Effect of a health literacy intervention trial on knowledge about cardiovascular disease medications among Indigenous peoples in Australia, Canada and New Zealand

"When you're in pain you do go into your shell" A community-based pain management programme co-designed with Māori whānau to address inequities to pain management - A qualitative case study

Chronic or persistent non-cancer pain disproportionately affects Māori - the Indigenous population of Aotearoa New Zealand (NZ) and their whānau (family and significant others). In a previous study with a Māori community service provider - Tū Kotahi Māori Asthma and Research Trust - Tū Kotahi, identified a need for a Kaupapa Māori (by Māori, for Māori) pain management programme (PMP) with embedded principles of Whānau Ora (care focusing on the wellbeing of the individual and their significant others as a collective). Using a qualitative case-study design, the main aims were to describe (1) the implementation of a community-based, whānau-focused PMP; (2) the participant experiences of the programme. This is community-based participatory action research guided by a Māori-centred research approach. Based on our previous co-design study with Tū Kotahi, a 6-week PMP (July - August 2021) was implemented at Kokiri Marae (community meeting place). Eight whānau living with persistent pain participated in the 6 sessions led by our Māori community partner and a pain management physiotherapist including a dedicated session on Rongoā Māori (Māori traditional treatment). Supporting resources were co-developed with our community partner, pain service clinicians, a Māori Health literacy expert, and a Māori illustrator. On completion, whānau reported enhanced confidence towards managing pain with "more tools to manage". The role of meaningful relationships, co-design, use of metaphors, and inclusion of traditional treatments - Rongoā were key aspects for the successful implementation. This initiative provides an exemplar for community and mainstream pain service partnership to address inequities in accessing pain management services for Māori. PERSPECTIVE: This study explains the key cultural processes of implementing a community-based pain management programme for Māori with persistent pain in Aotearoa New Zealand. The principles from our engagement could be applicable globally to engage with Indigenous and culturally and linguistically diverse communities with persistent pain to address longstanding health inequities.

Path Analysis of Health Literacy, Social Support, and Self-Efficacy on Decisional Conflict in Patients with Stable Schizophrenia

Purpose

Constructing a multiple mediation model based on two mediating variables, social support and self-efficacy, to explore the mechanism of health literacy's effect on decisional conflict in patients with stable schizophrenia.

Patients and Methods

A total of 205 patients with stable schizophrenia who were hospitalized in a psychiatric hospital in Guangdong Province, China, were selected for the study. The All Aspects of Health Literacy Scale (AAHLS), Decisional Conflict Scale (DCS), Social Support Rating Scale (SSRS) and General Self-Efficacy Scale (GSES) were used to evaluate health literacy, decisional conflict, social support and self-efficacy. Path analysis was performed by constructing a structural equation model, and the mediating effect between variables was validated by the bias-corrected nonparametric percentile bootstrap method.

Results

Health literacy, social support, and self-efficacy together explained 20.4% of the variance in decisional conflict. (1) Severe decisional conflict group accounted for 82% of overall patients with stable schizophrenia. (2) there were strong and significant negative relationships between decisional conflict and health literacy, social support, self-efficacy and each of their dimensions (r=-0.14-0.27, P<0.01 or P<0.05). (3) The path analysis showed that health literacy directly affects decisional conflict (β=-0.282); additionally, health literacy indirectly affects decisional conflict through social support (β=-0.319), self-efficacy (β=-0.010) and through the chain mediating effect of social support and self-efficacy (β=-0.008).

Conclusion

Patients with stable schizophrenia have serious decisional conflict in China, and necessary interventions have to be made. This study found that social support and self-efficacy mediate the relationship between health literacy and decisional conflict in patients with stable schizophrenia in China. Healthcare professionals should emphasize health literacy education for patients, and implement pathway-based targeted interventions to improve health literacy, reduce decisional conflict, and promote the recovery of patients with stable schizophrenia.

An Occupational Health Literacy Intervention in Nursing Homes Improved Organizational Health Literacy-A Quasi-Experimental Stepped Wedge Cluster Trial

OBJECTIVE

This study examined the effectiveness of a workplace health literacy intervention on individual, interpersonal, and organizational health literacy.

METHOD

Using a quasi-experimental stepped wedge cluster design, we evaluated an intervention for 509 nursing home employees with two elements: 1) courses for employees and management on pain prevention, management, and communication and 2) structured dialogues between employees and supervisors, emphasizing pain prevention.

RESULTS

One organizational health literacy item improved, with supervisors helping with pain prevention increasing by 0.42 points (95% CI 0.11;0.73). Positive trends were observed in supervisor actions when informed about pain (0.39 points, 95% CI -0.09;0.86), ease of finding workplace pain solutions (0.12 points, 95% CI -0.03;0.79), and employees having pain management information (0.44 points, 95% CI -0.03;0.92).

