Fear, trust and Aborigines : The historical experience of state institutions and current encounters in the health system

Troubled dynamics between residents of an Aboriginal town in Queensland and the local health system were established during colonisation and consolidated during those periods of Australian history where the policies of 'protection' (segregation), integration and then assimilation held sway. The status of Aboriginal health is, in part, related to interactions between the residents' current and historical experiences of the health and criminal justice systems as together these agencies used medical and moral policing to legitimate dispossession, marginalisation, institutionalisation and control of the residents. The punitive regulations and ethnocentric strategies used by these institutions are within the living memory of many of the residents or in the published accounts of preceding generations. This paper explores current residents' memories and experiences.

Quality-based benefit design in health insurance : the impact of a product benefit design change on the utilisation of oral health services by members of a private health insurance fund in regional and rural New South Wales, Australia

Objective: To examine the impact on dental utilisation following the introduction of a participating provider scheme (Regional and Rural Oral Health Program {RROHP)). In this model dentists receive higher third party payments from a private health insurance fund for delivering an agreed range of preventive and diagnostic benefits at no out-ofpocket cost to insured patients. Data source/Study setting: Hospitals Contribution Fund of Australia (HCF) dental claims for all members resident in New South Wales over the six financial years from l99811999 to 200312004. Study design: This cohort study involves before and after analyses of dental claims experience over a six year period for approximately 81,000 individuals in the intervention group (HCF members resident in regional and rural New South Wales, Australia) and 267,000 in the control group (HCF members resident in the Sydney area). Only claims for individuals who were members of HCF at 31 December 1997 were included. The analysis groups claims into the three years prior to the establishment of the RROHP and the three years subsequent to implementation. Data collection/Extraction methods: The analysis is based on all claims submitted by users of services for visits between 1 July 1988 and 30 June 2004. In these data approximately 1,000,000 services were provided to the intervention group and approximately 4,900,000 in the control group. Principal findings: Using Statistical Process Control (SPC) charts, special cause variation was identified in total utilisation rate of private dental services in the intervention group post implementation. No such variation was present in the control group. On average in the three years after implementation of the program the utilisation rate of dental services by regional and rural residents of New South Wales who where members of HCF grew by 12.6%, over eight times the growth rate of 1.5% observed in the control group (HCF members who were Sydney residents). The differences were even more pronounced in the areas of service that were the focus of the program: diagnostic and preventive services. Conclusion: The implementation of a benefit design change, a participating provider scheme, that involved the removal of CO-payments on a defined range of preventive and diagnostic dental services combined with the establishment and promotion of a network of dentists, appears to have had a marked impact on HCF members' utilisation of dental services in regional and rural New South Wales, Australia.

The oral health of critically ill children

Introduction. In adults, oral health has been shown to worsen during critical illness as well as influence systemic health. There is a paucity of paediatric critical care research in the area of oral health; hence the purpose of the Critically ill Children’s Oral Health (CCOH) study is to describe the status of oral health of critically ill children over time spent in the paediatric intensive care unit (PICU). The study will also examine the relationship between poor oral health and a variety of patient characteristics and PICU therapies and explore the relationship between dysfunctional oral health and PICU related Healthcare-Associated Infections (HAI). Method. An observational study was undertaken at a single tertiary-referral PICU. Oral health was measured using the Oral Assessment Scale (OAS) and culturing oropharyngeal flora. Information was also collected surrounding the use of supportive therapies, clinical characteristics of the children and the occurrence of PICU related HAI. Results. Forty-six participants were consecutively recruited to the CCOH study. Of the participants 63% (n=32) had oral dysfunction while 41% (n=19) demonstrated pathogenic oropharyngeal colonisation during their critical illness. The potential systemic pathogens isolated from the oropharynx and included Candida sp., Staphylococcus aureus, Haemophilus influenzae, Enterococcus sp. and Pseudomonas aeruginosa. The severity of critical illness had a significant positive relationship (p=0.046) with pathogenic and absent colonisation of the oropharynx. Sixty-three percent of PICU-related HAI involved the preceding or simultaneous colonisation of the oropharynx by the causative pathogen. Conclusion. Given the prevalence of poor oral health during childhood critical illness and the subsequent potential systemic consequences, evidence based oral hygiene practices should be developed and validated to guide clinicians when nursing critically ill children.

