Ella Louise Bracci

Background: Behaviour-change outcomes are often incompletely reported in multidomain trials. We evaluated behaviour change during a 12-month Mediterranean diet (MedDiet) and physical activity (PA) intervention.Participants and Setting: Adults aged 60 to 90 years without cognitive impairment, independently living in two Australian cities.Methods: n=83 participants (MedWalk group) were supported over 12 months to consume a MedDiet and engage in at least 150 minutes of moderate to vigorous PA (MVPA) per week. Control group participants (n=73) maintained habitual diet and PA. Four validated measures (MedWalk MedDiet Adherence Screener (MW-MEDAS), MedDiet Score, accelerometry-derived MVPA and MET minutes by International Physical Activity Questionnaire-elderly) were analysed separately and combined into a total adherence score to determine change in behaviour from baseline. Differences within and between groups were analysed at baseline, 6-months and 12-months using linear mixed effect modelling, controlling for predictors of attrition and baseline group differences.Results: Participants were 74% female, with a mean±SD age of 74.9 ± 5.9 years. After 12 months, MW-MEDAS had increased by an average of 3.3/14 points, and total adherence score by 1.4/8 points in the MedWalk group (p<.001), with no significant change in the control group. There were no significant changes in dietary behaviours in the control group, and MVPA declined in both groups at 6 months.Conclusions: The MedWalk intervention improved overall adherence among older adults over 12 months, driven by an increase in MedDiet adherence. PA did not increase, potentially due to high baseline PA or challenges in changing PA behaviours.

Objective: The Mediterranean Diet (MedDiet) and physical activity (PA) can enhance mood and support psychological wellbeing in adults. However, the combined effect is relatively unknown. MedWalk aimed to determine the combined effect on wellbeing, psychological health and quality of life (QoL), compared to a control group. Design: This is an analysis of secondary outcomes from the MedWalk 12-month cluster-randomised controlled trial. Participants completed the Total and Secure Flourishing Index (FI), the four domain General Health Questionnaire (GHQ-28) and the 8-domain Assessment of Quality of Life (AQoL-8D). Data were analysed using general linear models using change scores (FI and AQoL-8D) or generalised linear mixed models with a time × group interaction effect (GHQ-28). Setting: Independent living facilities across South Australia and Victoria in 2021–2022. Participants: One hundred and sixty-one older men and women. Results: Participants were 74·9 ± 5·9 years of age and predominantly female (74 %). A greater improvement was found for the MedWalk group (marginal means (MM) = 1·65, se = 1·36) than the control group (MM = –2·50, se = 1·32) for the Total Flourish score ( P = 0·003) and Secure Flourish score ( P = 0·009) ((MM = 1·06, se = 1·65) v . (MM = –3·34, se = 1·61)) from baseline to 6 months. The MedWalk group (MM = 0·021, se = 0·014) had more positive changes ( P = 0·048) to the Mental Health AQoL-8D domain than the control group (MM = –0·007, se = 0·014). No significant group × time interactions were identified for the GHQ-28. Conclusions: Combined MedDiet and walking interventions can modify psychological health, wellbeing and QoL in relatively healthy populations.

Background: EDDIE + was a stepped wedge cluster randomised controlled trial with an embedded process evaluation in 11 residential aged care (RAC) homes in Queensland, Australia. The intervention aimed to upskill RAC staff to identify and manage deterioration to reduce unnecessary hospital transfer through education, decision support tools, diagnostic equipment and local facilitation. Main trial results indicated 46% of hospital admissions were due to falls and no significant improvements to outcome measures including hospital bed days were achieved. These findings were examined through a process evaluation. Methods: A mixed methods approach guided by the i-PARIHS framework was used to assess fidelity, acceptability, mechanisms of impact and feasibility of implementation, including barriers and enablers. Semi-structured interviews, self-efficacy surveys, and project tracking documents were used. Qualitative data were coded to the i-PARIHS framework and quantitative data were analysed using linear mixed modelling. Results: Fidelity varied considerably due to workforce shortages including vacancy in the local clinical facilitator role, high workload, COVID-19, and other contextual factors. Differences in job and team-related staff self-efficacy before and after the introduction of EDDIE + were not statistically significant. However, inductive thematic analysis of the questionnaires indicated that staff felt their knowledge, skills, confidence and communication had increased. Conclusions: The process evaluation indicates high acceptability of the EDDIE + intervention. However, fidelity and intended mechanisms of impact were mixed despite substantial pre-planning prior to implementation. For future studies, specific barriers in the RAC setting such as staffing and turnover may be unable to be adequately addressed without systemic change. Trial registration: The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

