Building capacity for rural health : the role of boundary crossers in coalition maturity for partnerships with external agents

The concept of partnership has entered policy rhetoric and is urged as good practice in a variety of domains including health. Rural communities tend to have fewer resources available for the provision of services such as health than their metropolitan counterparts, and so could be expected to benefit from partnerships with external agencies. Indicators of coalition maturity for working in partnership with external agents in order to build stronger communities are distilled from the group development and partnership research literature and considered in the light of the experiences of the University Department of Rural Health in community engagement. The chapter draws on experiences of two rural community coalitions working to plan and negotiate health service provision. The coalitions were analysed against the indicators. A key indicator of maturity and readiness for working in partnership with external agents is related to the behaviour of ‘boundary crossers’. Boundary crossers are defined as people who move freely between two or more domains and who understand the values, cultures and language, and have the trust, of both. Domains can be within a community or be the community and an external sector. Community health professionals, especially those in senior positions, often act as boundary crossers between the community and broader domains such as regional/state health services or policy, although other community members can fill the role. Other key indicators of coalition maturity for working in partnership with external agents include local leadership that empowers the community, a willingness of community coalitions to take risks and mould opportunities to meet their vision, and a culture of critical reflection and evaluation of past actions.

This chapter analyses the impact of boundary crossing behaviour on community readiness and partnerships with external agents that are intended to build rural community capacity to plan and negotiate health service provision. It is argued that the characteristics and modus operandi of boundary crossers who are members of rural community coalitions affect the level of maturity of the coalitions and community readiness to work with external agents. An understanding of the characteristics and modus operandi of boundary crossers provides valuable insights for external agents in designing their approach to partnerships that build rural community capacity for health.

Boundary crossers, communities, and health : exploring the role of rural health professionals

Boundary crossers understand the culture and language of community and health service domains and have the trust of both. Rural health professionals living within the communities they serve are ideally placed to harness community capacity so as to influence community-level determinants of health. We analyse five case studies of rural health professionals acting as boundary crossers against indicators of capacity for communities and external agents such as health services working in partnership. A more explicit evidence base for inclusion of community health development in the jobs of rural health professionals is needed.

Program sustainability of a community-based intervention to prevent falls among older Australians

Multi-strategy interventions have been demonstrated to prevent falls among older people, but studies have not explored their sustainability. This paper investigates program sustainability of Stay on Your Feet (SOYF), an Australian multi-strategy falls prevention program (1992–1996) that achieved a significant reduction in falls-related hospital admissions. A series of surveys assessed recall, involvement and current falls prevention activities, 5 years post-SOYF, in multiple original SOYF stakeholder groups within the study area [general practitioners (GPs), pharmacists, community health (CH) staff, shire councils (SCs) and access committees (ACs)]. Focus groups explored possible behavioural changes in the target group. Surveys were mailed, except to CH staff and ACs, who participated in guided group sessions and were contacted via the telephone, respectively. Response rates were: GPs, 67% (139/209); pharmacists, 79% (53/67); CH staff, 63% (129/204); SCs, 90% (9/10); ACs, 80% (8/10). There were 73 older people in eight focus groups. Of 117 GPs who were practising during SOYF, 80% recalled SOYF and 74% of these reported an influence on their practice. Of 46 pharmacists operating a business during SOYF, 45% had heard of SOYF and 79% of these reported being ‘somewhat’ influenced. Of 76 community health staff (59%) in the area at that time, 99% had heard of SOYF and 82% reported involvement. Four SCs retained a SOYF resource, but none thought current activities were related. Seven ACs reported involvement, but no activities were sustained. Thirty-five focus group participants (48%) remembered SOYF and reported a variety of SOYF-initiated behaviour changes. Program sustainability was clearly demonstrated among health practitioners. Further research is required to assess long-term effect sustainability.

