Title: Adherence Patterns to Cardiovascular Medications in People with Type 2 Diabetes Mellitus: A Retrospective Cohort Study Using Group-Based Trajectory Analysis in Primary Care
Authors: Sri Chodapuneedi, MPH1; Zhomart Orman, PhD1; Jia Wei Koh, PhD1,2; Danijela Gasevic, MD, PhD1; Dianna J Magliano, PhD1,3; Sophia Zoungas, PhD1; Peter Hamblin, MB BS (Hons)1,4; Caroline Trin, PhD candidate1; Ella Zomer, PhD1; Pilar Cataldo, MPH1; Stella Talic, PhD1
1School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia;
2Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia;
3Baker Heart and Diabetes Institute, Melbourne, VIC, Australia;
4Department of Endocrinology & Diabetes, Western Health, Melbourne, VIC, Australia.

Correspondence: Dr. Stella Talic, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne VIC 3004, Australia
Tel: +61 3 9903 0021; Email: stella.talic@monash.edu
ABSTRACT
Objectives:
To identify adherence trajectories and associated adherence probabilities to glucose-, lipid-, and blood pressure-lowering medications in individuals with type 2 diabetes mellitus (T2DM), and to examine demographic and clinical factors linked to non-persistent adherence behaviours.
Methods:
We conducted a retrospective cohort study using primary care data from January 2013 to March 2023 for individuals diagnosed with T2DM. Medication adherence was assessed over a 60-month period and defined as the supply of at least one prescription every six months. Group-Based Trajectory Analysis (GBTA) was used to identify distinct adherence patterns, and multinomial logistic regression was applied to examine predictors of trajectory group membership.
Results:
Three consistent adherence trajectories were identified across all therapeutic classes: persistent adherence (40.6%–44.3%), gradual decline (32.7%–36.6%), and early discontinuation (21.0%–26.7%). Persistent adherers maintained high adherence probabilities (0.85–0.88 at 12 months; 0.70–0.76 at 60 months). Gradual decliners exhibited a steady decrease in adherence from approximately 0.84 at 12 months to below 0.20 at 60 months. Early discontinuers ceased therapy almost entirely by 24 months. Key risk factors for early discontinuation included female sex (e.g., glucose-lowering: RRR 0.72; 95% CI: 0.57–0.92 for males vs females), metropolitan residence (RRR 1.38; 95% CI: 1.07–1.78), and having an elevated LDL cholesterol in the lipid-lowering cohort (RRR 1.75; 95% CI: 1.36–2.26). Older age was associated with increased early discontinuation in glucose-lowering therapy but was protective against gradual decline in lipid-lowering therapy.
Conclusion:
This study revealed consistent and clinically relevant adherence patterns across cardiovascular medication classes in people with T2DM. Over one in five individuals either discontinued or gradually reduced medication use, underscoring the need for targeted, data-informed interventions. Identifying at-risk populations is essential to improving long-term adherence and optimising therapeutic outcomes.

Public health action on the prevention, treatment and management of obesity presents a critical opportunity to reduce Australia's cancer burden and cannot be overlooked. Obesity increases the risk of 13 cancer types, and has been attributed to 4.3% of all cancers diagnosed in Australia in 2013. Australian cancer rates are rapidly increasing, with over 4.5 million cases expected to be diagnosed between 2020 and 2044. Adult obesity rates in Australia have nearly tripled in the last 30 years, with over 18 million Australians projected to have overweight or obesity by 2030.

Reducing obesity rates is vital to lowering Australia’s cancer burden, and responsive national government action is essential. This must be implemented with care, as weight stigma is a primary driver of weight-related behaviours among those with obesity. Holistic, non-stigmatising strategies that address population-level barriers are crucial.

To guide advocacy and call for greater government action, we recently expanded our National Cancer Obesity Prevention Policy to include treatment and management. This involved a comprehensive evidence review and engaging with experts in obesity prevention, treatment and management. Identified priority areas were:

1) Implement actions under the National Obesity Strategy and the National Preventive Health Strategy
2) Create environments that support healthy eating
3) Support Australians through social marketing campaigns encouraging healthy eating behaviours
4) Promote equitable access to quality, evidence-based, obesity treatment and management services
5) Eliminate weight stigma in the prevention, management and treatment of obesity.