There is growing evidence that optimising dietary quality and engaging in physical activity (PA) can reduce dementia and cognitive decline risk and improve psychosocial health and quality of life (QoL). Multimodal interventions focusing on diet and PA are recognised as significant strategies to tackle these behavioural risk factors; however, the cost-effectiveness of such interventions is seldom reported. A limited cost consequence based on a 12-month cluster-randomised Mediterranean diet (MedDiet) and walking controlled trial (MedWalk) was undertaken. In addition, QoL data were analysed. Programme costs ($AUD2024) covered staff to deliver the MedWalk programme and foods to support dietary behaviour change. The primary outcome measure of this study was change in QoL utility score, measured using the Assessment of Quality of Life (AQoL-8D). Change scores were compared for the groups using general linear models while controlling for demographic factors associated with baseline group differences and attrition. Change in QoL (decreased, maintained or improved) was determined using a cross-tabulation test. MedWalk programme costs were estimated at $2695 AUD per participant and control group cost at $165 per person – a differential cost of $2530. Mean change in utility scores from baseline to 12 months was not statistically significant between groups. Nevertheless, the MedWalk group was significantly less likely to experience a reduction in their QoL (20·3 % MedWalk v . 42·6 % control group) ( P = 0·020). A MedDiet and walking intervention may have a role in preventing decline in QoL of older Australians; however, longer-term follow-up would be beneficial to see if this is maintained.

Background: EDDIE + was a stepped wedge cluster randomised controlled trial with an embedded process evaluation in 11 residential aged care (RAC) homes in Queensland, Australia. The intervention aimed to upskill RAC staff to identify and manage deterioration to reduce unnecessary hospital transfer through education, decision support tools, diagnostic equipment and local facilitation. The main trial results indicate that the expected changes in outcomes were not achieved, which is examined through this process evaluation. Methods: A mixed methods approach guided by the i-PARIHS framework was used to assess fidelity, acceptability, mechanisms of impact and feasibility of implementation, including barriers and enablers. Semi-structured interviews, self-efficacy surveys, and project tracking documents were used. Qualitative data were coded to the i-PARIHS framework and quantitative data were analysed using linear mixed modelling. Results: Fidelity varied considerably due to the considerable impacts of workforce shortages including vacancy in the clinical facilitator role, high workload, COVID-19, and other contextual factors. Differences in job and team-related staff self-efficacy before and after the introduction of EDDIE + were not statistically significant. However, inductive thematic analysis of the self-efficacy questionnaires indicated that staff felt their knowledge, skills, confidence and communication had increased. Conclusions: The process evaluation indicates good acceptability of the EDDIE + intervention. However, fidelity and intended mechanisms of impact were mixed due to a combination of contextual barriers, exacerbated by workforce shortages and COVID-19. Despite substantial pre-planning prior to implementation, specific barriers in the RAC setting such as staffing and turnover may be unable to be adequately addressed without system change. Trial registration: The trial is prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

Older people returning home after unplanned hospital admissions often experience fragmented care, leading to poor health outcomes and rehospitalisation. Taking a person-centred approach, we co-designed and piloted a care transition service with older people, their carers, and health professionals, to improve the care of older people as they transitioned from hospital to home. We conducted five co-design workshops with healthcare professionals and older people who had experienced frequent hospital presentations, to explore ways to improve the transition from hospital to home. The workshops culminated in the co-design of a Care transition Coordinator (CTC) role. We undertook a 6-month pilot study in one metropolitan hospital in Adelaide, Australia, to determine the feasibility and preliminary effectiveness of the role from an older person and health system perspective. Descriptive data were extracted from Comprehensive Geriatric Assessments, action sheets, patient checklists, and hospital databases, while semi-structured interviews were conducted with service users, providers, and referrers and thematically analysed to provide qualitative insights into the service. Thirty-five older people were cared for by the CTC during their transition from hospital to home. The CTC was perceived to meet the needs of older people and was well received by older people, their families/carers, and referrers. However, there were some challenges to the feasibility of the service from a service-provider perspective. Our findings indicate that it is possible to engage frail, older people who are frequent hospital presenters in a co-design process, and to design services that are informed by, and meet their needs.