Towards a culturally appropriate mental health system: Sudanese-Australians' experiences with trauma

Australia is fortunate to welcome approximately 13,000 humanitarian entrants per year, most of whom have experienced protracted violence, hardship and life in refugee camps. The majority of humanitarian migrants were raised in cultural contexts very different to that of Australia, contributing to the increasing diversity of this region. With this diversity comes a responsibility to ensure every Australian receives culturally appropriate mental healthcare. Those who are forced into migration have experienced trauma and the stress of acculturation often compounds this trauma. This study investigated the experience of trauma from the perspectives of Sudanese-Australians. Grounded theory methodology was employed to extract themes from interviews with 15 Sudanese-Australians aged between 19 and 49 years. Results demonstrated four overarching themes: support, religion, strength and new possibilities. The data within these themes are compared and contrasted with previous literature that has examined notions of trauma, distress and growth in western populations. Conclusions drawn from these results highlight the need to build inclusive practices that support diversity into existing trauma services in Australia.

The legal framework of the Australian health system

This chapter is about the role of law in the creation and operation of Australian health systems. Accordingly, this chapter discusses how law regulates the way in which health services in Australia are funded, organised, regulated, managed, operated and governed. (The question of how health professionals are regulated is discussed in Chapter 15.) Although the focus of much of health law is on legal mechanisms for the resolution of disputes or disagreements between the state, health providers, professionals, patients and families and friends, and through dispute resolutions processes setting standards for practice, these are only some of the “jobs” that health law performs. In health systems where the state undertakes a significant role in regulating, funding, managing and providing health services, health law also performs an important constitutive function. Health law declares the values upon which the health system is based, shapes social processes to achieve public ends and provides a structure for the complex interactions that occur within a modern health system. Health law regulates decision-makers in health systems by establishing who has the power to participate in decisions and in what circumstances, establishing processes through which decisions are made and creating mechanisms for decision-makers to be held publicly accountable. It is this broader constitutive function of health law that is a primary focus of much of this chapter — how and why governments use their legislative powers to structure and shape the health system.

The oral health of critically ill children : an observational cohort study

Aims and objectives: This study will describe the oral health status of critically ill children over time spent in the paediatric intensive care unit, examine influences on the development of poor oral health and explore the relationship between dysfunctional oral health and healthcare-associated infections. Background: The treatment modalities used to support children experiencing critical illness and the progression of critical illness may result in dysfunction in the oral cavity. In adults, oral health has been shown to worsen during critical illness as well as influence systemic health. Design: A prospective observational cohort design was used. Method: The study was undertaken at a single tertiary-referral Paediatric Intensive Care Unit. Oral health status was measured using the Oral Assessment Scale and culturing oropharyngeal flora. Information was also collected surrounding the use of supportive therapies, clinical characteristics of the children and the occurrence of healthcare-associated infections. Results: Of the 46 participants, 63% (n = 32) had oral dysfunction and 41% (n = 19) demonstrated pathogenic oropharyngeal colonisation during their critical illness. The potential systemic pathogens isolated from the oropharynx and included Candida sp., Staphylococcus aureus, Haemophilus influenzae, Enterococcus sp. and Pseudomonas aeruginosa. The severity of critical illness had a significant positive relationship (p < 0·05) with pathogenic and absent colonisation of the oropharynx. Sixty-three percent of healthcare-associated infections involved the preceding or simultaneous colonisation of the oropharynx by the causative pathogen. Conclusions: This study suggests paediatric oral health to be frequently dysfunctional and the oropharynx to repeatedly harbour potential systemic pathogens during childhood critical illness. Relevance to clinical practice: Given the frequency of poor oral health during childhood critical illness in this study and the subsequent potential systemic consequences, evidence based oral hygiene practices should be developed and validated to guide clinicians when nursing critically ill children.