CONCLUSION

The intervention improved one organizational health literacy item, with positive trends in three other items.

Survey on health literacy and related factors among firefighters of emergency management departments in Southwest China

OBJECTIVE

Although health literacy (HL) has emerged as a critical public health concern, research on HL in emergency management departments is limited. This study aimed to investigate the awareness of HL and associated factors among firefighters of emergency management departments in southwest China to provide a basis for carrying out targeted health education.

METHODS

A cross-sectional convenience sample of 1,742 firefighters from an emergency management department in southwestern China was surveyed from February to April 2023 using the Chinese Citizen's Health Literacy Questionnaire (2019 version). The chi-square test, linear trend chi-square test, Fisher's test, rank sum test, and multifactorial logistic regression model were used to identify influential factors associated with HL.

RESULTS

The HL level of the 1742 respondents was 34.3%. Age, ethnicity, education level, length of service, type of job, smoking status, types of parental jobs, annual household income, time of daily internet use, etc. (P < 0.05). The results of multivariate logistic regression analysis indicate that type of job (OR = 0.648, 95%CI:0.426-0.985), length of service (OR = 0.496, 95%CI:0.251-0.981), household income (OR = 1.900, 95%CI:1.443-2.502), daily internet usage time (OR = 0.726, 95%Cl:0.588-0.896), health status (OR = 0.750, 95%Cl:0.585-0.962) and frequency of organizing HL sessions (OR = 1.603, 95%Cl:1.101-2.330) were influencing factors affecting the HL of the officers and soldiers.

CONCLUSION

The health literacy level of firefighters in the Emergency Management Department in Southwest China was 34.3%. Lower levels were found in the health-related skills dimension (HRS, 30.1%) and in infectious disease control (ID, 30.7%). Health information literacy (HI, 34.3%) was lower than the national level. The type of urban and rural areas, literacy level, and household income level may be the factors affecting the level of health literacy among the respondents. Therefore, health education and promotion interventions should target high priority dimensions (HRS, HI, and ID) and should focus on strengthening health literacy levels of firefighters with rural types, low education levels, and low household income to improve their health.

Indigenizing Cardiac Rehabilitation: The Role for Cultural Adaptation

Cardiac rehabilitation (CR) is an integral component of cardiovascular care, which reduces morbidity and mortality, and improves quality of life. Largely as a result of Canada's colonial history, Indigenous communities face higher rates of cardiovascular morbidity and mortality. Indigenous Peoples in Canada have a unique cultural, historical, and geographic context that limits access to high-quality cardiovascular care, including CR, which has traditionally been delivered in an urban, hospital-based setting. Culturally adapted, holistic exercise and diet programs and CR programs have been successful in Canada, Australia, and New Zealand, demonstrating acceptability to the community, safety, and improvements in cardiovascular risk factors. Key components of a successful culturally adapted CR program include program leadership and development by Indigenous community members and key partners, cultural sensitivity training for health care providers and financial and geographic accessibility. Encouragement of traditional practices, including healthy traditional dietary practices, and recognizing land-based activities as exercise have also proved important in the successful delivery of CR in Indigenous communities. This review summarizes the current evidence for culturally adapted CR programming for Indigenous patients, including strategies to engage communities in education on cardiovascular risk-factor optimization and to promote guideline-based exercise and diet through an Indigenous lens.

Systematic review of Internet of medical things for cardiovascular disease prevention among Australian first nations

Chronic diseases within Indigenous communities constitute the most compelling ill-health burdens and treatment inequalities, particularly in rural and remote Australia. In response to these vital issues, a systematic literature review of the adoption of wearable, Artificial Intelligence-driven, electrocardiogram sensors, in a telehealth Internet of Medical Things (IoMT) context was conducted to scale up rural Indigenous health. To this end, four preselected scientific databases were chosen for data extraction to align with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) technique. From the initially collected (n = 4436 ) articles, a total of 32 articles were analysed, being synthesised from the review inclusion criteria, maintaining strict eligibility and eliminating duplicates. None of the various studies found on this innovative healthcare intervention has given a comprehensive picture of how this could be an effective method of care dedicated to rural Indigenous communities with cardiovascular diseases (CVDs). Herein, we presented the unique concepts of IoMT-driven wearable biosensors tailored for rural indigenous cardiac patients, their clinical implications, and cardiovascular disease management within the telehealth domain. This work contributes to understanding the adoption of wearable IoMT sensor-driven telehealth model, highlighting the need for real-time data from First Nations patients in rural and remote areas for CVD prevention. Pertinent implications, research impacts, limitations and future research directions are endorsed, securing long-term Wearable IoMT sensor-driven telehealth sustainability.

