboriginal Health Worker• Individuals• Working with Families• Nutrition/Schools• Organisations and Prisons• Community Action• Special GroupsFrom the initial effort to develop and trial this trainingpackage, several National Heart Foundation Divisionsin Australia have worked towards engaging theRegistered Training Organisations (RTO) to integrate theCardiovascular Health Training Program into their existingtraining programs.It has been noted that sections of the initial courseare now included in the Aboriginal Primary HealthCare (APHC) Certificate which is being completed byAboriginal Health Workers. As a result, discussionsare taking place with the AHCSA to trial an abridgedversion of the CVH course in conjunction with the APHCcertificate.ConclusionWhile the accredited course continues to be wellsupported nationally, it has been recognised thatstrategies to embed the content of the CardiovascularHealth Course for AHWs into other existing educationalactivities are also critical.In South Australia, the Heart Foundation believesthat work in this area can only be successful if closepartnerships with Aboriginal health services are ongoing.As a result, we continue to work with AHCSA to providethe level of support required to maintain training in thisarea.It is also acknowledged that the NHFA can bring a levelof expertise to the area, and can play an important rolein promoting cardiovascular heath as a priority on thealready full Aboriginal Health agenda. However, to makean ongoing difference and actually to improve the healthstatus of Aboriginal people, clearly it is the AboriginalHealth Workers who must embrace the information,develop the skills and lead the community basedprojects.References1. National Heart Foundation Australia. Future Direction(2003 – 2007). Melbourne: National Heart FoundationAustralia, 2003.So what has actually happened in South Australia?Project staff at the NHFSA, working closely withNunkuwarrin Yunti, Pika Wiya and the AHCSA, adaptedthe accredited Western Australian resources to ensurethat they were appropriate for South Australia. Thecourse was then conducted as a pilot program atNunkuwarrin Yunti in metropolitan Adelaide, and at PikaWiya in Pt Augusta. Eight students completed the 10-day course in Adelaide and another eight in Pt Augusta.As a result of these successful pilots, AHCSA has beenprepared to take on the ongoing role of RTO, workingcollaboratively with the Heart Foundation to continueconducting courses throughout South Australia. To date,the course has been successfully run in Ceduna, PtLincoln and Coober Pedy, and there are plans for MtGambier, the Riverland and another metropolitan-basedcourse.29

The South AustralianHealth Omnibus Survey15 Years on: Has PublicHealth Benefited?Anne TaylorManagerPopulation Research and Outcome Studies UnitSouth Australian Department of HealthEleonora Dal GrandeSenior EpidemiologistPopulation Research and Outcome Studies UnitSouth Australian Department of HealthDavid WilsonHealth Observatory,The Queen Elizabeth HospitalWoodville, South AustraliaIntroductionCross-sectional surveys are the most commonlyused method of assessing health-related behaviours,determinants of behaviour, and prevalence estimates fornon-registry based chronic diseases in the population.These types of survey can also be used to identifypreferences, satisfactions, perceptions and attitudes,and how these may vary across subgroups andsituations.The South Australian Health Omnibus Survey (HOS)is a representative, cross-sectional survey that hasbeen in operation since 1990. It is administered bythe Population Research and Outcome Studies unit(PROS) of the South Australian Department of Health,in conjunction with a private Health Research company(Harrison Health Research). The goal of HOS is to collect,analyse and interpret data, which can then be usedto plan, implement and monitor health programs andother initiatives. HOS is a ‘user-pays’ service, but eachorganisation pays only for questions that have directrelevance to their information requirements. This allowsseveral organisations to share the operating costs ofundertaking and administering such a survey. HOS isused by a number of government and non-governmentorganisations to obtain data on a range of health issuesin South Australia (SA). Surveys have been conductedannually each October/November. On occasions, tosatisfy customer demand, a second survey has beenundertaken (as in 1995, 1998, 2004) and is nominallycalled the ‘autumn’ HOS. Methodology for the AutumnHOS is identical to that of the yearly ‘spring’ survey.This paper addresses the HOS methodology, the rangeof uses of the survey vehicle over the years, and thebenefits to South Australia of having the ability to satisfy,under one umbrella, a wide range of public health dataneeds.30MethodHOS has been designed to meet the highest standardsof population survey methodology with rigorousadherence to formal statistical techniques.SamplingThe survey sample is a clustered, multi-stage,systematic, self-weighting area sample. Each surveysamples 4,400 households. The observed response rateduring the years 1991-2003 has been approximately70%, resulting in a minimum of 3000 interviews (withpersons aged 15 years and over) per survey. The largesample size and high response rate facilitates a highlevel of confidence that the results and trends notedfrom the survey are applicable to the South Australianpopulation as a whole.Seventy-seven percent of the sample is selected fromthe Adelaide metropolitan area, with the remainderbeing drawn from those country towns with apopulation of 1,000 or more (based on AustralianBureau of Statistics [ABS] latest Census information).Country towns with smaller populations are not includedbecause of the additional cost of interviewing peopleliving in remote areas. Within the selected metropolitanand country areas, the ABS Collection Districts (CDs) arethe basis of the sample frame. A CD is a geographicalarea comprising approximately 200 dwellings. Clustersampling means that some, but not all, of these CDsare included in the sample. To achieve a sample of 4,400households, 10 households are selected from each of440 selected CDs. Table 1 details the sample procedureand other sampling criteria.Table 1: Health Omnibus sampling criteria

