Professor Bunmi Malau-Aduli

OBJECTIVE: This study aimed to assess the prognostic accuracies of Doppler ultrasound measures in predicting adverse perinatal outcomes for pregnancies complicated with preexisting or gestational diabetes mellitus. DATA SOURCES: An online database search of MEDLINE, Cochrane, Embase, CINAHL, Scopus, and Emcare from inception to April 2022 was conducted. STUDY ELIGIBILITY CRITERIA: Studies reporting singleton, nonanomalous fetuses of women with either preexisting (type 1 or 2 diabetes mellitus) or gestational diabetes mellitus during pregnancy were included. In addition, the included studies assessed cerebroplacental ratio and middle cerebral artery and/or umbilical artery pulsatility index in the prediction of either: preterm birth, cesarean delivery for fetal distress, APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score <7 at 5 minutes, neonatal intensive care unit admission (>24 hours), acute respiratory distress syndrome, jaundice, hypoglycemia, hypocalcemia, or neonatal death. METHODS: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed and 610 articles were identified, of which 15 were included. Two authors independently extracted prognostic data from each article and assessed the study applicability and risk of bias using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) scoring criteria. RESULTS: A total of 15 studies were included in the review and comprised prospective (n=10; 66%) and retrospective (n=5; 33%) cohorts. Sensitivity and positive predictive values varied widely across each Doppler measurement. Umbilical artery sensitivities were higher than those of cerebroplacental ratio and middle cerebral artery for hypoglycemia, jaundice, neonatal intensive care unit admission, respiratory distress, and preterm birth. Cerebroplacental ratio was the most reported index test; however, prognostic accuracy was worse than that of umbilical artery and middle cerebral artery Doppler across all adverse perinatal outcomes. Significant risk of bias was present in 14 (94%) studies, with substantial heterogeneity observed across studies in terms of study design and outcomes assessed. CONCLUSION: Abnormal umbilical artery pulsatility index may be of more clinical value in predicting adverse perinatal outcomes compared with cerebroplacental ratio and middle cerebral artery pulsatility index in diabetic pregnancies. Further evaluation of umbilical artery Doppler measurements in diabetic pregnancies using standardized variables across studies is required for broader clinical application. The significant association between abnormal Doppler measurement and hypoglycemia may warrant further investigation.

Novel warnings on individual cigarettes represent a potentially effective means for reducing tobacco use. This study evaluated perceptions of Australians towards health warnings on cigarettes. Participants rated and commented on their perceived effectiveness of current cigarette packaging warnings, and 12 text warnings (divided into four themes) on cigarette sticks in preventing non-smokers from smoking, and prompting current smokers to quit. Quantitative data were analysed using proportional odds logistic regression, and qualitative data using conceptual content analysis. From 637 participants, three themes were rated as more effective than current cigarette packaging warnings: mortality statistics, health condition consequences, and social and financial consequences of smoking. Packaging warnings were perceived as less effective due to desensitisation and smoker self-exemption. Stick warnings were considered more novel and engaging, especially the financial costs of smoking. Novel warnings on cigarettes that describe a broader range of consequences of smoking may be effective in combatting tobacco use.

Background: The Ghanaian government has implemented interventions that integrate traditional medicine (TM) into its national health system in response to the high prevalence of TM use. However, empirical evidence of the experiences of service users and the practice of integrated health in Ghana is scanty. Therefore, this study explored the experiences of people with TM integration into the formal health system in Ashanti region using an adapted TM integration framework. Methods: A sequential explanatory mixed methods study design comprising survey administration and in-depth interviews for data collection was utilised to address the research objective. Framework analysis was used in analysing the qualitative data and for triangulation of results. Results: Participants were aware of licensing and training of TM practitioners in a science-based university in Ghana. However, knowledge of the existence of TM units in selected hospitals in the region was minimal. Integration knowledge was largely influenced by sex, marital status, household size and residential status, where males and urban dwellers were more familiar with the process than females and rural dwellers. Low patronage of integrated health services in the region was attributable to weak cross referrals. However, service users who had engaged with the integrated system recounted a satisfactory outcome. Conclusion: Service users¿ unfamiliarity with the presence of integrated facilities in Ghana could be an impediment to the practice of integrated healthcare. Sensitisation of the public about the practice of an integrated system could refine the Ghanaian integrated system. Regular evaluation of patient satisfaction and outcome measures might also serve as an effective strategy for improving health services delivery since evaluation is becoming an important component of health service design and implementation. There is the need for future studies to focus on exploring the perceptions and experiences of health practitioners and hospital administrators¿regarding the practice of integrated health in Ghana.

Background: Perceived readiness for practice can help mitigate the stress and uncertainty associated with transitioning from university into the workforce. This study aimed to identify factors influencing the readiness for clinical practice among final-year medical, dental, and pharmacy students at an Australian regional university. Methods: The study utilised a sequential explanatory mixed-methods approach with surveys administered for the quantitative phase and interviews/focus groups for the qualitative phase. Descriptive statistics and inductive thematic analysis were utilised for the quantitative and qualitative data, respectively. Triangulation of findings from both phases facilitated in-depth understanding of the factors that influenced participants¿ self-perceived readiness for clinical practice. Results: From the three disciplines, 132 students completed the survey and 14 participated in the focus groups and interviews. Students felt most prepared in their patient-centred capabilities, core skills, and advanced consultation skills, and least prepared in their system-related capabilities and clinical care skills. Themes identified as essential enablers and confidence builders in relation to workforce readiness in all three disciplines were: gained knowledge and skills, value of clinical placement experiences, support from peers, family and staff. However, students felt their work-readiness was impaired by heavy academic workloads and poor knowledge of health care systems, which affected skills development. Participants suggested additional support in health care system and clinical governance, mental healthcare, and induction to placement sites to further improve their work readiness. Conclusions: The findings of this study suggest that improving work-readiness of healthcare students requires alignment of learning needs to real-world practice opportunities, ensuring support systems are appropriate, and early familiarisation with the healthcare system.

