Changes in Australian injecting drug users’ mental health problems and service uptake from 2006-2012

Purpose– The purpose of this paper is to assess changes in rates of mental health problems and service utilisation for Australian regular injecting drug users (IDUs) from 2006 to 2012. Design/methodology/approach – Data were taken from Illicit Drug Reporting System national surveys with 914 regular IDUs in 2006 and 883 in 2012. Changes in rates of self-reported mental health problems and service use were assessed. Findings – Rates of self-reported mental health problems increased from 38.3 per cent in 2006 to 43.7 per cent in 2012 – mainly due to increases in anxiety rates. Conversely, there was a decrease in mental health service use from 70.2 to 58.4 per cent by 2012. However, there was a proportional increase in the use of psychologists. These trends remained after controlling for socio-demographic and medical differences between the 2006/2012 samples. K10 scores for 2012 participants validated the use of the self-report measures. Practical implications – Reductions in stigma, improvements in mental health literacy, and modest increases in anxiety may explain increases in self-report of mental health problems. Stagnant service utilisation rates in an expanding population willing to self-report may explain decreasing service use. The introduction of key mental health reforms also may have contributed, particularly with the increase in psychologist access. This paper highlights the need for improved population monitoring of mental health in disadvantaged groups such as IDUs. Originality/value – This paper is the first to assess changes in mental health outcomes over time in Australian IDUs. This examination covered a critical era in the mental health landscape, with significant increases in public awareness campaigns and major mental health reforms.

Health beliefs and practices in three generations of Greek Australian women in Melbourne.

This research explores the health beliefs of three generations of Greek Australian women in Melbourne. It describes their experience of illness and wellbeing in the context of a culture-specific understanding of health with strong cultural, religious, and linguistic bases that derive from the community’s Greek heritage.

Optimising health literacy and access of service provision to community dwelling older people with diabetes receiving home nursing support

Background. Health literacy is the ability to access, understand, and use information and services for good health. Among people with chronic conditions, health literacy requirements for effective self-management are high. The Optimising Health Literacy and Access (Ophelia) study engaged diverse organisations in the codesign of interventions involving the Health Literacy Questionnaire (HLQ) needs assessment, followed by development and evaluation of interventions addressing identified needs. This study reports the process and outcomes of one of the nine organisations, the Royal District Nursing Service (RDNS).

Methods. Participants were home nursing clients with diabetes. The intervention included tailored diabetes self-management education according to preferred learning style, a standardised diabetes education tool, resources, and teach-back method.

Results. Needs analysis of 113 quota-sampled clients showed difficulties managing health and finding and appraising health information. The service-wide diabetes education intervention was applied to 24 clients. The intervention was well received by clients and nurses. Positive impacts on clients' diabetes knowledge and behaviour were seen and nurses reported clear benefits to their practice.

Conclusion. A structured method that supports healthcare services to codesign interventions that respond to the health literacy needs of their clients can lead to evidence-informed, sustainable practice changes that support clients to better understand effective diabetes self-management.

HealthMap: a cluster randomised trial of interactive health plans and self-management support to prevent coronary heart disease in people with HIV

BACKGROUND: The leading causes of morbidity and mortality for people in high-income countries living with HIV are now non-AIDS malignancies, cardiovascular disease and other non-communicable diseases associated with ageing. This protocol describes the trial of HealthMap, a model of care for people with HIV (PWHIV) that includes use of an interactive shared health record and self-management support. The aims of the HealthMap trial are to evaluate engagement of PWHIV and healthcare providers with the model, and its effectiveness for reducing coronary heart disease risk, enhancing self-management, and improving mental health and quality of life of PWHIV.