Transformative, multisector government action is critical to building environments that support healthy choices and equitable access to obesity treatment and management. Implementing our National Cancer Obesity Prevention Policy could reduce both cancer and obesity incidence, improving public health outcomes nationwide. We call on the Federal Government and public health organisations to commit to bold, coordinated action to address the growing burden of obesity.

Teacher food and nutrition (FN) practices are negatively impacted by workload, with implications for health and wellbeing. Traditionally FN factors have not been considered as predictors of teacher wellbeing. This study investigates potential FN predictors of teacher burnout using data across four time points (September 2023- June 2024).
Participants (n=137) received the four teacher food and nutrition questionnaire (TFNQ) links across the study. Descriptive statistics and Pearson correlation coefficient (r) were used to assess relationships between constructs, followed by stepwise regression to review potential predictor variables. Qualitative data on teacher perceived barriers to maintaining healthy eating practices at school were thematically analysed.
Across time points (TP) completion was TP1: 112 (82%), TP2: 91 (67%), TP3: 88 (65%), TP4: 85 (63%), respectively. Of TFNQ constructs only six remained significant (p<0.05). Of these two were wellbeing constructs [stress (slope (s) 1.10, p<0.001), personal subjective wellbeing (s:-0.52, <0.001)], three were FN constructs [unhealthy eating social norms (s:-0.31, p<0.001), food agency (s:-0.25, p0.004), diet quality perceptions (s:0.59, p0.039)] along with ‘extra hours worked’ (s:0.38, p0.019). Of the 112 participants 62% (n=69) worked 7-15 additional hours weekly, and 9% (n=10) worked ≥16 additional hours. Qualitative data revealed limited time to prepare and eat healthy foods as a key barrier to healthy FN practices at school.
Of the constructs within TFNQ stress was identified as the strongest predictor of burnout with contributions from key FN measures of unhealthy social norms, food agency, and extra work hours. These need further research with consideration of implications for work-life balance on teacher FN practices such as preparing and eating healthy meals.

Background
While nurse-led interventions are increasingly recognised as effective strategies for managing cardiovascular risk factors, a broader synthesis is required to inform large-scale implementation across diverse healthcare systems.
Objective
To synthesise findings from the latest studies (2000 onwards) assessing nurse-led interventions for cardiovascular disease management and evaluating their impact on outcomes, adherence, and feasibility.
Methods
We scoped the available literature using the Arksey and O’Malley framework to synthesise the key insights. We searched PubMed, Embase, and the Web of Science using search terms related to nursing, cardiovascular disease management, and primary care. A total of 884 records were identified, of which 101 unique studies were included in the final analyses.
Results
Of 101 unique studies, the highest number (n=35) was from Europe, followed by North America (n=23) and Asia-Pacific (n=11). Only one country from Africa was reported. The average participant age was 60-70 years, and sex-disaggregated data were often missing or inconsistently reported. These included randomised controlled trials (n=63), evaluation studies (n=23), pilot/qualitative studies (n=8), cost-effectiveness studies (n=6), and quasi-experimental evaluation (n=1). The majority (n=79) of studies involved in-person educational and counselling sessions embedded within behavioural feedback models. Thirty-nine out of 101 studies reported improvements in ≥1 outcomes: blood pressure (n=32), medication adherence (n=6), lifestyle changes (n=38), quality of life (n=11) and hospital admissions (n=3). Out of 101 studies, 12 reported feasibility or economic aspects of interventions compared to existing GP-led primary care; 17 reported nurse-led initiatives as effective, and 18 studies described no effects.
Conclusion
A nurse-led model of care offers a pragmatic and impactful approach to improving cardiovascular outcomes. It should be prioritised in both national strategies and local implementation plans. Further research should focus on sustaining long-term outcomes and integrating nurse-led care into broader primary care and population health frameworks.