The emerging role of private health care provision in China : a critical analysis of the current health system

China continues to face great challenges in meeting the health needs of its large population. The challenges are not just lack of resources, but also how to use existing resources more efficiently, more effectively, and more equitably. Now a major unaddressed challenge facing China is how to reform an inefficient, poorly organized health care delivery system. The objective of this study is to analyze the role of private health care provision in China and discuss the implications of increasing private-sector development for improving health system performance. This study is based on an extensive literature review, the purpose of which was to identify, summarize, and evaluate ideas and information on private health care provision in China. In addition, the study uses secondary data analysis and the results of previous study by the authors to highlight the current situation of private health care provision in one province of China. This study found that government-owned hospitals form the backbone of the health care system and also account for most health care service provision. However, even though the public health care system is constantly trying to adapt to population needs and improve its performance, there are many problems in the system, such as limited access, low efficiency, poor quality, cost inflation, and low patient satisfaction. Currently, private hospitals are relatively rare, and private health care as an important component of the health care system in China has received little policy attention. It is argued that policymakers in China should recognize the role of private health care provision for health system performance, and then define and achieve an appropriate role for private health care provision in helping to respond to the many challenges facing the health system in present-day China.

When Can Oral Health Education Begin? Relative effectiveness of three oral health education strategies starting pre-partum

Objective: To test the impact of oral health education provided to pregnant mothers on subsequent practices within the infant’s family. Research design: A quasi-experimental intervention trial comparing the effectiveness of ‘usual care’ to one, or both, of two oral health education resources: a ‘sample bag’ of information and oral health care products; and/or a nine-minute “Healthy Teeth for Life” video on postnatal oral health issues. Participants: Women attending the midwife clinic at approximately 30 weeks gestation were recruited (n=611) in a public hospital providing free maternity services. Results and Conclusions: Four months after the birth of their infant, relative to the usual care condition, each of the oral health education interventions had independent or combined positive impacts on mother’s knowledge of oral health practices. However young, single, health care card-holder or unemployed mothers were less likely to apply healthy behaviours or to improve knowledge of healthy choices, as a result of these interventions. The video intervention provided the strongest and most consistent positive impact on mothers’ general and infant oral health knowledge. While mothers indicated that the later stage of pregnancy was a good time to receive oral health education, many suggested that this should also be provided after birth at a time when teeth were a priority issue, such as when “baby teeth” start to erupt.

Alternate healing and medicine : the roles of naturopathy, homeopathy, osteopathy, chiropractic and medical practice in the health system