METHODS/DESIGN: The study is a two-arm cluster randomised trial involving HIV clinical sites in several states in Australia. Doctors will be randomised to the HealthMap model (immediate arm) or to proceed with usual care (deferred arm). People with HIV whose doctors are randomised to the immediate arm receive 1) new opportunities to discuss their health status and goals with their HIV doctor using a HealthMap shared health record; 2) access to their own health record from home; 3) access to health coaching delivered by telephone and online; and 4) access to a peer moderated online group chat programme. Data will be collected from participating PWHIV (n = 710) at baseline, 6 months, and 12 months and from participating doctors (n = 60) at baseline and 12 months. The control arm will be offered the HealthMap intervention at the end of the trial. The primary study outcomes, measured at 12 months, are 1) 10-year risk of non-fatal acute myocardial infarction or coronary heart disease death as estimated by a Framingham Heart Study risk equation; and 2) Positive and Active Engagement in Life Scale from the Health Education Impact Questionnaire (heiQ).

DISCUSSION: The study will determine the viability and utility of a novel technology-supported model of care for maintaining the health and wellbeing of people with HIV. If shown to be effective, the HealthMap model may provide a generalisable, scalable and sustainable system for supporting the care needs of people with HIV, addressing issues of equity of access.

Tantalus and the tyranny of territory : pursuing the dream of parity in rural and metropolitan population health outcomes through primary health care programs

Many health professionals and rural health academics are motivated by the challenge of achieving equitable access to health care in rural communities with the implicit vision that fairer access to services might ultimately lead to more equitable health outcomes for people living in rural and remote settings. The purpose of this paper is to put the issue of rural and urban health outcome parity into perspective and assess recent progress towards achieving the ultimate goal of improving rural health status. I will also explore ways in which rural communities might increase their access to and use of primary health care revenue in the future to improve community health outcomes. While some improvements have been achieved across the rural health system in recent times, the fundamental problem of maintaining infrastructure to service community needs in rural areas remains as daunting as ever. Extensive evidence has now been assembled to show that rural people generally enjoy a much lower standard of health care, health outcomes and life expectancy than their urban cousins. The question underlying all of this evidence, however, is... must this always be so? Is it possible to redress the current inequities between rural and urban populations and could new primary health care initiatives, such as the Enhanced Primary Care (EPC) program, be vehicles for achieving more equitable health care arrangements and health outcomes for people living in rural communities?

New money for mental health : will it make things better for rural and remote Australia?

New Australian government funding for the Better Outcomes in Mental Health Care initiative is a significant step forward for mental health, with general practitioners now able to offer direct referrals to psychologists, social workers, occupational therapists and Aboriginal health workers. Incentives for better teamwork between GPs and other mental health professionals have been introduced, but may have unintended consequences, including an exacerbation of workforce shortages in rural and remote areas. Possible solutions to these shortages include rural scholarships for students in the mental health professions; recruitment and retention of students coordinated by university departments of rural health; better access to continuing professional development; and federally funded rural positions and additional financial incentives for rural mental health practitioners.

Health behaviors among individuals with schizophrenia and depression

This article presents findings from a study that evaluated the utility of Protection Motivation Theory to explain cardiovascular health behaviors among people with schizophrenia (n = 83) and depression (n = 70). Results indicated that the prevalence of overweight, cigarette smoking and a sedentary lifestyle were greater among people with a mental illness compared to individuals without a mental illness. Major predictors were high levels of fear of cardiovascular disease, lack of knowledge of correct dietary principles, lower self-efficacy, limited social support and psychiatric symptoms. Implications of these results are discussed in designing education and preventive health programs for individuals with schizophrenia and Mental Depressive Disorder (MDD).