Questionnaire administrationClients are offered assistance to develop questionswhere required. Background demographic questionsare included free of charge to users. HOS is a personalinterview survey, which is considered to be the ‘GoldStandard’ of interview techniques. 1,2 Interviewersread out the questions and, if necessary, promptcards are used. The questionnaire is designed totake approximately 30-40 minutes for respondents tocomplete. Prior to the main survey, a pilot study of 50interviews is conducted to test questions, validate thesurvey instrument and assess survey procedures. Aquality control committee chaired by an epidemiologistoversees all facets of HOS. Committee membersconsist of a representation of prior users of the survey.Data collectionThe company undertaking the data collectioncomponent is a member of Interviewer Quality ControlAustralia (ICQA), a national quality assurance initiativeof the Market Research Society of Australia. Accreditedorganisations must strictly adhere to rigorous qualityassurance requirements and are subject to regular auditin this regard. Interviewers are trained extensively,and ten percent of the interviewers’ surveys areselected for validation. Validation involves re-contactingsurvey respondents to ensure that they meet theselection criteria within that household, that they wereinterviewed, and that their recorded responses toselected questions agree with their original responses.Data entry is fully verified to ensure accuracy of datacapture. Recorded data is edited for accuracy andconsistency.amongst people with chronic diseases such as diabetesand smoking, asthma and smoking, diabetes andcardiovascular risk factors, psychosocial and traumaticevents, depression and diabetes, HRT and risk ofcardiovascular disease, and HRT and osteoporosis. Inaddition, various studies have shown the relationshipbetween quality of life and chronic diseases, chronicconditions and behaviours.Repeated cross-sectional surveys that exhibit a highlevel of consistency in methodology constitute asurveillance system and present opportunities for trendanalysis. As an outcome of the consistency of the HOSmethodology, changes in health problems and diseasetrends have been monitored. In particular over the past15 years, asthma prevalence, BMI, diabetes prevalence,HRT use and smoking trends have been establishedand reported. The trend series produced from HOS areamongst the longest in Australia. Figure 1 highlightsthe increasing prevalence of diabetes since data wasoriginally collected in 1991 with projections until 2016.Figure 1: Prevalence of self-reported diabetes in South Australia1991 to 2004 by agegroups, with projections to 2016WeightingThe survey data is weighted by sex, five-year agegroups, geographic area and probability of selectionwithin the household to provide estimates that apply tothe South Australian population.ResultsA major use of the data has been to estimate theprevalence of chronic conditions or health relatedbehaviours. This has included asthma, diabetes,arthritis, postnatal depression, hearing loss, hormonereplacement therapy (HRT), palliative care, osteoporosis,eating disorder, hysterectomies, urinary incontinence,pelvic floor disorders, smoking, body mass index (BMI),complementary and alternative medicine use andmental health issues.The power of the HOS, and one of the major benefitsof the survey, is the ability to share the data amongstpublic health users. This has encouraged collaborationbetween researchers, and enables identification anddetailed explanation of associations in the data in a costeffectiveway. Examples include assessing behaviours31HOS has also been used to evaluate the effectiveness ofpublic health programs and practices, to gain informationon perceptions towards, and acceptability of, healthservices and programs or organisations, or to supportchanges in legislation within the state. This has includedthe evaluation of health interventions, and programssuch as asthma management plans and smoke-freedining. The data has also been used to gain informationon the acceptability and uptake of new initiatives, andto inform program directions. Examples of these areuptake of nicotine replacement, assessing the degree ofconfidence in the community that healthcare providerskeep and use information responsibly, and asking menwho have had a blood test for prostate cancer abouttheir understanding of the test.Perceptions of the risk of disease have also beenassessed, and an evaluation has been conducted on theeffect of media on health behaviours. Data has also beenused to gain information that identifies target groups forpublic health interventions and campaigns, including earlydetection and prevention of osteoporosis, prevention of