Nursing work and nursing knowledge : exploring the work of women's health nurses, patterns of power and praxis

The majority of women's health nurses in this study work in generalist community health centres. They have developed their praxis within the philosophy and policies of the broader women's health movement and primary health care principles in Australia. The fundamental assumption underlying this study is that women's health nurses possess a unique body of knowledge and clinical wisdom that has not been previously documented and explored. The epistemological base from which these nurses' operate offers important insights into the substantive issues that create and continually shape the practice world of nurses and their clients. Whether this represents a (re)construction of the dominant forms of health care service delivery for women is examined in this study. The study specifically aims at exploring the practice issues and experience of women's health service provision by women's health nurses in the context of the provision of cervical cancer screening services. In mapping this particular group of nurses practice, it sets out to examine the professional and theoretical issues in contemporary nursing and women's health care. In critically analysing the powerful discourses that shape and reshape nursing work, the study raises the concern that previous analyses of pursing work tend to universalise the structural and social subordination of nurses and nursing knowledge. This universalism is most often based on examples of midwifery and nursing work in hospital settings, and subsequently, because of these conceptualisations, all of nursing is too often deemed as a dependent occupation, with little agency, and is analysed as always in relation to medicine, to hospitals, to other knowledge forms. Denoting certain discourses as dominant proposes a relationship of power and knowledge and the thesis argues that all work relations and practices in health are structured by certain power/knowledge relations. This analysis reveals that there IX are many competing and complimentary power/knowledge relations that structure nursing, but that nursing, and in particular women's health nurses, also challenge the power/knowledge relations around them. Through examining theories of power and knowledge the analysis, argues that theoretical eclecticism is necessary to address the complex and varied nature of nursing work. In particular it identifies that postmodern and radical feminist theorising provide the most appropriate framework to further analyse and interpret the work of women's health nurses. Fundamental to the position argued in this thesis is a feminist perspective. This position creates important theoretical and methodological links throughout the whole study. Feminist methodology was employed to guide the design, the collection and the analysis. Intrinsic to this process was the use of the 'voices' of women's health nurses as the basis for theorising. The 'voices' of these nurses are highlighted in the chapters as italicised bold script. A constant companion along the way in examining women's health nurses' work, was the reflexivity with feminist research processes, the theoretical discussions and their 'voices'. Capturing and analysing descriptive accounts of nursing praxis is seen in this thesis as providing a way to theorise about nursing work. This methodology is able to demonstrate the knowledge forms embedded in clinical nursing praxis. Three conceptual threads emerge throughout the discussions: one focuses on nursing praxis as a distinct process, with its own distinct epistemological base rather than in relation to 'other' knowledge forms; another describes the medical restriction and opposition as experienced by this group of nurses, but also of their resistance to medical opposition. The third theme apparent from the interviews, and which was conceptualised as beyond resistance, was the description of the alternative discourses evident in nursing work, and this focused on notions of being a professional and on autonomous nursing praxis. This study concludes that rather than accepting the totalising discourses about nursing there are examples within nursing of resistance—both ideologically and X in practice—to these dominant discourses. Women's health nurses represent an important model of women's health service delivery, an analysis of which can contribute to critically reflecting on the 'paradigm of oppression' cited in nursing and about nursing more generally. Reflecting on women's health service delivery also has relevance in today's policy environment, where structural shifts in Commonwealth/State funding arrangements in community based care, may undermine women's health programs. In summary this study identifies three important propositions for nursing: • nursing praxis can reconstruct traditional models of health care; • nursing praxis is powerful and able to 'resist' dominant discourses; and • nursing praxis can be transformative. Joining feminist perspectives and alternative analyses of power provides a pluralistic and emancipatory politics for viewing, describing and analysing 'other' nursing work. At the micro sites of power and knowledge relations—in the everyday practice worlds of nurses, of negotiation and renegotiation, of work on the margins and at the centre—women's health nurses' praxis operates as a positive, productive and reconstructive force in health care.

Addressing the contradiction between discourse and practice in health promotion

The main theme of this thesis is the contradiction between discourse and practice in health promotion. Many health promoters continue to exert power-over the community through top-down programming whilst at the same time using an emancipatory discourse. The thesis has addressed this contradiction in three parts. The first part determines how the emancipatroty discourse has evolved and eplores the role of social movements in the development of contemporary health discourses and their influence on the legitimisation of empowerment. Central to this discourse is the empowerment of communities. To understand the role of this concept the thesis provides an interpretation of the different meanings of power and community, and the different levels of analysis of empowerment in the context of health promotion programming. The second part identifies the nature of health programming and the dominance of top-down, and to a much lesser extent, bottom-up approaches. The thesis argues that these two approaches are not, and do not have to be, mutually exclusive. To address this issue the thesis presents a new methodology is situated within a framework developed for the accomodation of empowerment goals within health promotion programmes. The study also identifies the organisational areas of influence on the processs of community empowerment and it is these which are used for the assessment of this concept. Both the framework and the methodology address the contradiction in health promotion by making community empowerment operational within a programme context. The third part of the thesis supports the rationale for the design of the methodology with field work in rural Fijian communities. The findings are presented as a composite case study to highlight the experiences of implementing the methodolgy and the main themes that emerged during the field work. the final chapter of the thesis brings together the central themes of the study and draws from these and 'emergent agenda' as a way forward for health promotion research and practice.