Equity-focused health impact assessment framework

Background to the Development of the Equity-Focused HIA Framework
The equity focused health impact assessment (EFHIA) framework arises out of a two year research project funded for the most part by the Australian Government’s Public Health Education Research Program (PHERP) Innovations Grants (Round 2) scheme. This project had as its primary objective the development of a framework for health inequalities impact assessment, subsequently renamed equity focused health impact assessment. A partnership between the University of Newcastle, Deakin University and the University of New South Wales (the Project Management Steering Committee) received the funding and the Australasian Collaboration for Health Equity Impact Assessment (ACHEIA) was formed to undertake appropriate background research and to develop, pilot test, modify and disseminate the framework. The work commenced in September 2002 and concluded in October 2004. Part of the funding included a capacity building workshop in August 2004. ACT Health and the Division of Medicine at the John Hunter Hospital, Newcastle, also provided financial support for the project. The August 2004 Workshop was supported by NSW Health. All participants and organisations involved in the project gave extensive in-kind support.
The aims of the workshop were to bring together an international collaboration of multidisciplinary investigators, public health experts, and key senior health managers working in national, state and local settings, to inform the further development of the framework and to provide training in its application. The initial goals of the project were to work collaboratively to develop a strategic framework to assess the health inequalities of public health-related policies, plans, strategies, decisions, programs and services. The EFHIA framework as presented at the August workshop was developed through:
1. an extensive review of the relevant literature
2. formal and informal consultation with members of ACHEIA (the international
reference group), members of the Project Management Steering Committee and
other relevant experts; and
3. testing of the draft EFHIA framework with the 5 case study partners – who applied the draft framework in a range of health settings (see
Acknowledgements).
The result of this work has been the development of an equity focused health impact assessment framework that can be used to determine the unanticipated and systemic health inequities that may exist within the decision making processes or activities of a range of organisations and sectors. The EFHIA framework provides one approach that can be used to assist decision makers to put equity and health on their agenda in a more obvious and systematic way. The framework represents a ‘moment in time’ rather than a definitive statement or ‘toolkit’ on the best way to proceed. Further practice, refinement and adjustment will be needed over many years to consolidate both HIA and EFHIA. As well as this guide to the framework, additional outputs from the project team include:
- A literature review
- A position paper
- A report on the five case studies
- An evaluation report.
With the consent of the Australian Government, a monograph will be made available to workshop participants at the end of October which contains the framework and the appropriate background papers.

Cultural diversity and mental health : the relationship between leisure experiences and wellbeing in an ageing Italian community in Australia

One of the population health implications for Australia’s ageing population is that a larger proportion of the Australian community will be retired and have more time for leisure pursuits. Meaningful leisure activities for this group are thought to be a factor in promoting positive mental health. However, a search of health literature revealed a paucity of research on how older adults make use of their leisure time, what meaning these pursuits have to them, and whether their chosen leisure activities are health enhancing and promote wellbeing. Australia’s population is diverse with many cultures represented. As the population ages, mental health workers will be called upon to provide culturally-appropriate mental health services to clients from a range of ethnic groups. Literature on how people of culturally diverse backgrounds understand leisure activities is also limited. This paper reports on a study carried out in an Italian community in a large regional centre. The participants were selected based on the following criteria; aged 65 years and over, born in Italy, independently living in the community, ambulant, and retired from paid workforce. This study explored how a well-elderly group from an ethnic community derived meaning from their leisure activities and how this impacted on their mental health. Establishing the relationship between leisure and mental health in an ageing ethnic community is important because it sheds light on potential intervention strategies that can be used to maintain the mental health of people living independently in the community. Participants were interviewed using semi-structured questions about their perceptions of leisure, the meanings they derived from these activities, and their perceived impact of these activities on their health. Participant observation was also used to add trustworthiness to the data. Themes arising from the interviews and participant observation will be related to the participants’ sense of health. Results also revealed how older Italians engaged in leisure activities. Implications of the research findings will be directed towards mental health practice with older ethnic clients in community settings. The promotion of healthy lifestyles and positive mental health for Australia’s ageing population will also be discussed.

Heterogeneity in service delivery and inequity in access are common characteristics of chronic heart failure management programs

Background: The prevalence of heart failure in Australia is similar to that of Europe. In Australia, chronic heart failure management programs (CHF-MPs) have become part of standard care for patients with Chronic Heart Failure (CHF). However, heterogeneity among programs is common which can result in variable patient outcomes.