This thesis is concerned with understanding the roles of four alternate healing systems and medical practice in the community's health behaviour. The four alternate systems are naturopathy, homoeopathy, osteopathy and chiropractic. The research reported developed from work supported by the Committee of Inquiry into Chiropractic, Osteopathy, Homoeopathy and Naturopathy conducted under the chairmanship of Professor E. C. Webb set up by the Australian Government in 1975. The study concentrates on the factors which influence individual clients in their decisions to consult healers for treatment. An underlying assumption is that an analysis of the processes that effect such decisions will lead to further knowledge of the community's attitudes towards the functions of alternate healing and medicine. A review of the historical backgrounds and current status of the four alternate healing systems leads to the conclusion that they differ in a variety of areas. These areas include treatment modalities, historical backgrounds, occupational development and rapprochement with medicine. Homoeopathy, osteopathy and chiropractic emerged as distinct approaches to healing late in the nineteenth century. Naturopathy tends to be a philosophy or style of life as much as a health system in its own right. Their relationships with medicine also vary; osteopathy and naturopathy receive some acceptance, some homoeopaths are tolerated, whilst chiropractic is ostracised and vilified. A common paradigm of treatment underlies all four alternate approaches to healing. They all eschew the use of synthetic pharmaceuticals and invasive treatments and accept an indigenous theory of disease and a belief in the vis medicatrix naturae or the healing power of nature. An inevitable concomitant of this paradigm is that they believe that healing and health must be self-engendered. They rest within the client and his or her actions, not within the hands, skills or power of the healer. It is these characteristics combined with the alternate healers ' claims to espouse a similar scientific rationale for their approaches, and their functioning as parallel healers to medicine, that establishes their special relationship with medicine. This relationship become s more problematic in the face of medicine's hegemony and claim to unique legitimacy as the community's sole healing system. The interaction between these systems and medical practice can be gauged through articles related to the four alternate healing systems that have appeared in the medical literature. Interest has been cyclical but appears to have markedly increased in the past two decades. In this period it has included exploratory and descriptive writing; concern with controlling and/or eradicating the healers; desire to protect an ignorant and vulnerable public and. finally understanding and exploration of what the alternate healers might have to offer. At the same time, the public or institutionalized role has been one of denial and suppression through ostracism and legal constraints. In spite of medicine's position the alternate healing systems have found growing community acceptance so that it is problematical and probably unacceptable now to consider their use as a 'deviant ' health action. Increasing interest in the characteristics of clients has provided a consensus that they are similar to the adult population and are more likely to suffer from musculoskeletal and chronic illnesses. They are no more likely to be neurotic or gullible than the general community, but probably more practical and more oriented towards an active involvement in the healing process. The impact of these issues is explored, through comparing the strategies taken into account when choosing a treatment. These include attending one of the alternate healers exclusively for a condition; attending an alternate healer and a medical practitioner for the same problem; attending a medical practitioner solely or not consulting any healer. Respondents from surveys of alternate healer clients and the general community were classified according to their use of these four strategies, and the influences on their decisions at different stages of the treatment decision making process were compared.

Hospital care in Iran : an examination of national health system performance

This study examines hospital care system performance in Iran. We first briefly review hospital care delivery system in Iran. Then, the hospital care system in Iran has been investigated from financial, utilization, and quality perspectives. In particular, we examined the extent to which health care system in Iran protects people from the financial consequence of health care expenses and whether inpatient care distributed according to need. We also empirically analyzed the quality of hospital care in Iran using patient satisfaction information collected in a national health service survey. The Iranian health care system consists of unequal access to hospital care; mismatch between the distribution of services and inpatients' need; and high probability of financial catastrophe due to out-of-pocket payments for inpatient services. Our analysis indicates that the quality of hospital care among Iranian provinces favors patients residing in provinces with high numbers of hospital beds per capita such as Esfahan and Yazd. Patients living in provinces with low levels of accessibility to hospital care (e.g. Gilan, Kermanshah, Hamadan, Chahar Mahall and Bakhtiari, Khuzestan, and Sistan and Baluchestan) receive lower-quality services. These findings suggest that policymakers in Iran should work on several fronts including utilization, financing, and service quality to improve hospital care.

Developing pictorial conceptual metaphors as a means of understanding and changing the Australian health system for Indigenous people

This paper describes the development of Pictorial Conceptual Metaphors, created out of a literature review on gendered Indigenous health and wellbeing that depicts the inherited effects of the ‘system’ past, present and future. The Pictorial Conceptual Metaphors are pictures that were created to tell the story of colonisation and its inherited and ongoing impacts on Indigenous people’s health and wellbeing. Aboriginal historical experiences, past, present and future are briefly overviewed in order to unpack and communicate to readers the significance and impact of these experiences on Aboriginal health, and ultimately, to bring about understanding to initiate change within the Australian health system. Systemic racism, embedded in the Australian health system, excludes and discriminates against Indigenous peoples through a lack of cultural consideration resulting in a cumulative and ongoing negative effect on Indigenous people’s health (Dudgeon et al. 2014; Fredericks 2008; Marmot 2011; Queensland Government 2012). Systemic action research identifies actions and processes in large systems such as health and education in order to bring about systemic change. Our intention to highlight the systemic changes needed in the Australian health system to improve Indigenous people’s health and wellbeing require us to understand the processes involved in bringing about systemic change. For this to occur, we needed to ‘see the system’ in order to identify the system dynamics in operation. The Pictorial Conceptual Metaphors are the first step in ‘seeing the system’; they illustrate the past and the present, and identify the preferred future for Indigenous health and wellbeing outcomes