INTRODUCTION: Rural placements are an important component of rural medical education programs seeking to develop rural practice pathways for medical students. These placements are usually domestic, but James Cook University in Australia developed an international rural placement program in the first half of the medical course that was funded through bursaries. This study explores how the international rural placement helped to shape the lives (personal development and learning) of the participants, using Transformational Learning Theory as a framework for identifying and describing the transformational elements, process and impact of the program. METHODS: Sixty-five students received a bursary for an international rural placement between 2001-2019. All were contacted by email and invited to participate in a short survey and a follow-up interview. Fifteen participants agreed and twelve were able to participate in individual semi-structured interviews which were recorded, transcribed and analysed using inductive thematic analysis. RESULTS: Participants reported that the bursary provided a "once in a lifetime opportunity" to "experience eye-opening and culturally rich difference". Nonetheless, some elements of the placement experience presented disorientating dilemmas that triggered deep reflections and shifts in perceptions. The bursary recipients realised that "being open-minded" allowed them "enjoy good company". They were also able to assume "outsider view which allowed reassessment of their own country" and the "isolation experiences gingered desire to right health wrongs". The triggers and mental shifts had significant impact on the bursary recipients and fostered the development of "inspirational new horizons" based on an appreciation of the "value of rural practice" and "role-modelling for life-long learning." These findings are consistent with Transformational Learning Theory. CONCLUSION: Participants in this study reported meaningful and strongly positive impacts from the experiences gained during an international rural clinical placement early in their course. They described transformative experiences which appear to contribute strongly to personal development. This finding supports maintaining opportunities for international experiences during rurally-oriented medical programs as these may impact longer term career choice.

The Objective Structured Clinical Examination (OSCE) has been traditionally viewed as a highly valued tool for assessing clinical competence in health professions education. However, as the OSCE typically consists of a large-scale, face-to-face assessment activity, it has been variably criticized over recent years due to the extensive resourcing and relative expense required for delivery. Importantly, due to COVID-pandemic conditions and necessary health guidelines in 2020 and 2021, logistical issues inherent with OSCE delivery were exacerbated for many institutions across the globe. As a result, alternative clinical assessment strategies were employed to gather assessment datapoints to guide decision-making regarding student progression. Now, as communities learn to ¿live with COVID¿, health professions educators have the opportunity to consider what weight should be placed on the OSCE as a tool for clinical assessment in the peri-pandemic world. In order to elucidate this timely clinical assessment issue, this qualitative study utilized focus group discussions to explore the perceptions of 23 clinical assessment stakeholders (examiners, students, simulated patients and administrators) in relation to the future role of the traditional OSCE. Thematic analysis of the FG transcripts revealed four major themes in relation to participants' views on the future of the OSCE vis-a-vis other clinical assessments in this peri-pandemic climate. The identified themes are (a) enduring value of the OSCE; (b) OSCE tensions; (c) educational impact; and (d) the importance of programs of assessment. It is clear that the OSCE continues to play a role in clinical assessments due to its perceived fairness, standardization and ability to yield robust results. However, recent experiences have resulted in a diminishing and refining of its role alongside workplace-based assessments in the new, peri-pandemic programs of assessment. Future programs of assessment should consider the strategic positioning of the OSCE within the context of utilizing a range of tools when determining students' clinical competence.

Background: During 2020, the COVID-19 pandemic caused worldwide disruption to the delivery of clinical assessments, requiring medicals schools to rapidly adjust their design of established tools. Derived from the traditional face-to-face Objective Structured Clinical Examination (OSCE), the virtual OSCE (vOSCE) was delivered online, using a range of school-dependent designs. The quality of these new formats was evaluated remotely through virtual quality assurance (vQA). This study synthesizes the vOSCE and vQA experiences of stakeholders from participating Australian medical schools based on a Quality framework. Methods: This study utilized a descriptive phenomenological qualitative design. Focus group discussions (FGD) were held with 23 stakeholders, including examiners, academics, simulated patients, professional staff, students and quality assurance examiners. The data was analyzed using a theory-driven conceptual Quality framework. Results: The vOSCE was perceived as a relatively fit-for purpose assessment during pandemic physical distancing mandates. Additionally, the vOSCE was identified as being value-for-money and was noted to provide procedural benefits which lead to an enhanced experience for those involved. However, despite being largely delivered fault-free, the current designs are considered limited in the scope of skills they can assess, and thus do not meet the established quality of the traditional OSCE. Conclusions: Whilst virtual clinical assessments are limited in their scope of assessing clinical competency when compared with the traditional OSCE, their integration into programs of assessment does, in fact, have significant potential. Scholarly review of stakeholder experiences has elucidated quality aspects that can inform iterative improvements to the design and implementation of future vOSCEs.