incontinence, postnatal depression, smoking, obesity,suicidal ideation, depression and arthritis.Information on knowledge, attitudes and behaviours thatare related to public health problems have also beencollected, including knowledge about osteoporosis andthe associated risk factors, adults’ understanding ofdepression and beliefs about its appropriate treatment,mental health literacy, and the influences behind treatmentseekingbehaviour. HOS has been used to evaluate surveymethodologies, to provide cost analyses, and to comparehospital patients with the general community or withmetropolitan and country respondents.DiscussionHOS is a large, representative sample that providesreliable estimates for chronic conditions, health riskbehaviours and a range of other public health relatedissues including health service use, health management,health outcomes and policy support. As a result of itsstability and the methods employed, the survey is fullysubscribed (and often over subscribed) each year, with littleformal marketing. Use of the data has been widespreadand frequent, and the analyses well disseminated.Many Australian state and community based datacollection tools are fragmented, and the benefit of havingmajor policy-makers, planners, promoters and researchersunder one umbrella has been shown to be beneficial to theusers and the community. Policy makers, health plannersand health promoters require best available evidence andtimely, accurate data, for decision-making. The SA HOSconforms to best practice methods in providing thatevidence. Along with the user’s personal area of interest,consistent, reliable indicators on economic, social anddemographic correlates of health are routinely collected– adding to the benefit and comparability of the data.There are acknowledged limitations with HOS. Unlikecomputer assisted telephone interviewing (CATI)methodology, there is less control/supervision withface-to-face interviewing, and it is difficult to monitoreach interview. Owing to cost pressures, interviewsare conducted only in English, and only towns with over1,000 people are incorporated into the sampling strategy.In addition, along with other self-reported methodologies,self-reported conditions and behaviours may produceunder- or over-reporting.Challenges lie ahead for HOS. Response rates over thepast decade have been respectable (70%+), but withincreasingly inaccessible buildings (eg locked gates), busylifestyles, and security and privacy concerns, an impacton response rates is expected, following patterns andtrends interstate and overseas. 1 There is also an increasedconcern with the quality and safety of the interviewers.Future challenges include adapting the methodology toensure continued receipt of high quality, representative,timely data so that the HOS users of South Australia canhave access to this data. This may require incorporatingthe latest technology to make HOS more efficient,including using computer assisted personal interviewing(CAPI), computer assisted self-interviewing (CASI) oraudio computer assisted self-interviewing.HOS is an effective tool for obtaining public healthinformation for community based planning and activities.The methodology has been designed to meet the higheststandards of cross-sectional survey design (includingsampling, response rate, data quality and validity) so asto provide measures of the health status of the SouthAustralian population and to guide understandings ofthe determinants of health. Although a plethora of datasources are available to public health professionals,the value of a regular, reliable, methodologically sound,community based survey is worthwhile, and valuable inthe provision of a different but complementary and timelypublic health data source.References1. Dillman DA. Mail and other self-administered surveysin the 21 st Century: the beginning of a new era. TheGallup Research Journal 1999; 2(1): 121-140.2. Schonlau M, Friscker RD, Elliott MN. Conductingresearch surveys via email and the web. New York:Rand, 2001.32