Health Literacy in Adults with Chronic Diseases in the Context of Community Health Nursing: A Scoping Review

Background: Health literacy was identified as a main determinant in self-care of chronic diseases. This results in responsibilities for health professionals for daily practice. For primary care setting, special requirements arise due to the heterogeneity of communities. The objective of this scoping review was to explore and map the scope of the research material on strategies led by community health nurses to improve health literacy in (patients with) chronic diseases. This review aimed to identify gaps in the literature and existing approaches on promoting health literacy by community nurse practitioners. Methods: The following criteria were included for the research: Adults with chronic diseases, health literacy, community health nursing and primary healthcare. All types of searches for studies from 1970 to present were carried out in electronic databases and in a Google and a Google Scholar search. The search procedure is presented in a flow chart. Results: From all reviewed studies, nine records were included in the review. Findings with regard to the increase in health literacy in self-management of chronically ill patients were identified. Conclusion: Studies focusing on specific demands with regard to the role of community health nurses need to be carried out in depth.

Urbanization and cardiovascular health among Indigenous groups in Brazil

BACKGROUND

We described the prevalence of cardiovascular risk factors in groups of Brazilian Indigenous people at different degrees of urbanization.

METHODS

The Project of Atherosclerosis among Indigenous populations (Projeto de Aterosclerose em Indígenas; PAI) is a cross-sectional study conducted in Northeast Brazil between August 2016-June 2017. It included three populations: Fulni-ô Indigenous people (lowest degree of urbanization), Truká Indigenous people (greater urbanization), and a highly urbanized non-Indigenous local cohort (control group). Participants were assessed to register sociodemographic, anthropometric, as well as clinical and laboratory-derived cardiovascular (CV) risk parameters. Age-adjusted prevalence of hypertension was also computed. Nonparametric tests were used for group comparisons.

RESULTS

Here we included 999 participants, with a predominance of females in all three groups (68.3% Control group, 65.0% Fulni-ô indigenous group, and 60.1% Truká indigenous group). Obesity was present in 45.6% of the urban non-Indigenous population, 37.7% Truká and in 27.6% Fulni-ô participants. The prevalence of hypertension was 29.1% (n = 297) with lower prevalence in the less urbanized Fulni-ô people (Fulni-ô - 18.2%; Truká - 33.9%; and Control - 33.8%; p < 0.001). In the elderly male population, the prevalence of hypertension was 18.7% in the Fulni-ô, 45.8% in the Truká, and 54.5% in the control group. Of the 342 participants that self-reported hypertension, 37.5% (n = 68) showed uncontrolled blood pressure (BP). Uncontrolled BP was more prevalent among Truká people when compared to Fulni-ô people and non-Indigenous participants (45.4%, 22.9%, and 40.7%, respectively; p < 0.001).

CONCLUSIONS

We found a higher cardiovascular risk in communities with a higher degree of urbanization, suggesting that living in towns and cities may have a negative impact on these aspects of cardiovascular health.

"A bit of everything": Health literacy interventions in chronic conditions - a systematic review

OBJECTIVE

To systematically evaluate health literacy (HL) interventions in chronic conditions by exploring theoretical perspectives, intervention content and effectiveness.

METHOD

We searched MEDLINE, Cochrane, CINAHL, EMBASE, ERIC, Web of Science and PsycINFO. Standardised systematic review methods were used, and sequences informing our research question were extracted and analysed. The study includes a descriptive summary of the included papers.

RESULTS

We included 39 unique interventions, with diabetes and heart disease as the most targeted chronic conditions. Fifty-four percent of papers included a definition of HL, but the studies showed significant heterogeneity of theoretical underpinnings, modes, measures and content. We identified 23 HL measures, mostly assessing functional HL. The HL interventions were often more complex than the measures indicated. A significant change in HL was found in 28 studies. Study quality was generally poor.

CONCLUSIONS

Interventions optimizing HL appear important to improve health outcomes in chronic conditions. To ensure cumulative knowledge development of this field we need theory-based interventions, consistency in methods and more tailored and comprehensive measures to capture the interventions' complexity.

PRACTICE IMPLICATIONS

A more valid understanding of HL interventions and measurements is needed to reach an agreed understanding of their components and intentions.