Objective: The aim of this scoping review was to 1) consolidate the barriers and enablers to allied health service use for type 2 diabetes (T2D) management, and 2) identify knowledge gaps and priorities for future research and policy development.
Methods: This review followed the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Electronic databases including Medline, Scopus, Web of Science, INFORMIT, and Cumulative Index to Nursing and Allied Health (CINAHL) were searched from 1st January 2005 to 18 April 2025 for relevant articles. Peer-reviewed articles investigating barriers and enablers to allied health service use for T2D management in Australia were included. Barriers and enablers influencing 1) patient utilisation of services, 2) GP referral to services, and 3) allied health practitioners’ delivery of services were extracted and categorised according to the Theoretical Domains Framework (TDF).
Results: Forty-four articles (43 studies) were included. A total of 31 themes were identified across 11 TDF domains. Key barriers to patient use of services included limited available services, workforce shortages, long wait times for public services, high out-of-pocket costs for private services, and a lack of GP referral. Enablers included the delivery of person-centred care and culturally tailored services. The Medicare Chronic Disease Management (CDM) scheme was identified as both an enabler (facilitating patient use and GP referral to services) and a barrier (limiting allied health practitioners’ delivery of services due to inadequate rebates and session caps). Despite capturing diverse perspectives, few studies examined differences in barriers and enablers by age, sex, or geographic location.
Conclusions: Barriers and enablers to allied health service use for T2D are complex and vary by stakeholder and setting. Addressing these requires targeted policy reform, including workforce investment, Medicare CDM redesign, and enhanced allied health practitioner training. Future research should explore demographic and geographic disparities to inform equitable service delivery.

Alcohol is classified as a Class 1 carcinogen by the International Agency for Research on Cancer. Alcohol is causally linked to seven types of cancer including breast, bowel and liver cancer, and has been identified as having a role in at least five others. In Australia, each year 3,500 cancer cases are attributed to alcohol use. Evidence-based measures that protect the community from cancer and other harms due to alcohol use are vital.  

It took over two decades in Australia for the successful implementation of mandatory and evidence-based legal standards for pregnancy warning labels on alcohol products, overcoming ineffective self-regulation and coordinated industry lobbying. This hard-won success by the public health sector was a collective effort; with the aim to continue to build evidence to extend to other health warning labels on alcohol products in the future.

A substantial body of research has examined the effectiveness of the current industry-managed system of alcohol advertising regulation in Australia. This research has consistently concluded that the current industry-managed approach does not effectively protect children and young people from exposure to alcohol marketing.

Despite the extensive evidence outlined above on the continued impact and harms of alcohol to communities, and the influence of industry lobbying, there have been minimal successes in achieving policy change in Australia beyond pregnancy warning labels.

Those representing the alcohol industry still tend to be viewed by governments as legitimate informants on policy areas that have implications for public health. This is in contrast to the now accepted need to protect tobacco policy from industry interference. This presentation will explore, through the sharing of key examples, how we can draw on tobacco policy success in navigating the influence of the alcohol industry on Australian policy to achieve much-needed change.

Background: Harmful alcohol use is a complex issue in Australia, yet most research focuses on individual health and wellbeing impacts. International studies show that health professionals’ alcohol education and attitudes influence treatment outcomes. However, there is limited Australian research on how alcohol harm prevention professionals understand the impact of alcohol on health and social harms, and their role in public health responses.

Aim: To investigate health and community worker perceptions of alcohol-related harm in the NSW community and their attitudes toward alcohol harm reduction policies.

Methods: A pilot online survey, employing a mixed-methods design, collected quantitative and qualitative data from 20 health and community workers (professionals and volunteers) involved in alcohol harm prevention in metropolitan, regional, and rural NSW. The 10-minute survey included Likert-scale questions on harm priorities and open-ended questions on policy attitudes. Quantitative data were analysed using descriptive statistics, and qualitative responses were analysed thematically

Findings and Outcomes: To date, this project has collected responses from 20 individuals from metropolitan, regional and rural NSW. The harm ranked as most important in the participant’s community was domestic violence, followed by health problems/illness, mental illness and interpersonal conflict or relationship breakdown. Most reported active engagement in prevention activities, including peer education, comorbidity treatment, community outreach, and policy advocacy. However, limited policy knowledge and training were noted as barriers. These findings highlight the critical role of health and community workers in alcohol harm reduction.

Future Actions: To advance healthy cities, policymakers should integrate health and community workers into alcohol policy development through stakeholder forums and targeted training on advocacy and evidence-based interventions. Public health practitioners and local governments should collaborate to establish cross-sector networks, enhancing worker capacity to drive equitable, community-focused alcohol harm reduction strategies.