Decision-making in clinical assessment, such as exit-level medical school Objective Structured Clinical Examinations (OSCEs), is complex. This study utilized an empirical phenomenological qualitative approach with thematic analysis to explore OSCE assessors' perceptions of the concept of a ¿prototypical intern¿ expressed during focus group discussions. Topics discussed included the concept of a prototypical intern, qualities to be assessed, and approaches to clinical assessment decision-making. The thematic analysis was then applied to a theoretical framework (Cultural Historical Activity Theory¿CHAT) that explored the complexity of making assessment decisions amidst potentially contradicting pressures from academic and clinical perspectives. Ten Australasian medical schools were involved with 15 experienced and five less experienced assessors participating. Thematic analysis of the data revealed four major themes in relation to how the prototypical intern concept influences clinical assessors' judgements: (a) Suitability of marking rubric based on assessor characteristics and expectations; (b) Competence as final year student vs. performance as a prototypical intern; (c) Safety, trustworthiness and reliability as constructs requiring assessment and (d) Contradictions in decision making process due to assessor differences. These themes mapped well within the interaction between two proposed activity systems in the CHAT model: academic and clinical. More clinically engaged and more experienced assessors tend to fall back on a heuristic, mental construct of a ¿prototypical intern,¿ to calibrate judgements, particularly, in difficult situations. Further research is needed to explore whether consensus on desirable intern qualities and their inclusion into OSCE marksheets decreases the cognitive load and increases the validity of assessor decision making.

Feedlot performance and carcass characteristics of tropical beef steers backgrounded on buffel grass (Cenchrus ciliaris) only or buffel grass oversown with desmanthus (Desmanthus spp. ; 11.5% initial sward botanical composition) were evaluated. It was hypothesized that tropical beef cattle steers backgrounded on buffel grass only or buffel grass oversown with desmanthus with similar backgrounding growth performance will not differ in feedlot growth performance and carcass quality. Three hundred and twelve Bos indicus × Bos taurus tropical composite steers, 20¿23 months old and weighing 413 ± 24 kg, previously backgrounded on buffel grass only or buffel-desmanthus mixed pastures for 147 days were finished on a concentrate diet in the feedlot for 110 days before slaughter. Buffel¿desmanthus backgrounded steers had a slightly higher average daily gain (ADG; 1.8 kg/day) than the buffel grass backgrounded steers that had 1.7 kg/day ADG (p < 0.01). However, the final live weight and dry matter intake were not different (p = 0.59). All the carcass traits measured were not different (p = 0.18). Only 4% buffel grass and 8% buffel-desmanthus backgrounded steers fell short of the Meat Standards Australia (MSA) index, a level that is within the 4¿9% reported for cattle produced in Queensland and slaughtered between July 2019 and June 2020. These findings indicate that desmanthus can be used to background beef cattle in northern Australia vertosol soil regions, where there is a paucity of adapted pasture legumes, with no negative impact on feedlot performance and carcass quality. The hypothesis that tropical beef cattle steers backgrounded on buffel grass only pastures or buffel grass oversown with desmanthus with similar backgrounding growth performance will have similar feedlot growth performance and carcass quality was accepted.

The challenge of educating children with special educational needs in the same mainstream classroom settings as their peers has been recognised internationally. Research suggests mainstream teachers are inadequately prepared for inclusive education. Herein, we explored teachers¿ views on inclusive practice using a descriptive qualitative study design with semi-structured interviews and classroom observations in a mainstream private school. The participants comprised five mainstream classroom teachers, three learning support teachers and two teacher aides observed in four inclusive classrooms. Thematic analysis identified four major themes: Experience grows confidence; Available support; Resource needs and Changing mind-sets. Most participants did not receive formal inclusive practice training prior to commencing teaching and only acquired skills through teaching experience. The importance of administrative support, human resources, regular in-service training, changing mindsets and barriers to effective practices, including teaching undiagnosed children were major highlights emphasised by participants. Although the findings of this study are specific to the chosen mainstream inclusive primary school, the outcomes of the study could be beneficial to other primary education stakeholders as it has the potential to facilitate effective inclusive educational practice in the classroom.

Background: Optimum physical activity (PA) interventions could be delivered via physical activity referral schemes (PARS) if utilised adequately. However, the evidence supporting PARS effectiveness is weak due to low uptake and non-adherence to interventions. Objective: Patients¿ experiences of PARS were explored to obtain in-depth insight into their perceived quality of care and practical ways to optimise the programme's effectiveness. Methods: A sequential explanatory mixed methods design was employed to probe cross-sectional quantitative survey data (n = 111) on patients¿ knowledge and beliefs about PA and PARS and qualitative interview data (n = 15) on their experiences of PARS. Informed by Donabedian framework of healthcare quality assessment, quantitative and qualitative findings were integrated to identify practical ways to enhance PARS effectiveness. Results: Participants displayed good PA knowledge, had positive beliefs and perceived PARS to be useful. Nonetheless, bottlenecks in the structure and process of PARS impact on patient health outcomes and hinder the programme's uptake. Conclusion: Exploring other referral mechanisms into PARS such as self or nurse-initiated referrals could improve the programme's visibility and effectiveness. Practice implications: Improved support, enhanced visibility of EPs, ongoing interactions between GPs and EPs and education about referral pathways would foster improved uptake, adherence and health outcomes for patients.

This study employed interpretivist, grounded theory method and utilized semi-structured interviews to explore how 31 African migrant high school and university students from eight sub-Saharan African representative countries and currently residing in Townsville, Australia, perceived the roles of their parents in their career development. The study findings revealed that the support (financial, social and emotional) and encouragement (sacrificial love, role modeling and guidance) received from parents underpinned the youths¿ perceptions of their parents as influential in their career trajectories. Though participants acknowledged their indebtedness to parents and the system that nurtured them, they faced a dilemma conforming to parental preference or personal conviction, which presented ¿a fork in the career decision-making road.¿ Study findings indicate that participants¿ reactions and strategies for negotiating parental approval differ based on entry status and gender. Most participants, particularly those with professional entry status, conformed to their parents¿ career choice for fear of failure, while a few who followed their personal interests negotiated parental approval through dialogue and educating parents. Male participants with humanitarian entry status opposed their parents¿ career preferences and followed their own personal interests. Taken together, all participants had strong desire to obtain parental approval and whether sought early or later, the main focus for all participants was prioritizing family needs and obligations. The practical implications of these findings for all stakeholders are discussed.