Malnutrition and frailty are preventable and reversible. However, a significant proportion of aged care residents live with malnutrition and frailty which have associated complications such as increased falls, hospitalizations, infections, and decreased quality of life. Nutrition and dietary interventions can prevent these issues, however, there a few interventions conducted in this setting and no consensus on the most utilized interventions to improve health outcomes. In a crude literature search, we identified 65 nutrition-related randomized controlled trials worldwide in the aged care setting from 2000 to 2024. Most interventions were conducted in Europe and were oral nutrition supplementation or dietary supplements and/or food fortification. With few published studies, progressing nutrition interventions in aged care may be assisted by the mapping and identification of the key barriers and challenges related to engagement and collaboration with stakeholders and participants and the logistics of the aged care environment including staffing workload and kitchen capacity. Nutrition researchers should consider using process evaluations and qualitative research to map barriers and enablers to implementation in hopes to improve future research.

Background: Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) intervention was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention. Methods: Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the intervention at a site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed. Results: Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level. Conclusions: An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice. Trial registration: Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 06/05/2019).

Background Non-beneficial treatment affects a considerable proportion of older people in hospital, and some will choose to decline invasive treatments when they are approaching the end of their life. The Intervention for Appropriate Care and Treatment (InterACT) study was a 12-month stepped wedge randomised controlled trial with an embedded process evaluation in three hospitals in Brisbane, Australia. The aim was to increase appropriate care and treatment decisions for older people at the end-of-life, through implementing a nudge intervention in the form of a prospective feedback loop. However, the trial results indicated that the expected practice change did not occur. The process evaluation aimed to assess implementation using the Consolidated Framework for Implementation Research, identify barriers and enablers to implementation and provide insights into the lack of effect of the InterACT intervention.Methods Qualitative data collection involved 38 semi-structured interviews with participating clinicians, members of the executive advisory groups overseeing the study at site level, clinical auditors, and project leads. Online interviews were conducted at two times: implementation onset and completion. Data were coded to the Consolidated Framework for Implementation Research and deductively analysed.Results Overall, clinicians felt the premise and clinical reasoning behind InterACT were strong and could improve patient management. However, several prominent barriers affected implementation. These related to the potency of the nudge intervention and its integration into routine clinical practice, clinician beliefs and perceived self-efficacy, and wider contextual factors at the health system level.Conclusions An intervention designed to change clinical practice for patients at or near to end-of-life did not have the intended effect. Future interventions targeting this area of care should consider using multi-component strategies that address the identified barriers to implementation and clinician change of practice.Trial Registration Australia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 6 May 2019).

The impact of a Mediterranean diet on the intestinal microbiome has been linked to its health benefits. We aim to evaluate the effects of a Mediterranean diet supplemented with dairy foods on the gut microbiome in Australians at risk of cardiovascular disease. In a randomised controlled cross-over study, 34 adults with a systolic blood pressure ≥120 mmHg and with risk factors for cardiovascular disease were randomly allocated to a Mediterranean diet with 3–4 daily serves of dairy foods (Australian recommended daily intake (RDI) of 1000–1300 mg per day (MedDairy)) or a low-fat (LFD) control diet. Between each 8-week diet, participants underwent an 8-week washout period. Microbiota characteristics of stool samples collected at the start and end of each diet period were determined by 16S rRNA amplicon sequencing. MedDairy-associated effects on bacterial relative abundance were correlated with clinical, anthropometric, and cognitive outcomes. No change in the overall faecal microbial structure or composition was observed with either diet (p > 0.05). The MedDairy diet was associated with changes in the relative abundance of several bacterial taxa, including an increase in Butyricicoccus and a decrease in Colinsella and Veillonella (p < 0.05). Increases in Butyricicoccus relative abundance over 8 weeks were inversely correlated with lower systolic blood pressure (r = −0.38, p = 0.026) and positively correlated with changes in fasting glucose levels (r = 0.39, p = 0.019), specifically for the MedDairy group. No significant associations were observed between the altered taxa and anthropometric or cognitive measures (p > 0.05). Compared to a low-fat control diet, the MedDairy diet resulted in changes in the abundance of specific gut bacteria, which were associated with clinical outcomes in adults at risk of CVD.