Do health inquiries lead to health system change? What have we learnt from recent health inquiries and will the same mistakes happen again?

Since 2001 there have been numerous Commissions of Inquiry into health system failures across the world. While the Inquiries were established to examine poor patient outcomes, each has identified a range of leadership and management shortcomings that have contributed to a poor standard of patient care. While there is an acknowledgement that different heath systems have different contexts, this paper highlights a number of themes that are common across Inquiries. It will discuss a number of common system failures in Inquiries spanning from 2001 to 2013 and pose questions as to why these types of failures are likely to re-occur, as well as possible learnings for health service management and leadership to address a number of these common themes.

An empirical investigation of health information system failure in regional Sri Lanka

Public health decision making is critically dependant on accurate, timely and reliable information. There is a widespread belief that most of the national and sub-national health information systems fail in providing much needed information support for evidence based health planning and interventions. This situation is more acute in developing nations where resources are either stagnant or decreasing, coupled with the situations of demographic transition and double burden of diseases. Literature abounds with publications, which provide information on misguided health interventions in developing nations, leading to failure and waste of resources. Health information system failure is widely blamed for this situation. Nevertheless, there is a dearth of comprehensive evaluations of existing national or sub-national health information systems, especially in the region of South-East Asia. This study makes an attempt to bridge this knowledge gap by evaluating a regional health information system in Sri Lanka. It explores the strengths and weaknesses of the current health information system and related causative factors in a decentralised health system and then proposes strategic recommendations for reform measures. A mix methodological and phased approach was adopted to reach the objectives. An initial self administered questionnaire survey was conducted among health managers to study their perceptions in relation to the regional health information system and its management support. The survey findings were used to establish the presence of health information system failure in the region and also as a precursor to the more in-depth case study which was followed. The sources of data for the case study were literature review, document analysis and key stake holder interviews. Health information system resources, health indicators, data sources, data management, data quality, and information dissemination were the six major components investigated. The study findings reveal that accurate, timely and reliable health information is unavailable and therefore evidence based health planning is lacking in the studied health region. Strengths and weaknesses of the current health information system were identified and strategic recommendations were formulated accordingly. It is anticipated that this research will make a significant and multi-fold contribution for health information management in developing countries. First, it will attempt to bridge an existing knowledge gap by presenting the findings of a comprehensive case study to reveal the strengths and weaknesses of a decentralised health information system in a developing country. Second, it will enrich the literature by providing an assessment tool and a research method for the evaluation of regional health information systems. Third, it will make a rewarding practical contribution by presenting valuable guidelines for improving health information systems in regional Sri Lanka.

Preparation and in vitro release of zein microparticles loaded with prednisolone for oral delivery

Zein has been proposed as a polymer for targeted-drug delivery via the oral route. Zein microparticles were loaded with prednisolone and evaluated as an oral delivery system. Microparticles were formulated using phase separation. Starting quantities of zein and prednisolone, along with the agitation method and temperature were found to significantly impact drug loading and loading efficiency. Vortex mixing produced the highest drug loading and loading efficiency. Drug release was measured in simulated conditions of the stomach and small intestine using the microparticles made with the method that best improved drug loading. In simulated stomach and small intestine conditions, prednisolone release reached almost 70 over 3 and 4h, respectively. While a clinically relevant dose may be delivered using c. 100mg of zein microparticles, prednisolone release from the microparticles indicates that they may not be suited as a controlled-or targeted-delivery system.