Introduction: The transition to clinical studies can be a source of stress, though little is known about how pharmacy students manage this transition. This mixed-methods study investigated factors influencing student transition from pre-clinical to clinical years of an Australian pharmacy degree. Methods: Students rated and discussed their confidence in performing pharmacy-related skills, factors influencing their ability to carry out these skills and key enabling factors and barriers that influenced their transition. Results: Differences in teaching and assessment style and placement workload affected the transition experience. Self-confidence in the clinical learning environment was enhanced by patient contact, previous pharmacy work experience, case-based learning and supportive placement supervisors. A perceived lack of relevance of pre-clinical learning and heavy workload during placement were major barriers to a smooth transition. Conclusions: Support systems are essential to foster transition into the clinical learning environment with confidence and effective application of theoretical knowledge to real-world practice.

Background: Substantial government funding has been invested to support the training of General Practitioners (GPs) in Australia to serve rural communities. However, there is little data on the impact of this expanded training on smaller communities, particularly for smaller rural and more remote communities. Improved understanding of the impact of training on underserved communities will assist in addressing this gap and inform ongoing investment by governments and communities. Method: A purposive sample of GP supervisors, GP registrars, practice managers and health services staff, and community members (n = 40) from previously identified areas of workforce need in rural and remote North-West Queensland were recruited for this qualitative study. Participants had lived in their communities for periods ranging from a few months to 63 years (Median = 12 years). Semi-structured interviews and a focus group were conducted to explore how establishing GP training placements impacts underserved communities from a health workforce, health outcomes, economic and social perspective. The data were then analysed using thematic analysis. Results: Participants reported they perceived GP training to improve communities' health services and health status (accessibility, continuity of care, GP workforce, health status, quality of health care and sustainable health care), some social factors (community connectedness and relationships), cultural factors (values and identity), financial factors (economy and employment) and education (rural pathway). Further, benefits to the registrars (breadth of training, community-specific knowledge, quality of training, and relationships with the community) were reported that also contributed to community development. Conclusion: GP training and supervision is possible in smaller and more remote underserved communities and is perceived positively. Training GP registrars in smaller, more remote communities, matches their training more closely with the comprehensive primary care services needed by these communities.

Background: The diverse rural medical education initiatives that have been developed in Australia to address the medical workforce maldistribution have been less successful in many smaller and remote communities. This study explored the factors that attract and retain GP registrars and supervisors and the impact that localised training (i.e., rural and remote workplace-based training and support) has on both GP registrars and supervisors, and the GP workforce in rural and remote underserved areas. Methods: A purposive sample of 79 GP registrars, supervisors, practice managers, health services staff and community representatives living and working in areas of low GP workforce in rural and remote Australia were invited to participate in semi-structured interviews and one focus group divided over two phases. Thematic analysis was used to explore themes within the data. Findings: Attractors and barriers to rural and remote practice were identified as the main themes. Attractors include family and community lifestyle factors, individual intrinsic motivators, and remote medicine experiences. In contrast, barriers include work related, location, or family factors. Further, localised GP training was reported to specifically influence GP registrars and supervisors through education, social and financial factors. Conclusion: The current study has provided a contemporary overview of the issues encountered in expanding GP training capacity in rural and remote communities to improve the alignment of training opportunities with community and workforce needs. Strategies including matching scope of practice to registrar interests have been implemented to promote the attractors and lessen the barriers associated with rural and remote practice.

Objectives This review aimed to describe the epidemiology of all heat-related illnesses in women compared with men in the armed forces and to identify gender-specific risk factors and differences in heat tolerance. Design A systematic review of multiple databases (MEDLINE, Emcare, CINAHL, PsycINFO, Informit and Scopus) was conducted from the inception of the databases to 1 April 2019 using the preferred reporting items for systematic review and meta-analysis guidelines. Eligibility criteria All relevant studies investigating and comparing heat illness and heat tolerance in women and men in the armed forces were included in the review. Results Twenty-four studies were included in the systematic review. The incidence of heat stroke in women ranged from 0.10 to 0.26 per 1000 person-years, while the incidence of heat stroke ranged from 0.22 to 0.48 per 1000 person-years in men. The incidence of other heat illnesses in women compared with men ranged from 1.30 to 2.89 per 1000 person-years versus 0.98 to 1.98 per 1000 person-years. The limited evidence suggests that women had a greater risk of exertional heat illness compared with men. Other gender-specific risk factors were slower run times and body mass index. Although there was a higher proportion of women who were heat intolerant compared with men, this finding needs to be interpreted with caution due to the limited evidence. Conclusion The findings of this review suggest that men experienced a slightly higher incidence of heat stroke than women in the armed forces. In addition, the limited available evidence suggests that a higher proportion of women were heat intolerant and being a female was associated with a greater risk of exertional heat illnesses. Given the limited evidence available, further research is required to investigate the influence of gender differences on heat intolerance and heat illness.

Some students struggle through medical school and do not have the confidence to seek help. This pilot study sought to explore the challenges and needs of medical students experiencing academic difficulty. Semi-structured interviews and online surveys were used to collect data from an academic advisor and thirteen medical students who had experienced academic difficulty. Unexpected academic failure and the loss of self-efficacy contributed to students hiding their academic difficulty and avoiding available support systems. Despite the sampling limitations, the findings of this pilot study have value in giving direction to future research. Programs that will change the current attitudes to academic difficulty, normalising access to support and encouraging early intervention, are needed to build the capacity for excellence among these students.