Access to Cardiovascular Care for Indigenous Peoples in Canada: A Rapid Review

Indigenous peoples in Canada are at an increased risk of cardiovascular disease compared to non-Indigenous people. Contributing factors include historical oppression, racism, healthcare biases, and disparities in terms of the social determinants of health. Access to and inequity in cardiovascular care for Indigenous peoples in Canada remain poorly studied and understood. A rapid review of the literature was performed using the PubMed/MEDLINE, Web of Science, and Indigenous Studies Portal (iPortal) databases to identify articles describing access to cardiovascular care for Indigenous peoples in Canada between 2002 and 2021. Included articles were presented narratively in the context of delays in seeking, reaching, or receiving care, or as disparities in cardiovascular outcomes, and were assessed for their successful engagement in indigenous health research using a preexisting framework. Current research suggests that gaps most prominently present as delays in receiving care and as poorer long-term outcomes. The literature is concentrated in Alberta, Manitoba, and Ontario, as well as among First Nations people, and is largely rooted in a biomedical worldview. Additional community-driven research is required to better elucidate the gaps in access to holistic cardiovascular care for Indigenous peoples in Canada. Healthcare professionals, researchers, and policymakers should reflect further upon their actions and privilege, educate themselves about historical facts and the Truth and Reconciliation Commission, tackle prevailing disparities and systemic barriers in the healthcare systems, and develop culturally safe and ethically appropriate healthcare interventions to improve the health of all Indigenous peoples in Canada.

Medium-term outcomes from mitral valve surgery for rheumatic heart disease in young adults in Aotearoa New Zealand: a cohort study

BACKGROUND

Rheumatic heart disease (RHD) remains an important cause of morbidity and mortality in New Zealand. Factors associated with the choice of surgical treatment for advanced RHD in young adults are poorly understood. We sought to review our local experience with the surgical management of young adults with rheumatic mitral valvular disease.

METHODS

From 2003 to 2016, all patients aged 15-24 years undergoing mitral valve surgery for rheumatic disease at Auckland City Hospital, New Zealand were retrospectively reviewed.

RESULTS

During the 13-year study period, 73 young adults underwent mitral surgery; 85% were Maori or Pacific Islanders. Mitral repair was performed in 32 patients and replacement in 41 patients. Isolated mitral valve surgery was performed in 36%, double valve procedures in 47%, and triple valve procedures in 17% of patients. The 30-day mortality rate and stroke rate were 1.4% and 2.7% respectively. The medium-term mortality rate was 11.9% across a mean follow-up of 6 years (6.9% in the repair group, 15.8% in the replacement group, p = 0.25). There were increased bleeding complications (p = 0.04) in patients with mechanical mitral valve replacement. For patients on warfarin, across medium-term follow-up, the INR was in the therapeutic range only 23% of the time.

CONCLUSION

Most young adults in New Zealand with severe RHD requiring surgery are of indigenous Maori or Pacific Island ethnicity. There is a trend towards improved survival with mitral repair. There is a significant tendency towards increased bleeding complications in patients on warfarin for mechanical mitral replacement. Warfarin compliance is poor.

Health promotion interventions supporting Indigenous healthy ageing: a scoping review

Aging well is a priority in Canada and globally, particularly for older Indigenous adults experiencing an increased risk of chronic conditions. Little is known about health promotion interventions for older Indigenous adults and most literature is framed within Eurocentric paradigms that are not always relevant to Indigenous populations. This scoping review, guided by Arksey and O'Malley's framework and the PRISMA-ScR Checklist, explores the literature on Indigenous health promoting interventions across the lifespan, with specific attention to Indigenous worldview and the role of older Indigenous adults within these interventions. To ensure respectful and meaningful engagement of Indigenous peoples, articles were included in the Collaborate or Shared Leadership categories on the Continuum of Engagement. Fifteen articles used Indigenous theories and frameworks in the study design. Several articles highlighted engaging Elders as advisors in the design and/or delivery of programs however only five indicated Elders were active participants. In this scoping review, we suggest integrating a high level of community engagement and augmenting intergenerational approaches are essential to promoting health among Indigenous populations and communities. Indigenous older adults are keepers of essential knowledge and must be engaged (as advisors and participants) in intergenerational health promotion interventions to support the health of all generations.