Communicable Disease Control Branch Report– 01 January to 30 June 2005VECTORBORNE DISEASESMalariaTwenty three (13 males, 10 females, age range: 2 to 49years) cases of malaria were reported. In the period underreview there were 22 reports of Plasmodium falciparumand one mixed infection of Plasmodium malariae andPlasmodium falciparum received for persons reportingexposures in Africa.Ross River virusIn the period under review, 30 cases of Ross River virusinfection were reported. This compares with 40 casesnotified during the corresponding period in 2004.The last major outbreak of Ross River virus infections inSouth Australia occurred during the summer of 2000-2001. Figure 1 illustrates 3 to 4 year cyclic increases inthe number of cases of Ross River virus infection.Barmah Forest virusIn the period under review, 12 cases of Barmah Forestvirus were reported. This compares to 2 cases notifiedduring the corresponding period in 2004. Eleven of thesecases (92%) either reside in rural South Australia orreported recent travel to rural South Australia.Dengue feverIn the period under review, there were 3 reports of denguefever in people who reported recent travel to South EastAsia.Health InformationInformation on preventing vector borne diseases and thefight the bite campaign can be obtained by visiting ourweb site: http://www.health.sa.gov.au/pehs/ZOONOSESQ feverThere were 14 (13 males, 1 female, age range: 17-73years) reports of Q fever infection.Five of these (all males, age range: 35-73 years) caseswere associated with the outbreak investigation in theMid North of the State and reported on in the June 2005edition of the Public Health Bulletin.The remaining 9 cases all reported various risk factorsassociated with animal contact.The Communicable Disease Control Branch investigated2 small clusters of Q fever. One cluster involved 2Figure 1: Notified cases of Ross River virus infection in South Australia bymonth of notification January 1993 to June 200533

Figure 2: Number of notifications of pertussis in South Australiaby age groups, 1996 to 2005unvaccinated males, aged 19 and 23 years respectivelywho worked as sheep crutchers at the same place ofemployment. The other involved 1 male, 1 female aged 17and 32 years respectively, and employed as meat workersin a meat processing plant. One of the cases was notvaccinated and the other case’s vaccination status wasunknown.VACCINE PREVENTABLE DISEASESPertussisIn the period under review, there was a continuingincrease in the number of cases of pertussis reported. Intotal, 651 (252 males, 399 females) cases were reportedfor residents of rural, remote and metropolitan areas ofSouth Australia.Figure 2: illustrates the increase in the number of casesreported by age grouping and year.InfluenzaSouth Australian influenza surveillance combineslaboratory-confirmed cases reported by the Institute ofMedical and Veterinary Science and South Path, withclinical diagnoses of “influenza-like illness” collectedby the Royal College of General Practitioners membersparticipating in the Australian Sentinel Practice Network,and Emergency Departments of the Royal AdelaideHospital, Women’s and Children’s Hospital, NoarlungaHealth Service and the Queen Elizabeth Hospital.In the period under review, there were 31 influenza Aand 24 influenza B laboratory diagnoses of influenza virusreported. Refer Figure 3 (next page).The influenza strains circulating in South Australia in theperiod under review, as typed by the WHO CollaboratingCentre for Reference and Research, are mainly A/H3/California/7/224-like and B/Shanghai/361/2002-like. Therehave also been positive cultures of A/H3/Wellington1/2004-like, B/Hong Kong/330/2001-like and A/H1/NewCaledonia/20/99-like.Invasive Haemophilus influenzaeIn the period under review, there were 5 (2 males, 3females, age range: 10 to 87 years) cases of Haemophilusinfluenzae reported. Of these, 1 case was identified asIndigenous.Invasive pneumococcal diseaseIn the period under review, there were 61 (36 males, 25females,) laboratory confirmed cases of pneumococcaldisease reported. Two of the cases were Indigenous.The median age of cases was 52 years (age range: 8months to 98 years). Eleven (18%) cases were in childrenaged less than 5 years. Two deaths were reported to belinked to this disease.34