Background/Objective: Community-developed place-based health promotion interventions have been identified as one way to improve child health. This study sought to identify the barriers and facilitators to the implementation of physical activity and healthy eating actions. These actions had previously been identified through a participatory group model building process to prevent childhood obesity in five rural and regional communities in Victoria, Australia.

Methods: Two online semi-structured focus groups were conducted with community-based facilitation teams which consisted of health promotion teams and other agencies responsible for supporting implementation of community-based programs such as local council, district health services and agencies. The Consolidated Framework of Implementation Research (CFIR) formed the analytical framework. Responses were audio-recorded and transcribed. The data were then coded and analysed thematically according to the CFIR using a deductive approach.

Results: Several facilitators and barriers to implementation emerged which mapped to ten constructs across the five CFIR domains. Community empowerment and leadership were key facilitators while limited resources was a key barrier to effective and sustained implementation.

Conclusion: Long term oversight and community capacity are intertwined in the success of action implementation. Community engagement and empowerment are critical in the continued success of implementation efforts for current and future community-generated obesity prevention trials. Future community-led interventions would benefit from using a systems-thinking approach and ensuring appropriate long-term investment in community capacity building when addressing the underlying drivers of childhood obesity.

Background: Access to affordable and nutritious food is a key determinant of health. University students are in a critical transition stage of life and may be particularly vulnerable to food insecurity, particularly in the current challenging economic climate. Our aim was to determine the prevalence of food insecurity among university students, explore differences between experiences of domestic and international university students and determine strategies to improve the situation.
Methods: Three cross-sectional online surveys were conducted among students 18 years and over, enrolled at Macquarie University, in 2020, 2022 and 2024. Food insecurity status was assessed using the 6 item US Adult Food Security Module (USDA FSSM) questionnaire, psychological distress using the K-10. Demographic data and data on degree, enrolment and Faculty were also collected. Qualitative interviews were conducted (n=29) with students to assess their experiences of food insecurity with a view to co-designing appropriate interventions.
Results: In 2020 (n=105), food insecurity was prevalent among university students (41.9%), with international students reporting higher levels of both food insecurity and psychological distress. The 2022 survey (n=237) showed a similar prevalence (41.4%), and in 2024 (n=710) the remained high at 39.9%, again with international students at a higher risk. In qualitative interviews many students, particularly international students, reported that the food on campus was not affordable, leading to coping mechanisms such as skipping meals. Intervention ideas for easing the burden of food insecurity included free fruit and vegetables, discounted meals, improved self-catering facilities and food relief for severely affected students.
Conclusions: Building on these findings, an advocacy strategy has been developed to improve the University food environment and provide targeted financial and psychological support, for both international and domestic university students. Ongoing evaluation of these initiatives as well as the monitoring changes to the prevalence of food insecurity is recommended.

Background
This study estimates the overall gaps between health system capacity provided by physicians and non-physician providers (nurses, pharmacists, community health workers) and patients’ needs for hypertension management, with stratification based on the regional economy.

Methods
We extracted data on population, physician, and non-physician provider density (including nurses, pharmacists, and community health workers) per 10,000 people from the World Bank Databases for 199 countries and territories in 2021. Data on the prevalence of hypertension were obtained from the NCD-RisC Factor Collaboration (NCD-RisC) in 2021. We estimated the patient need to visit a clinic for hypertension management under three scenarios: 12 visits per patient per year (base scenario, reflecting the standard practice in many low-and middle-income countries (LMICs) where physicians conduct monthly clinic visits to prescribe medication refills), six visits (intermediate scenario), three visits (low scenario), one visit (minimal scenario), and two scenarios based on health worker capacity to provide clinic services: 20 patients per day (base capacity), and 10 patients per day (low capacity) per providers.