The Health Literacy Status and Its Role in Interventions in Iran: A Systematic and Meta-Analysis

There are increasing calls for public health policies to realize the visions of a health literate society and health literacy on a global scale. However, there are still more gaps in what researchers recognize and what steps they should take to improve health literacy (HL) skills. This review aimed to measure the HL status of the Iranian population and the effect size of the underlying association between HL and other health outcomes, and to examine the effectiveness of HL interventions on improving the functional dimension of HL, self-efficacy, and health-promoting behaviors. All full text published articles written in English and Persian language were included from inception until January 2019, but the type of study is not limited. A total of 52 potentially relevant articles with data on 36,523 participants were included in this review. In the population with health conditions, the average HL score was 62.51 (95% CI: 59.95-65.08), while in the patient population, the HL score was 64.04 (95% CI: 60.64-67.45). Health literacy was positively and significantly correlated with self-care behaviors 0.42 (95% CI; 0.35-0.49), self-efficacy 0.35 (95% CI; 0.26-0.43), knowledge 0.50 (95% CI; 0.44-0.55), communication skills 0.33 (95% CI; 0.25-0.41), and health promotion behaviors 0.39 (95% CI; 0.35-0.44). The meta-analyses showed that overall, HL interventions significantly improved HL status, self-efficacy, and health promotion behaviors. Results indicate that HL status was in the range of marginal HL level in the Iranian population. Our finding highlights the beneficial impact of HL intervention on health-promoting behaviors and self-efficacy, particularly in low literacy/socioeconomic status people.

Interventions to improve health literacy among Aboriginal and Torres Strait Islander Peoples: a systematic review

BACKGROUND

Aboriginal and Torres Strait Islander peoples continue to experience poorer health outcomes than other population groups. While data specific to Indigenous Australians are scarce, a known social health literacy gradient exists linking low health literacy and poor health outcomes within many minority populations. Improving health literacy among Indigenous Australians is an important way to support self-determination and autonomy in both individuals and communities, by enhancing knowledge and improving health outcomes. This review aims to rigorously examine the effectiveness of health literacy interventions targeting Aboriginal and Torres Strait Islander peoples.

METHODS

A systematic review across six databases (The Cochrane Library, PubMed, Embase, SCOPUS, ProQuest Dissertation and Thesis and Web of Science) was performed for publications evaluating interventions to improve health literacy among Indigenous Australian adults using search terms identifying a range of related outcomes.

RESULTS

Of 824 articles retrieved, a total of five studies met the eligibility criteria and were included in this review. The included studies evaluated the implementation of workshops, structured exercise classes and the provision of discounted fruit and vegetables to improve nutrition, modify risk factors for chronic diseases, and improve oral health literacy. All interventions reported statistically significant improvement in at least one measured outcome. However, there was limited involvement of the Aboriginal and Torres Strait Islander community members in the research process and participant retention rates were sub-optimal.

CONCLUSION

There is limited evidence on interventions to improve health literacy in Indigenous Australian adults. Participation in interventions was often suboptimal and loss to follow-up was high. Future studies co-designed with Aboriginal and Torres Strait Islander community members are needed to improve health literacy in this population.

What do you mean by engagement? - evaluating the use of community engagement in the design and implementation of chronic disease-based interventions for Indigenous populations - scoping review

BACKGROUND

Indigenous populations have remained strong and resilient in maintaining their unique culture and values, despite centuries of colonial oppression. Unfortunately, a consequential result of facing years of adversity has led Indigenous populations to experience a disproportionate level of poorer health outcomes compared to non-Indigenous populations. Specifically, the rate of Indigenous chronic disease prevalence has significantly increased in the last decade. Many of the unique issues Indigenous populations experience are deeply rooted in their colonial history and the intergenerational traumas that has subsequently impacted their physical, mental, emotional and spiritual well-being. With this, to better improve Indigenous health outcomes, understanding the local context of their challenges is key. Studies have begun to use modes of community engagement to initiate Indigenous partnerships and design chronic disease-based interventions. However, with the lack of a methodological guideline regarding the appropriate level of community engagement to be used, there is concern that many interventions will continue to fall short in meeting community needs.

OBJECTIVE

The objective of this study was to investigate the how various community engagement strategies have been used to design and/or implement interventions for Indigenous populations with chronic disease.

METHODS

A scoping review guided by the methods outlined by Arksey and O'Malley was conducted. A comprehensive search was completed by two reviewers in five electronic databases using keywords related to community engagement, Indigenous health and chronic disease. Studies were reviewed using a descriptive-analytical narrative method and data was categorized into thematic groups reflective of the main findings.

RESULTS

We identified 23 articles that met the criteria for this scoping review. The majority of the studies included the use a participatory research model and the procurement of study approval. However, despite the claimed use of participatory research methods, only 6 studies had involved community members to identify the area of priority and only five had utilized Indigenous interview styles to promote meaningful feedback. Adapting for the local cultural context and the inclusion of community outreach were identified as the key themes from this review.