Figure 3: Influenza activity in South Australia 2004 to 2005 by number of clinical and laboratory diagnoses per weekHealth InformationInformation about the pneumococcal vaccinationprogramme can be obtained by telephoning theSouth Australian Immunisation Coordination Unit (08)82267177.MumpsThere were 3 (2 males, 1 female, age range: 39-69years) cases of mumps reported during the time periodunder review. Two of the cases were not vaccinated; theremaining case’s vaccination status was unknown.GASTROINTESTINAL DISEASESCampylobacterCampylobacter remains the most commonly reportednotifiable disease in South Australia. In the period underreview, 876 notifications were received for residents ofmetropolitan Adelaide, rural and remote areas of SouthAustralia. A similar number of cases were notified in thesame period last year.Hepatitis AIn the period under review, there were 2 (2 males,aged 14 and 22 years respectively) cases of hepatitisA reported. Risk factors included recent overseas travelto an area endemic for hepatitis A infection and male tomale sex.ShigellosisThere were 17 (8 males, 9 females) cases of shigellosisreported. Of these, Shigella flexneri 2a and Shigellaflexneri 4a mannitol negative variant were the mostfrequently reported species.Transmission of Shigella flexneri 2a occurred in urban andrural South Australia, including 1 case in an Indigenousperson. In total 6 (3 males, 3 females, age range: 2 to 44years) cases were reported.Transmission of Shigella flexneri 4a mannitol negativevariant occurred among remote indigenous communitiesin South Australia. In total, 4 (3 males, 1 female, age range:1 to 48 years) cases were reported. All were Indigenous.CryptosporidosisIn the period under review there were 101 ( 52 males,49 females, age range: 9 months to 79 years) cases ofcryptosporidiosis reported. At the same time period in2004 there were 29 cases reported.The Communicable Disease Control Branch conductedan investigation of a cluster of 8 (5 males, 3 females,median age 6 years) cases of cryptosporidiosis linkedto use of public swimming pools. Advice resultingfrom the epidemiological investigation resulted in thesuperchlorination of two public swimming pools.35

SalmonellaIn the period under review, 292 (156 males, 136 females)cases of salmonellosis were reported. Of these, 68 (23%)cases were aged less than 5 years.The most commonly reported Salmonella were SalmonellaTyphimurium phage type 9 (43 cases), Salmonella Infantis(25 cases), Salmonella Typhimurium phage type 186 (22cases), Salmonella Typhimurium phage type 108 (20cases) and Salmonella Typhimurium phage type 135 (15cases).Salmonella Typhimurium phage type 186In the period under review, The Communicable DiseaseControl Branch investigated 3 separate outbreaks ofSalmonella Typhimurium phage type 186. The first involved9 (5 males, 4 females, age range: 0 -39 years) cases, eightwere from metropolitan Adelaide and one from rural SA.Epidemiological and environmental investigations wereunable to identify the source of infection.Results of the descriptive investigation of 2 furtheroutbreaks of Salmonella Typhimurium phage type 186 (9cases in total) among residents of metropolitan and ruralSouth Australia were suggestive of person-to-persontransmission in 8 of the 9 cases of illness.Salmonella Typhimurium phage type 9The Communicable Disease Control Branch investigatedan outbreak of salmonellosis (9 cases) associated with anAsian restaurant. Results of the descriptive epidemiologyand environmental investigation were suggestive offood borne transmission but no specific food item wasidentified.Salmonella Typhimurium phage type 108The Communicable Disease Control Branch investigatedan outbreak of salmonellosis (9 cases) associated witha restaurant in a rural setting. A case control studyshowed elevated odds ratio (OR: 35.2; 95%CI:2.6– 1047) for marinated chicken roll suggestive of foodborne transmission as the cause of this outbreak. Theenvironmental investigation was not able to identify thesource of contamination of the chicken roll.Salmonella Typhimurium phage type 135The Communicable Disease Control Branch investigateda cluster of 6 cases of salmonellosis from metropolitanAdelaide and rural South Australia. Hypothesis generatinginterviews could not identify the source of the illness.Salmonella Typhimurium phage type 64The Communicable Disease Control Branch investigatedconcurrent outbreaks of salmonellosis (46 cases)associated with a café in metropolitan Adelaide. Intotal, 6 separate functions catered for by the café wereinvestigated. In addition cases emerged from thecommunity that reported eating at the same café.Cross contamination involving a common food is the likelyexplanation of this outbreak.Salmonella Paratyphi AIn the period under review there were 4 (4 females,age range: 6 to 30 years) cases of paratyphoid feverreported. All cases reported recent travel to either Indiaor Cambodia.Shiga toxin producing Escherichia coli (STEC)In the period under review there were 24 detections ofShiga-toxin producing Escherichia coli. The age range ofcases (12 males, 12 females) was 9 months to 68 years.Cases were residents of rural and metropolitan areas ofSouth Australia.The Communicable Disease Control Branch investigateda small cluster of Shiga-toxin producing Escherichia coliserotype O111. A detection of STEC serotype O111 wasfound in a 1 year old male indigenous child with haemolyticuraemic syndrome (HUS). This case was linked by timeand place to another STEC case, a 5 year old male child,also serotype O111 and with the same molecular typingpattern. A third STEC serotype O111 occurred in thesibling (3 year old male) of the HUS case and this wasthought to be due to person to person transmission.However the mode of transmission for the first 2 casescould not be determined.A sporadic case of haemolytic uraemic syndrome wasalso reported in a 7 year old male child from metropolitanAdelaide.During this period, sporadic cases of Shiga-toxinproducing Escherichia coli were enrolled in a nationalcase-control study designed to identify risk factors forSTEC in Australia.OUTBREAKS OF GASTROENTERITISIn the period under review, the Communicable DiseaseControl Branch and local government EnvironmentalHealth Officers investigated 6 reported outbreaks ofgastroenteritis.Two of the reported outbreaks were among residentsand staff of aged care facilities in South Australia. Intotal, 52 residents and staff experienced gastrointestinalillness during these outbreaks. In 4(67%) of all reportedoutbreaks, norovirus was identified as the agentresponsible for the illnesses.Norovirus was also identified as the agent responsiblefor an outbreak of gastrointestinal illness at a childcarecentre where 12 staff and 25 students reported illness.36