There are numerous theories on parenting styles, however, they are Western-oriented and may not be applicable to collectivist non-Western societies. A qualitative study which utilised semi-structured interviews was conducted to explore the perceived parenting roles of 26 Sub-Saharan African (SSA) migrant parents (both humanitarian and professional migrants) in their children¿s career pathways after they migrated to Australia. Data were analysed using grounded theory methods and this process facilitated the creation of a new framework to provide an in-depth understanding of how SSA parenting styles informed the migrant children¿s career choices while living in Australia. The study revealed that most SSA migrant parents maintained their style of parenting as used in their home countries. Interestingly, some parents adapted their parenting styles due to their perceptions of changed circumstances within the host country. Other parents, who would normally be authoritative, became trustful due to their perceived lack of educational expertise to guide their children. Conversely, some other parents who would normally be authoritarian employed wily tactics in influencing their children¿s decision, so as to circumvent the strict Australian legal framework around children¿s rights. Irrespective of parenting style applied, all the parents aimed to either guide or direct their children¿s educational and career development to ensure that they become economically productive adults. From the discourse of the SSA migrants¿ perceptions of their parental role, we offer potential explanations for what underpins their parenting preferences and the rippling effects on their children¿s career trajectories. Direction for areas of continued research are presented, and implications of the findings are discussed.

Background: Physical activity (PA) is vital to maintaining good health. However, WHO estimates that 60% of the world¿s population are inadequately active. To enhance PA, Physical Activity Referral Schemes (PARS) have been established by some countries. Objective: This study examined the functionality of the PARS process across different countries. Methods: This systematic review was performed and reported in accordance with the PRISMA guidelines. Sixteen electronic databases were searched from January 1990 to May 2020. PARS studies, published in English language and in peer-reviewed journals, that reported adherence, outcomes, disease conditions, interventions, facilitators and barriers, were included in this review. Results: Twenty-seven studies conducted across eight countries met the inclusion criteria. Most patients were referred for sedentary/inactivity reasons and supervised group-based activities was the most used intervention. Participants¿ average adherence rate was 77.5%. Adherence was either facilitated or hindered by type of support provided during and after intervention period. Inclusion of PA allied health specialist in the intervention enhanced positive health outcomes. Conclusion: PARS is a key driver and motivator for individuals to undertake and adhere to PA interventions. Utilization of guidelines on evidence-based interventional PA for different types of diseases, effective use of common group supervised activities and the involvement of PA specialists may aid PA adherence and foster positive health outcomes.

Pre-existing acculturation models have focused on individual orientation and may not be fully applicable to African migrants due to their strong connection to family. In this study, we utilised qualitative semi-structured interviews to explore how 22 migrant families from eight sub-Saharan African representative countries: Congo, Eritrea, Kenya, Nigeria, Rwanda, Sierra Leone, Uganda and Zimbabwe, who now reside in Townsville, Australia experienced the acculturation process. Data were analysed at the family unit level using the three steps of grounded theory method: open, axial and selective coding. The theory derived illustrates that the acculturation process involves two major phases (maintaining core moral values and attaining a sense of belonging) within which six categories were identified. Three of the categories were related to deeply held heritage values and beliefs (family relationships, societal expectations and cultural norms), while the other three (religious beliefs, socio-economic gains and educational values) indicated integration with the host culture. These categories constitute central concerns for the participants and demonstrate what matters to them as a family unit and not as individuals. We conclude that a selective process of "prioritising family needs" determines the acculturation strategy of sub-Saharan African migrant families, aiding the fulfilment of their migration goals, ensuring effective functioning of the family unit, and enabling them to be productive members of their local community.

Objectives: We aimed to identify the experiences of Australian community pharmacists with smokers and their associated perceptions of effective health warnings on individual cigarette sticks. Methods: A mixed-methods online survey was distributed to Australian pharmacists through pharmacy-specific social media pages, and the Pharmaceutical Society of Australia, followed by semi-structured face-to-face interviews with pharmacists in Townsville, Australia, who were purposively sampled. The interviews continued until data saturation was achieved. Participants described their experiences with smokers, perceptions and effectiveness ratings of current cigarette packaging warnings, and 12 text warnings (divided into four themes) on individual cigarette sticks, and their general opinions on effective anti-tobacco health warnings. Key findings: Seventy pharmacists participated in the survey and 17 pharmacists in the interviews. Both groups of pharmacists cited smoking-related personal or close-contact illness, pressure by family members or physicians and the financial costs of smoking as being the main drivers for quit attempts. Most interviewed pharmacists interact with smokers several times per week. Cigarette stick warnings describing mortality consequences (especially the ¿minutes of life lost¿ warning) and the financial consequences of tobacco use were rated as significantly more effective than current packaging warnings (odds ratio [OR] = 2.23; 95% confidence interval [CI]: 1.12¿4.12, P = 0.02, and 1.97; 95%CI: 1.01¿3.84, P = 0.04, respectively). Conclusions: Pharmacists have considerable experience assisting smokers with quitting and based on these experiences believe that novel and tangible health warnings on cigarette sticks may be an effective future measure to combat tobacco use. Further research on the opinions of a more diverse range of health professionals and the general community will generate more robust findings regarding this method of intervention.