CONCLUSION

Many studies have begun to adopt community engagement strategies to better meet the needs of Indigenous Peoples. With the lack of a clear guideline to approach Indigenous-based participatory research, we recommend that researchers focus on 1) building partnerships, 2) obtaining study approval and 3) adapting interventions to the local context.

mHealth education interventions in heart failure

BACKGROUND

Heart failure (HF) is a chronic disease with significant impact on quality of life and presents many challenges to those diagnosed with the condition, due to a seemingly complex daily regimen of self-care which includes medications, monitoring of weight and symptoms, identification of signs of deterioration and follow-up and interaction with multiple healthcare services. Education is vital for understanding the importance of this regimen, and adhering to it. Traditionally, education has been provided to people with heart failure in a face-to-face manner, either in a community or a hospital setting, using paper-based materials or video/DVD presentations. In an age of rapidly-evolving technology and uptake of smartphones and tablet devices, mHealth-based technology (defined by the World Health Organization as mobile and wireless technologies to achieve health objectives) is an innovative way to provide health education which has the benefit of being able to reach people who are unable or unwilling to access traditional heart failure education programmes and services.

OBJECTIVES

To systematically review and quantify the potential benefits and harms of mHealth-delivered education for people with heart failure.

SEARCH METHODS

We performed an extensive search of bibliographic databases and registries (CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, IEEE Xplore, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) Search Portal), using terms to identify HF, education and mHealth. We searched all databases from their inception to October 2019 and imposed no restriction on language of publication.

SELECTION CRITERIA

We included studies if they were conducted as a randomised controlled trial (RCT), involving adults (≥ 18 years) with a diagnosis of HF. We included trials comparing mHealth-delivered education such as internet and web-based education programmes for use on smartphones and tablets (including apps) and other mobile devices, SMS messages and social media-delivered education programmes, versus usual HF care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias, and extracted data from all included studies. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the odds ratio (OR) for dichotomous data with a 95% confidence interval (CI). We assessed heterogeneity using the I2 statistic and assessed the quality of evidence using GRADE criteria.

MAIN RESULTS

We include five RCTs (971 participants) of mHealth-delivered education interventions for people with HF in this review. The number of trial participants ranged from 28 to 512 participants. Mean age of participants ranged from 60 years to 75 years, and 63% of participants across the studies were men. Studies originated from Australia, China, Iran, Sweden, and The Netherlands. Most studies included participants with symptomatic HF, NYHA Class II - III. Three studies addressed HF knowledge, revealing that the use of mHealth-delivered education programmes showed no evidence of a difference in HF knowledge compared to usual care (MD 0.10, 95% CI -0.2 to 0.40, P = 0.51, I2 = 0%; 3 studies, 411 participants; low-quality evidence). One study assessing self-efficacy reported that both study groups had high levels of self-efficacy at baseline and uncertainty in the evidence for the intervention (MD 0.60, 95% CI -0.57 to 1.77; P = 0.31; 1 study, 29 participants; very low-quality evidence).Three studies evaluated HF self-care using different scales. We did not pool the studies due to the heterogenous nature of the outcome measures, and the evidence is uncertain. None of the studies reported adverse events. Four studies examined health-related quality of life (HRQoL). There was uncertainty in the evidence for the use of mHealth-delivered education on HRQoL (MD -0.10, 95% CI -2.35 to 2.15; P = 0.93, I2 = 61%; 4 studies, 942 participants; very low-quality evidence). Three studies reported on HF-related hospitalisation. The use of mHealth-delivered education may result in little to no difference in HF-related hospitalisation (OR 0.74, 95% CI 0.52 to 1.06; P = 0.10, I2 = 0%; 3 studies, 894 participants; low-quality evidence). We downgraded the quality of the studies due to limitations in study design and execution, heterogeneity, wide confidence intervals and fewer than 500 participants in the analysis.

AUTHORS' CONCLUSIONS

We found that the use of mHealth-delivered educational interventions for people with HF shows no evidence of a difference in HF knowledge; uncertainty in the evidence for self-efficacy, self-care and health-related quality of life; and may result in little to no difference in HF-related hospitalisations. The identification of studies currently underway and those awaiting classification indicate that this is an area of research from which further evidence will emerge in the short and longer term.

'Dudes Are Meant to be Tough as Nails': The Complex Nexus Between Masculinities, Culture and Health Literacy From the Perspective of Young Aboriginal and Torres Strait Islander Males - Implications for Policy and Practice