Figure 4: Reports of invasive meningococcal serogroup C disease in South Australia, 1990 to 2005No agents were identified for outbreaks of gastroenteritisreported at a community centre and within the generalcommunity.“Guidelines for the management of gastroenteritis inaged care facilities” are available on our website. http://www.health.sa.gov.au/pehs/OTHER DISEASESLegionella pneumophila serogroup 1There were 2 sporadic cases of legionellosis (1 male, 1female, age range: 77- 81 years) reported during the timeperiod under review.Several possible sources for the illness were investigatedfor both cases. A domestic hot water system wasidentified as the source of infection for 1 of the cases.Invasive meningococcal diseaseIn the period under review, there were 5 (3 males, 2females, age range: 6 months – 51 years) laboratoryconfirmed cases of meningococcal disease reported.Three of the cases were aged less than 5 years.Of the 5 reported cases, 3 were identified as serogroup Band 2 were identified as serogroup C.During the same time period in 2004, 3 cases ofmeningococcal disease were reported.Figure 4 illustrates the decrease in the number of casesof invasive meningococcal serogroup C infection inSouth Australia since the introduction of the vaccinationprogramme.37

Table 1: Notifiable Disease in Sou38

th Australia, 1 Jan to 30 June 200539H1 = Half Year

The Public Health Bulletin South Australia is a publication of the S.A. Department of Health. The Bulletinaims to provide current data and information to practitioners and policy makers emphasising the value oforienting services towards prevention, promotion and early intervention and to support effective public healthinterventions.The Editorial team welcomes correspondence and suggestions for public health/ primary prevention themes forfuture editions of the PHBSA. Please email phbsa@health.sa.gov.au or write toThe Managing Editor, Public Health Bulletin South Australia, Health Promotion Branch, Department of Health,PO Box 287, Rundle Mall, Adelaide 5000 or fax (08) 8226 6133. Comments and reports should be 500 – 600 words.Guidelines for authors are available from the managing editor.To add your name to the distribution list for the Public Health Bulletin South Australia please email:phbsa@health.sa.gov.auThe PHBSA can also be accessed in PDF format fromhttp://www.dh.sa.gov.au/pehs/publications/public-health-bulletin.htmThe articles appearing in this publication represent the views of the authors and not necessarily those of theMinister for Health or the Department of Health. No responsibility is accepted by the Minister for Health or theDepartment of Health for any errors or omissions contained within this publication. The information containedwithin the publication is for general information only. Readers should always seek independent, professionaladvice where appropriate and no liability will be accepted for any loss or damage arising from reliance upon anyinformation in this publication.