Introduction: Outcomes-based education requires active student learning with assessment strategies that foster deep approaches to learning, which are often influenced by students' perceptions of assessment. We aimed to investigate the perceptions of pharmacy students at an Australian university about their experiences of assessment and its impact on their learning. Methods: A mixed-methods study was conducted involving a self-administered questionnaire and semi-structured focus groups. Descriptive statistics were used to rate the perceived value of different assessment tools and confirmed by themes arising from the focus groups. Examination results over a five-year period were also collated to assess congruence between perceptions and academic performance. Results: From the 123 questionnaire and nine focus group participants, short-answer questions were the most positively-received form of assessment due to students being able to demonstrate and receive marks for partial knowledge. Multiple-choice questions received mixed response as they were cited as being useful in assessing student knowledge but potentially difficult to interpret/answer correctly. Reflective pieces received the lowest ratings and were considered the least beneficial. Key identified themes were ensuring quality assurance of assessment processes, use of authentic assessment, timely feedback, and appropriate match between workload and assessment weightings. Overall, there was congruence between students' exam scores and their perceptions of the different assessment types. Conclusions: Strategic planning and delivery of correctly-weighted authentic assessments with the provision of constructive feedback are key elements for active engagement of students and achievement of life-long learning outcomes.

An in-depth review of Australia¿s tropical beef cattle production system is presented with emphasis on the use of Desmanthus, a tropical legume, as a nutritional supplementation strategy for the abatement and mitigation of methane emissions. It also identifies current knowledge gaps in in vivo methane emissions research.: The Australian beef industry is a major contributor to the economy with an estimated annual revenue generation of over seven billion dollars. The tropical state of Queensland accounted for 48% of Australian beef and veal production in 2018. As the third biggest beef exporter in the world, Australia supplies 3% of the world¿s beef exports and its agricultural sector accounts for an estimated 13.2% of its total greenhouse gas emissions. About 71% of total agricultural emissions are in the form of methane and nitrous oxide. In this review, an overview of the carbon footprint of the beef cattle production system in northern Australia is presented, with emphasis on the mitigation of greenhouse gases. The review also focuses on the tropical legume, Desmanthus, one of the more promising nutritional supplements for methane abatement and improvement of animal growth performance. Among the review¿s findings is the need to select environmentally well-adapted and vigorous tropical legumes containing tannins that can persistently survive under the harsh northern Australian conditions for driving animal performance, improving meat quality and reducing methane emissions. The paper argues that the use of appropriate legumes such as Desmanthus, is a natural and preferred alternative to the use of chemicals for the abatement of methane emanating from tropical beef cattle production systems. It also highlights current gaps in knowledge and new research opportunities for in vivostudies on the impact of Desmanthus on methane emissions of supplemented tropical beef cattle.

Objective The study aimed to identify the common gaps in skills and self-efficacy for diabetes self-management and explore other factors which serve as enablers of, and barriers to, achieving optimal diabetes self-management. The information gathered could provide health professionals with valuable insights to achieving better health outcomes with self-management education and support for diabetes patients. Methods International online survey and telephone interviews were conducted on adults who have type 1 or type 2 diabetes. The survey inquired about their skills and self-efficacy in diabetes self-management, while the interviews assessed other enablers of, and barriers to, diabetes self-management. Surveys were analysed using descriptive and inferential statistics. Interviews were analysed using inductive thematic analysis. Results Survey participants (N = 217) had type 1 diabetes (38.2%) or type 2 diabetes (61.8%), with a mean age of 44.56 SD 11.51 and were from 4 continents (Europe, Australia, Asia, America). Identified gaps in diabetes self-management skills included the ability to: recognize and manage the impact of stress on diabetes, exercise planning to avoid hypoglycemia and interpreting blood glucose pattern levels. Self-efficacy for healthy coping with stress and adjusting medications or food intake to reach ideal blood glucose levels were minimal. Sixteen participants were interviewed. Common enablers of diabetes self-management included: (i) the will to prevent the development of diabetes complications and (ii) the use of technological devices. Issues regarding: (i) frustration due to dynamic and chronic nature of diabetes (ii) financial constraints (iii) unrealistic expectations and (iv) work and environment-related factors limited patients¿ effective self-management of diabetes. Conclusions Educational reinforcement using technological devices such as mobile application has been highlighted as an enabler of diabetes self-management and it could be employed as an intervention to alleviate identified gaps in diabetes self-management. Furthermore, improved approaches that address financial burden, work and environment-related factors as well as diabetes distress are essential for enhancing diabetes self-management.

Positive association between physical activity and spirometry has been reported to be possibly attributed to handgrip strength (HGS), particularly in the elderly. However, the nature of the association between HGS and lung function in young adults is still unclear. This study investigated the prediction of lung function using HGS in young adults. A cross-sectional analytical study was carried out on four hundred (400) apparently healthy medical students who are aged 16¿30¿years. Handgrip strength (dominant and nondominant) and lung function (FEV 1 , FVC and PEFR) of these students were assessed using Jamar dynamometer and a portable spirometer, respectively. Data were analyzed using inferential statistics. Independent t-test showed that the mean values of HGS and lung function of the males were significantly higher than the females (P¿<¿0.0005). The relationship between HGS and lung function indices was significant (P¿<¿0.0005) in all the participants but strongest for FEV 1 (r¿=¿0.64). The regression analysis showed that in addition to gender and height, HGS was a significant (P¿<¿0.0005) predictor of lung function. Regression equations were also proposed for the prediction of these lung function indices using HGS, gender and height. This study is the first to report HGS as a significant predictor of pulmonary function in healthy young adults living in a low-resource country. Hence, its use could enhance medical practice in being an indicator of lung function status in healthy young adults.