Health literacy is generally conceptualized as skills related to successfully navigating health - ultimately linked to well-being and improved health outcomes. Culture, gender and age are considered to be influential determinants of health literacy. The nexus between these determinants, and their collective relationship with health literacy, remains understudied, especially with respect to Indigenous people globally. This article presents findings from a recent study that examined the intersections between masculinities, culture, age and health literacy among young Aboriginal and Torres Strait Islander males, aged 14-25 years in the Northern Territory, Australia. A mixed-methods approach was utilized to engage young Aboriginal and Torres Strait Islander males. The qualitative components included Yarning Sessions and Photovoice using Facebook, which are used in this article. Thematic Analysis and Framework Analysis were used to group and analyse the data. Ethics approval was granted by Charles Darwin University Human Research Ethics Committee (H18043). This cohort constructs a complex interface comprising Western and Aboriginal cultural paradigms, through which they navigate health. Alternative Indigenous masculinities, which embrace and resist hegemonic masculine norms simultaneously shaped this interface. External support structures - including family, friends and community engagement programs - were critical in fostering health literacy abilities among this cohort. Young Aboriginal and Torres Strait Islander males possess health literacy abilities that enable them to support the well-being of themselves and others. Health policymakers, researchers and practitioners can help strengthen and expand existing support structures for this population by listening more attentively to their unique perspectives.

Patient activation and Type 2 diabetes mellitus self-management: a systematic review and meta-analysis

Patient activation has been recognised as a reliable driver of self-management decision-making. This systematic review and meta-analysis examines existing evidence on whether embedding patient activation within Type 2 diabetes mellitus (T2DM) self-management programs can improve patient outcomes. This review has included 10 randomised controlled trials (RCTs) conducted between 2004 and 2019 retrieved from well-known databases such as MEDLINE, PubMed, CINAHL Plus, Scopus, ProQuest and ScienceDirect. The eligible RCTs were excluded if they scored low according to Cochrane Collaboration’s ‘risk of bias’ criteria. Random-effects meta-analyses showed that there were no significance changes in haemoglobin A1C (HbA1c), body mass index (BMI) and patient activation measure (PAM) between intervention and control groups after the intervention; however, the systematic review findings indicated that an improved patient activation level led to significant improvements in T2DM self-management and clinical outcomes including HbA1c level. Studies with a longer follow-up period conducted in community settings and delivered by peer coaches were more likely to lead to significant improvement in both patient activation levels and T2DM self-management and clinical outcomes. This review concludes that patient activation can be used as a reliable tool for improving T2DM self-management and clinical outcomes.

The effectiveness of preventive counseling with the use of remote technologies on medical awareness of cardiovascular risk factors in patients with high and very high cardiovascular risk

Purpos. To assess the effectiveness of preventive counseling with focus on diet modification followed by remote support via telephone on awareness of cardiovascular (CV) risk factors (RFs) in patients (pts) with high/very high CV risk. Material and methods. This is a prospective randomized controlled study of 100 pts with high/very high CV risk (5-9% and ≥10% according to the SCORE scale) and any 2 criteria for metabolic syndrome.  Pts were randomized into 2 groups in 1:1 ratio - the intervention group (n=50) and the control group (n=50). The intervention group received comprehensive preventive counseling with focus on diet modification followed by remote preventive counseling by phone every two weeks for the first 3 months after enrollment (a total of 6 sessions). The control group received usual care in Health centers which also included basic preventive counseling. A specially designed questionnaire was used to evaluate the awareness of the basic CV RFs, including open questions. The awareness was assessed at baseline, 6 and 12 months. Results. The groups were well balanced according to demographic and clinical features. The results of the study revealed an extremely low awareness of major CV RFs of pts in both groups at baseline: practically none of them indicated as RFs for cardiovascular disease elevated cholesterol (8,0% and 4,0%, respectively) and blood pressure (14.0% and 4.0%). At 6 month the level of awareness of CV RFs has increased significantly. Moreover, pts of the intervention group were more informed about elevated cholesterol (58,0% vs. 28,0%; p<0,01) and unhealthy diet (76,0% vs. 52,0%; p<0,05). At 12 month the level of awareness of CV RFs was significantly higher in both groups  to compare from baseline. Conclusion. Preventive counseling with focus on diet modification followed by 3 months  remote support via phone provided a significant improvement of awareness of CV RFs in pts with high/very high CV risk.

Understandings of disease among Pacific peoples with diabetes and end-stage renal disease in New Zealand

BACKGROUND

Compared with New Zealand Europeans, Pacific peoples in New Zealand develop type 2 diabetes at a higher rate and a younger age, and have 3.8 times higher incidence of end-stage renal disease (ESRD).

OBJECTIVE

To investigate contextual factors that shape understandings of disease for Pacific peoples with diabetes and ESRD.

METHODS

Focussed ethnography. In-depth interviews were conducted with 16 Pacific people on haemodialysis for diabetic ESRD, in Auckland, New Zealand. Study participants aged between 30 and 69 years old were of Samoan, Cook Islander, Tongan, Niuean or Tokelauan ethnicity. Thematic analysis was used to code and identify themes.