Method: A national survey was undertaken of 59 post-discharge CHF-MPs identified from within the Australian health care system. Two had ceased operating and one centre declined to participate in the study. A 33-item investigator-developed questionnaire, examining the characteristics and interventions used within each CHF-MP, was sent to the remaining 56 CHF-MPs. A response rate of 100% was achieved.

Results: Our survey revealed a disproportional distribution of CHF-MPs across the Australian continent: the State of Victoria had 3.6 CHF-MPs/million population, New South Wales had 3.7 CHF-MPs/million population, Queensland had 1 program/million population, South Australia had 0.3 CHF-MPs/million population and Western Australia had 1 program/million population.Overall, 8000 postdischarge CHF pts (median: 126; IQR: 26-260) were managed via CHF-MPs. Approximately 40,000 CHF pts are discharged from metropolitan institutions nationally, this represents only 22% of the potential caseload for these cost-effective CHF-MPs. Only 8% of these programs were located within rural regions. The majority of CHF-MPs were located within an acute metropolitan hospital (52%) and 36% were community based (all associated with a hospital). Heterogeneity of CHF-MPs in applied models of care was evident with 75% of CHF-MPs offering CHF outpatient clinics and 77% conducting home visits. Of the programs offering home visits 78% were funded by regional government (p<0.048). There were no nurse-led CHF outpatient clinics. A hybrid approach to CHF-MPs was common with many CHF-MPs comprising an outpatient clinic, home visits and inpatient visits. Various medications were titrated by nurses in 43% of CHF-MPs. In the programs that allowed nurses to titrate medications 79% were located in an acute hospital (p<0.011).

Conclusion: Variability of service availability is of concern within the context of universal coverage. In addition, heterogeneity between programs and the diversity in models of care delivery highlights the inconsistency and questions the quality of health related outcomes. We are currently analysing health outcome data from the 1015 patients managed in these CHF-MPs to describe the relationship between quality of care and health outcomes.

‘Be yourself and have a ball’ : using a school and community based health education model to build young women’s resilience and connectedness

Recognition of the important role schools play in the promotion of student wellbeing can be seen in the growing number of polices and programs being implemented in schools across the Australia. This paper reports on some initial data from focus group interviews with year 9 and 10 girls involved in the pilot of a health and physical activity intervention designed to connect them to their local community and reconnect them with their school and their peers. The aim of the program was to build connectedness and resilience by engaging young women in non-traditional physical activities whilst providing them with a sound understanding of health issues relevant to adolescent girls. Situated in a relatively isolated rural community 200 kilometers south east of Melbourne the program was overwhelmingly delivered by regional and local agencies in conjunction with the local secondary school. The intervention was built on a partnerships model designed with the purpose of increasing participation and access for young women whilst building a sustainable program run in partnership between the school and local agencies and services. The initial data from this pilot indicates the program is having a positive impact on the young women’s sense of self and their bodies, their relationships with their peers and in reducing bullying behaviour amongst the girls. However the data raises some important questions around the adequacy of school-based health education, and the sustainability of approaches designed to be delivered by outside agencies rather than classroom teachers.

Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs

Objective: The objectives of this study were to: (i) identify local barriers and enablers to the uptake of hospital-based cardiac rehabilitation (CR) programs, and (ii) identify preferred alternatives for the delivery of CR.

Design: A questionnaire administered by local CR coordinators and focus groups facilitated by the research team.

Setting: Six regional hospitals in south-west Victoria offering hospital-based CR programs.

Participants: Patients and their carers referred to and eligible for local CR programs; health professionals working within local CR programs.

Main outcomes measures: CR attendees and decliners demographics, patient and health professional perceived factors which contribute to enabling hospital-based CR attendance, patient and health professional perceived barriers to CR attendance, and receptiveness and preferences for alternative modes of CR delivery.

Results: This study identified distance to travel to hospital-based CR programs the only statistically significant factor in determining uptake of CR. Easy access to transport (63%) and to a lesser extent family support (49%) and work flexibility (43%) were the primary enablers to attendance. Of the 97 study participants, 38% were receptive to alternative CR methods such as programs in outlying communities, evening facility-based programs, home and GP based programs, telephone support and a patient manual/workbook.