We investigated the effect of various dietary polyunsaturated fatty acid (PUFA) sources on the fatty acid profiles of muscle, liver, heart and kidney of Australian prime lambs. Seventy-two White Suffolk x Corriedale first-cross lambs weaned at 6 months of age were randomly allocated to the following six treatments: (1) Control: Lucerne hay only; wheat-based pellets infused with 50 ml/kg dry matter (DM) of oil from (2) rice bran (RBO); (3) canola (CO); (4) rumen-protected (RPO), (5) flaxseed (FSO) and (6) safflower (SO) sources in a completely randomized experimental design. Lambs in CO, FSO, SO and RPO treatments achieved contents of eicosapentaenoic acid (EPA, 22:5n-3) plus docosahexaenoic acid (DHA, 22:6n-3) in the longissimus dorsi muscle ranging from 31.1 to 57.1 mg/135 g, over and above the 30 mg per standard serve (135 g) threshold for ¿source¿ claim under the Australian guidelines. There was no difference in n-3 LC-PUFA contents in longissimus dorsi muscle of lambs fed dietary oils of plant origin. The highest 18:3n-3 (ALA) contents achieved with FSO diet in the muscle, liver and heart were 45.6, 128.1 and 51.3 mg/100 g, respectively. Liver and kidney contained high contents of n-3 LC-PUFA (ranging from 306.7 to 598.2 mg/100 g and 134.0 to 300.4 mg/100 g, respectively), with all values readily exceeding the ¿good source¿ status (60 mg per serve under Australian guidelines). The liver and kidney of PUFA fed lambs can be labelled as ¿good source¿ of n-3 LC-PUFA based on EPA and DHA contents stipulated by the Food Standards of Australia and New Zealand guidelines. Therefore, if lamb consumers consider eating the liver and kidney as their dietary protein sources, they can adequately obtain the associated health benefits of n-3 LC-PUFA.

Background: Graphic health warnings on tobacco packaging and the plain packaging of tobacco products are key tobacco control interventions. This systematic review investigates the perceptions of adolescents towards these packaging interventions. Methods: Published, original-research, English-language articles from 1 January 2000 to 1 September 2017 were identified through a systematic literature search of the PubMed, CINAHL, PsycINFO, Web of Science, and Scopus databases. Articles describing investigations into the perceptions of adolescents aged 11 to 19 years towards graphic health warnings and/or plain-packaged cigarettes were included in this review. Results: Nineteen articles, involving 15,935 adolescent participants, of which 72.85% were non-smokers or ex-smokers and 27.15% occasional or daily smokers, met the eligibility criteria. Graphic health warnings were perceived as more effective than text-only warnings, with warnings depicting lung cancer, and oral diseases being perceived as particularly effective. Health warnings increased viewer fear, anxiety, shock, and guilt and were considered effective in preventing non-smokers from experimenting with tobacco and prompting current smokers to quit. Plain packaging reduced the attractiveness and other positive attributes of cigarette packaging, with darker colours found to be the most effective. When used in combination, plain packaging increased the visibility of graphic health warnings, with participants also perceiving them as having an increased tar content and having more serious health risks, and increased thoughts of quitting amongst smokers. Conclusions: Graphic health warnings and plain packaging appear to increase adolescent awareness of the dangers of tobacco use. Further research into the most effective warnings to use in combination with plain packaging is needed to ensure the greatest reduction in tobacco use and prevent tobacco-attributable morbidity and mortality in this vulnerable population.

INTRODUCTION Innovations in tobacco control interventions are required to ensure continued reductions in global tobacco use, and to minimise attributable morbidity and mortality. We therefore aimed to investigate the perceived effectiveness of current cigarette packaging warnings and the potential effectiveness of cigarettestick warnings across four countries. METHODS An online survey was distributed to adult smokers in Australia, Canada, the United Kingdom, and the United States. Participants rated (using a 5-point Likert scale) and commented on the effectiveness of current cigarette packaging warnings and text warnings on eight cigarette sticks that prompted smokers to quit. Ratings were analysed using proportional odds logistic regression, and comments were analysed using content analysis. RESULTS Participants (N=678, mean age=44.3 years) from all four countries perceived cigarette packaging warnings as being minimally effective in prompting smokers to quit, citing desensitisation and irrelevance of the warnings, with US participants particularly critical of the text-only warnings. Compared to packaging warnings, the cigarette-stick warnings describing the financial costs of smoking and the effect of smoking on others, were the highest rated in all four countries (OR=3.42, 95% CI: 2.75-4.25, p<0.001 and OR=2.85, 95% CI: 2.29-3.55, p<0.001, respectively) and cited as strong messages to reduce smoking. Half of the participants either 'agreed' or 'strongly agreed' to the use of cigarette-stick warnings. CONCLUSIONS The findings of this study suggest that cigarette packaging warnings may experience a loss of effectiveness over time, eventually resulting in minimal impact on smoker behaviour. Health and non-health focused warnings and messages on individual cigarette sticks represent a novel and potentially effective method for reducing tobacco use. This would complement tobacco control interventions currently employed, resulting in public health benefits.

Good career planning leads to life fulfillment however; cultural heritage can conflict with youths' personal interests. This systematic review examined existing literature on factors that influence youths' career choices in both collectivist and individualistic cultural settings from around the globe with the aim of identifying knowledge gaps and providing direction for future research. A systematic review strategy using the Joana Briggs Institute's format was conducted. The ERIC, PsychInfo, Scopus, and Informit Platform databases were searched for articles published between January 1997 and May 2018. A total of 30 articles were included in the review, findings revealed that youth from collectivist cultures were mainly influenced by family expectations, whereby higher career congruence with parents increased career confidence and self-efficacy. Personal interest was highlighted as the major factor that influenced career choice in individualistic settings, and the youth were more independent in their career decision making. Bicultural youth who were more acculturated to their host countries were more intrinsically motivated in their career decision making. Further research is imperative to guide the understanding of parental influence and diversity, particularly for bicultural youths' career prospects and their ability to use the resources available in their new environments to attain meaningful future career goals.