RESULTS

Participants were embedded in a multigenerational legacy of diabetes. The limited diabetes-related education of earlier generations influenced how future generations behaved and understood diabetes. Perceptions were compounded by additional factors including the invisibility of early-stage diabetes; misunderstandings of health risks during communication with health providers; and misunderstandings of multiple conditions' symptoms and management. Participants had limited engagement with health services until their diagnosis of ESRD acted as a trigger to change this behaviour. However, this trigger was not effective in itself-rather, it was in combination with relevant education delivered in a way that made sense to participants, given their current understandings.

CONCLUSIONS

Illness representations drive choices and behaviours with respect to self-management of diabetes and engagement with health services. Diabetes is often present in multiple generations of Pacific people; therefore, illness representations are developed and shared within a family. Changing illness representations requires engagement with the individual within a family context.

Geographical analysis of evaluated chronic disease programs for Aboriginal and Torres Strait Islander people in the Australian primary health care setting: a systematic scoping review

BACKGROUND

Targeted chronic disease programs are vital to improving health outcomes for Indigenous people globally. In Australia it is not known where evaluated chronic disease programs for Aboriginal and Torres Strait Islander people have been implemented. This scoping review geographically examines where evaluated chronic disease programs for Aboriginal people have been implemented in the Australian primary health care setting. Secondary objectives include scoping programs for evidence of partnerships with Aboriginal organisations, and use of ethical protocols. By doing so, geographical gaps in the literature and variations in ethical approaches to conducting program evaluations are highlighted.

METHODS

The objectives, inclusion criteria and methods for this scoping review were specified in advance and documented in a published protocol. This scoping review was undertaken in accordance with the Joanna Briggs Institute (JBI) scoping review methodology. The search included 11 academic databases, clinical trial registries, and the grey literature.

RESULTS

The search resulted in 6894 citations, with 241 retrieved from the grey literature and targeted organisation websites. Title, abstract, and full-text screening was conducted by two independent reviewers, with 314 citations undergoing full review. Of these, 74 citations evaluating 50 programs met the inclusion criteria. Of the programs included in the geographical analysis (n = 40), 32.1% were implemented in Major Cities and 29.6% in Very Remote areas of Australia. A smaller proportion of programs were delivered in Inner Regional (12.3%), Outer Regional (18.5%) and Remote areas (7.4%) of Australia. Overall, 90% (n = 45) of the included programs collaborated with an Aboriginal organisation in the implementation and/or evaluation of the program. Variation in the use of ethical guidelines and protocols in the evaluation process was evident.

CONCLUSIONS

A greater focus on the evaluation of chronic disease programs for Aboriginal people residing in Inner and Outer Regional areas, and Remote areas of Australia is required. Across all geographical areas further efforts should be made to conduct evaluations in partnership with Aboriginal communities residing in the geographical region of program implementation. The need for more scientifically and ethically rigorous approaches to Aboriginal health program evaluations is evident.

Effect of a community-based participatory health literacy program on health behaviors and health empowerment among community-dwelling older adults: A quasi-experimental study

This study evaluated the effect of a community-based participatory health literacy program aimed at improving the health behaviors and health empowerment for older adults. A two-group pretest and posttest quasi-experimental design with surveys conducted at baseline (T₁), immediately after the intervention (T₂), and 6 months after the intervention (T₃). The intervention group (n = 94) attended a 12-week health literacy program; while the comparison group (n = 78) did not. The results demonstrated that intervention group had significantly better health behavior practices for weight control (OR = 3.71, 95% CI = 1.59-8.64), regular exercise (OR = 15.26, 95% CI = 1.92-121.13), and health information navigation (OR = 2.61, 95% CI = 1.16-5.84). Health empowerment was significantly higher in the intervention group than the comparison group (p < 0.01).This study suggests that integrating community-based participatory design is effective in improving some health behaviors and health empowerment in older adults over a short period.

Association of health literacy and diabetes self-management: a systematic review

The purpose of this review is to summarise the existing evidence about the association of health literacy (HL) with type 2 diabetes mellitus self-management. The PubMed, Medline, CINHAL, Scopus and Web of Science databases were searched for randomised control trials of type 2 diabetes mellitus (T2DM) self-management and HL published between 2009 and 2018. Fourteen randomised control trials were included in this review. Our findings showed that HL was instrumental in improving diabetes knowledge, physical activity, self-efficacy and quality of life; however, its associations with glycaemic control, self-monitoring of blood glucose, foot care and medication adherence was inconclusive. Customized and community-based HL interventions were more efficient compared to patient-focused HL interventions. This review concludes that HL is key for T2DM self-management, but customised, structured and community-based interventions are more likely to yield better outcomes.