Conclusions: The results of this study provide valuable information for designing strategies to increase utilisation and improve patient acceptability of existing hospital-based CR programs. It provides a basis for pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.

Can a disease-specific education program augment self-management skills and improve Health-Related Quality of Life in people with hip or knee osteoarthritis?

Background: Patient education and self-management programs are offered in many countries to people with chronic conditions such as osteoarthritis (OA). The most well-known is the disease-specific Stanford Arthritis Self-Management Program (ASMP). While Australian and international clinical guidelines promote the concept of self-management for OA, there is currently little evidence to support the use of the ASMP. Several meta-analyses have reported that arthritis self-management programs had minimal or no effect on reducing pain and disability. However, previous studies have had methodological shortcomings including the use of outcome measures which do not accurately reflect program goals. Additionally, limited cost-effectiveness analyses have been undertaken and the cost-utility of the program has not been explored.

Methods/design: This study is a randomised controlled trial to determine the efficacy (in terms of Health-Related Quality of Life and self-management skills) and cost-utility of a 6-week group-based Stanford ASMP for people with hip or knee OA.

Six hundred participants referred to an orthopaedic surgeon or rheumatologist for hip or knee OA will be recruited from outpatient clinics at 2 public hospitals and community-based private practices within 2 private hospital settings in Victoria, Australia. Participants must be 18 years or over, fluent in English and able to attend ASMP sessions. Exclusion criteria include cognitive dysfunction, previous participation in self-management programs and placement on a waiting list for joint replacement surgery or scheduled joint replacement.

Eligible, consenting participants will be randomised to an intervention group (who receive the ASMP and an arthritis self-management book) or a control group (who receive the book only). Follow-up will be at 6 weeks, 3 months and 12 months using standardised self-report measures. The primary outcome is Health-Related Quality of Life at 12 months, measured using the Assessment of Quality of Life instrument. Secondary outcome measures include the Health Education Impact Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (pain subscale and total scores), Kessler Psychological Distress Scale and the Hip and Knee Multi-Attribute Priority Tool. Cost-utility analyses will be undertaken using administrative records and self-report data. A subgroup of 100 participants will undergo qualitative interviews to explore the broader potential impacts of the ASMP.

Discussion: Using an innovative design combining both quantitative and qualitative components, this project will provide high quality data to facilitate evidence-based recommendations regarding the ASMP.

The Health Education Impact Questionnaire (heiQ): An outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions

Objective: This paper describes the development and validation of the Health Education Impact Questionnaire (heiQ). The aim was to develop a user-friendly, relevant, and psychometrically sound instrument for the comprehensive evaluation of patient education programs, which can be applied across a broad range of chronic conditions.

Methods: Item development for the heiQ was guided by a Program Logic Model, Concept Mapping, interviews with stakeholders and psychometric analyses. Construction (N = 591) and confirmatory (N = 598) samples were drawn from consumers of patient education programs and hospital outpatients. The properties of the heiQ were investigated using item response theory and structural equation modeling.

Results: Over 90 candidate items were generated, with 42 items selected for inclusion in the final scale. Eight independent dimensions were derived: Positive and Active Engagement in Life (five items, Cronbach's alpha (α) = 0.86); Health Directed Behavior (four items, α = 0.80); Skill and Technique Acquisition (five items, α = 0.81); Constructive Attitudes and Approaches (five items, α = 0.81); Self-Monitoring and Insight (seven items, α = 0.70); Health Service Navigation (five items, α = 0.82); Social Integration and Support (five items, α = 0.86); and Emotional Wellbeing (six items, α = 0.89).

Conclusion:The heiQ has high construct validity and is a reliable measure of a broad range of patient education program benefits.

Practice Implications: The heiQ will provide valuable information to clinicians, researchers, policymakers and other stakeholders about the value of patient education programs in chronic disease management.