Background: Recent research posits that anti-tobacco health warnings on cigarette packaging may gradually lose their effectiveness in dissuading adolescents from tobacco products several years after implementation. Health warnings on individual cigarette sticks represent a novel warning medium, and may further educate adolescents on the dangers associated with smoking, and reduce tobacco experimentation amongst this vulnerable population. Methods: In an online survey of school students in Queensland, Australia, participants were requested to rate (on five-point Likert scales) and comment on the perceived effectiveness of current cigarette packaging warnings, and 12 text warnings on cigarette sticks, in preventing non-smokers from smoking, and encouraging current smokers to quit. The warnings were divided into four themes to establish the most effective types of anti-tobacco messages: mortality statistics, health condition consequences, social and financial consequences, and supportive messages. These themes were based on current anti-tobacco interventions within Australia, and the rising cost of tobacco products, and designed to align with the Health Belief Model. Results: Participants (N = 150; Age = 15¿18) from five schools completed the survey, and generally viewed current packaging warnings as gross and disgusting, and rating them as somewhat effective in preventing non-smokers from smoking. Current warnings were however considered less effective in prompting current smokers to quit with participants describing them as being un-relatable to teenagers, and smokers as having become desensitized to the warnings used. One theme of cigarette-stick warning (mortality statistics) was rated as significantly more effective (p < 0.001) than current cigarette packaging, with an odds ratio (OR) of 2.77 (95% confidence interval [CI]: 1.67¿4.62). Overall, warnings were considered to be 4.71 times (95%CI: 2.72¿6.43, p < 0.001) more effective on non-smokers than on smokers. Over three-quarters of participants supported using health warnings on individual cigarette sticks. Conclusions: Current cigarette packaging warnings have retained some effectiveness in dissuading adolescents from smoking, though novel and thought-provoking text-only warnings on cigarette sticks may serve as an additional intervention in reducing tobacco use. Further research requires identification of the most effective warnings, and the perceptions of a more diverse participant base.

Introduction: The efficacy of varenicline as a smoking cessation aid is affected by commonly-occurring issues, such as intolerable adverse events, cravings and withdrawal symptoms, and poor medication adherence. Improvement in quit rates may be achieved through tailoring doses relative to individual smokers' behaviours, and previous experiences with smoking cessation medications. Aims: The aim of this review is to evaluate smoking cessation outcomes from published randomised controlled trials that have attempted to improve the efficacy and tolerability of varenicline through modifying its dosage regimen compared to placebo. Methods: A systematic search of the literature up to June 2016 was conducted to identify randomised controlled trials, where varenicline was administered in a regimen not consistent with the current clinical guidelines. Outcome measures evaluated included continuous abstinence rates, changes in cravings, withdrawal symptoms, smoking behaviours, adverse event rates, and premature therapy discontinuations. Results: Ten randomised controlled trials, encompassing four different modifications to standard varenicline therapy, matched the eligibility criteria. Modifications such as the extended duration of therapy and the use of a flexible quit date were effective compared to placebo and have been implemented into some clinical guidelines, whereas other modifications do not appear to produce any benefit for smokers, or require further research to ascertain their suitability for clinical practice. Conclusions: Some varenicline therapy modifications may lead to improvements in efficacy and tolerability. Further research on the effect of modifications such as daily doses higher than 2mg, tapering doses, and the use of extended pre-quit varenicline may advance varenicline therapy outcomes.

In this report, an overview of the health benefits of omega-3 long-chain (=C20) polyunsaturated fatty acids (n-3 LC-PUFA) and recent progress in using alpha linolenic acid (ALA) rich sources derived from oilseeds to enhance productive performance, n-3 PUFA profiles and sensory properties of lamb for human consumption is reviewed. Omega-3 LC-PUFA can prevent mental health issues and chronic human disorders including cancer, cardiovascular and inflammatory diseases. The median amount of n-3 LC-PUFA consumption is generally lacking in Western diets. More attention is now being paid to the use of innovative nutritional strategies to improve PUFA content in ruminants, which could subsequently increase the content of health-benefitting n-3 LC-PUFA for human consumption. The richest sources of dietary n-3 LC-PUFA are derived from marine products, while forage and oilseeds such as flaxseed, canola, and their oils are abundant in ALA. Numerous studies have shown that dietary ALA increases n-3 LC-PUFA levels of edible tissues. However, other studies concluded that ALA rich supplementation led to no differences in tissue FA profiles because of extensive biohydrogenation of dietary ALA, limited conversion from ALA to n-3 LC-PUFA and low incorporation of n-3 LC-PUFA into edible tissues. Generally, the inclusion of ALA rich sources in lamb diets potentially increases ALA content in lamb. It is proposed that supplementing ruminants with ALA-rich sources at or below 6% can promote n-3 PUFA profiles in lamb and is unlikely to have negative effects on feed intake, growth, carcass and sensory properties.

Background: This study was undertaken to improve assessment practice on OSCEs through collaboration across geographically dispersed medical schools in Australia.Methods: A total of eleven OSCE stations were co-developed by four medical schools and used in summative 2011 and 2012 examinations for the assessment of clinical performance in the early clinical and exit OSCEs in each schools medical course. Partial Credit Rasch Model was used to evaluate the psychometric properties of the shared OSCE data. Evaluation of the quality assurance reports was used to determine the beneficial impact of the collaborative benchmarking exercise on learning and teaching outcomes.Results: The data for each examination demonstrated sufficient fit to the Rasch model with infit mean square values ranging from 0.88 to 0.99. Person separation (1.25-1.63) indices indicated good reliability. Evaluation of perceived benefits showed that the benchmarking process was successful as it highlighted common curriculum areas requiring specific focus and provided comparable data on the quality of teaching at the participating medical schools.Conclusion: This research demonstrates the validity of the psychometric data and benefits of evaluating clinical competence across medical schools without the enforcement of a prescriptive national curriculum or assessment.