Results
The overall prevalence of hypertension was 37.5 (SD=6.6%): 36.2 (7.0%) in HIC, 40.3 (6.7) in UMIC, 36.1 (5.7%) in LMIC, and 36.7(4.8%) in LIC. Physicians (mean=19.2,SD=17.4), nurses (47.3, SD=54.1), pharmacists (3.9, SD=4.7) per 10,000 were higher in high income countries, while CHWs (3.4, SD=7.3) were higher in low- and middle-income countries. All countries and territories showed deficits in the base scenario, with deficits decreasing when switching to intermediate and minimal scenarios. In LMICs, deficits persisted even with a single visit per year. Incorporating non-physicians in hypertension workforce under the same scenario reduced these deficits, resulting in 36 countries achieving net surpluses.

Conclusions
Our analysis highlights significant disparities in health service capacity globally if hypertension management continues to rely solely on physicians. Addressing these gaps requires targeted interventions, involving non-physician health workers and leveraging innovative technologies, improving training, and enhancing healthcare infrastructure, to meet the growing demand for hypertension services globally.

Aim: To systematically review cohort studies on the association of physical activity (PA) and sedentary behaviour (SB) with microvascular complications (retinopathy, nephropathy, neuropathy) in adults with type 1 (T1D) and type 2 diabetes (T2D).

Methods: Electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus; Cochrane Library, and Web of Science platform were searched from inception to the 25th of March 2025 using search terms related to “diabetes”, “PA and SB”, “microvascular complications” and “cohort studies” to identify studies on the association between PA/SB and microvascular complications in persons with T1D and T2D. A narrative synthesis was performed.

Results
Of 1,311 screened records, 12 cohort studies (10 on PA and 2 on SB; 53,934; follow-up 4-12 years) met the inclusion criteria. The majority of studies were from Europe (50%) and Asia (33.3%), followed by North America (16.6%) and Oceania (8.3%). Four studies enrolled persons with T1D, seven of those with T2D and one included a mixed T1D/T2D cohort. In all studies, PA and SB were self-reported. Two T1D studies reported that higher PA was associated with lower risk of retinopathy and nephropathy, while another two observed no association between PA and microvascular complications. Six T2D studies reported that higher PA levels were linked to lower risk of retinopathy, nephropathy, and neuropathy. Two SB studies reported that greater sedentary time was associated with a higher risk of foot ulcers in T1D/T2D patients with neuropathy and another reported that greater sedentary time was associated with higher risk of retinopathy in T2D persons.

Conclusion: Higher PA and lower SB were associated with a lower risk of microvascular complications in persons with T1D and T2D. Healthcare providers should routinely incorporate PA counseling and SB reduction strategies into diabetes management plans to help prevent or slow the progression of microvascular complications in individuals with T1D and T2D.

Background:
Undernourished children are more prone to disease and death due to high rates of underweight, wasting, and stunting. Malnutrition and infectious diseases are interlinked. Undernutrition weakens immunity, increasing infection risk, while illness depletes nutritional reserves. Addressing these dual burdens through integrated strategies could improve child health. This study explores the association between nutritional status and age-appropriate immunization among children enrolled in the digital registry at private clinics in Karachi.
Methods:
This retrospective cross-sectional study was conducted at 33 private clinics implementing a digital nutrition registry in two super high-risk and high-risk union councils of Karachi, identified by the National Emergency Operations Center (NEOC) as polio reservoirs. These clinics also served as fixed expanded program on immunization (EPI) sites. A total of 124 children aged 9-59 months were screened using mid-upper arm circumference (MUAC) and categorized as healthy, moderate acute (MAM), and severely acute malnourished (SAM). MR-1 status was assessed for children ≥ 9 months, and MR-2 for those ≥ 15 months. Vaccination data were cross-tabulated with nutritional status
Results:
Age-appropriate MR-1 coverage was high: 93.7% in healthy, 100% in MAM, and 93.1% in SAM. Among the 7 unvaccinated MR-1 cases, 42.8% were SAM. In contrast, MR-2 coverage declined: 75.8% in healthy, 81.2% in MAM, and only 68.2% in SAM children. Notable, 31.7% of SAM children were not age- appropriately immunized with MR-2-the highest among all groups.
Conclusion:
This preliminary analysis suggests that while MR-1 coverage was high, MR-2 uptake was lower among severely malnourished children. Strengthening integrated follow-up in private clinics is essential. Leveraging the Mazboot Bunyad digital nutrition registry offers an innovative approach to improve child health outcomes with potential to scale-up through public-private collaboration.