Scale development of individual and organisation infrastructure for heart health promotion in regional health authorities

Objective : The purpose of this study was to validate measures of individual and organisational infrastructure for health promotion within Alberta's (Canada) 17 Regional Health Authorities (RHAs).

Design : A series of phases were conducted to develop individual and organisational scales to measure health promotion infrastructure. Instruments were designed with focus groups and then pre-tested prior to the validation study.

Setting : In 1993 all hospitals and Public Health Units in the province of Alberta were regionalised into 17 RHAs, with responsibility for public health, community health, and acute and long-term care. While regionalisation may offer more opportunity for community participation, reorganisation of the public health system may have fragmented and diluted resources and skills for heart health promotion in some RHAs. Infrastructure (for example, human and financial resources), amongst other items, is believed to contribute to the capacity to promote health.

Method : All 17 RHAs participated in the study, yielding a total of 144 individuals (that is board members, senior/middle management, and front line staff). These representative employees completed a self- administered questionnaire on individual- and organisational-level infrastructure measures.

Results : Psychometric analyses of survey data provided empirical evidence for the robustness of the measures. Principal component analyses verified the construct validity of the scales, with alpha coefficients ranging from 0.75 to 0.95.

Conclusion : The scales can be used by health professionals and researchers to assess individual- and organisational-level infrastructure, and tailor interventions to increase infrastructure for health promotion in health organisations.

It's all a bit wishy washy : the challenge of building partnerships for effective mental health evaluation

Mental wellbeing and social connectedness is a key health priority in Victoria. Actions and interventions that may contribute to the promotion of community level mental wellbeing and social connectedness often occurs in other, non-health sectors. Including evidence from these sectors in evaluations of community based interventions around mental wellbeing and social connectedness is important to ensure comprehensive evaluation, and the development of best practice in this health priority area. However, published evaluation material of community based interventions around this health topic is limited, and rarely captures information from non-health sectors. This pilot study investigated the capacity of health promotion practitioners and other key stakeholders working in this area in Victoria to undertake evaluation of community based mental wellbeing and social connectedness interventions, issues and barriers faced in evaluation, and practitioners’ needs to be able to conduct effective and comprehensive evaluations.

Qualitative methods including semi-structure interviews and document analysis were used. Data was coded and analysed inductively, and key themes developed.

Results indicate that evaluating such interventions is challenging for practitioners due to the broad nature of the topic, and the measurement tools available. Many practitioners would like to conduct more comprehensive evaluation and include evidence from other sectors. Managerial and organizational support to develop partnerships both within the health sector and inter-sectorally was identified as a need in order to develop evaluation skills and facilitate more comprehensive evidence gathering.

This study underscores the importance of inter-sectoral partnerships for developing best evidence-based practice in community health. Partnerships are necessary for conducting comprehensive and effective evaluation to contribute to the evidence base. However, developing effective partnerships is challenging, and acts as a barrier to effective evaluation in a key health area for some community health practitioners. The findings also highlight an agenda for more action by managers to facilitate the development of relevant inter-sectoral partnerships.

Community led regeneration - experiences from London

The Community Health Project (CHP) is a community development project based in a multicultural deprived area of London, set up to tackle health inequalities. It is a partnership with the local Housing Action Trust, Health Authority and local residents and was established in 1994. The paper describes the work of the project, identifying the influences the project has been able to exert at a number of different levels: local, regional, national and international. The CHP provides a case study of how local people can act together to take part in development opportunities, with considerable and far-reaching effects. The experience of the CHP and other similar initiatives are analysed to identify elements of a framework for supporting the involvement of local communities in social and economic regeneration programs in ways that are empowering, giving local communities greater control over their lives and local resources and enabling the development of community capacity.

Building health promotion capacity in the workforce : participatory action research

This study used participatory action research to describe and analyse the elements of building health promotion capacity in a primary health care workforce in an urban community health setting, reinforcing the importance of provider informed evidence. It presents an integrated model for health promotion and capacity building in the workforce.

Improving the coordination of care for low back pain patients by creating better links between acute and community services

This paper reports on the development of a care-pathway to improve service linkages between the acute setting and community health services in the treatment of low back pain. The pathway was informed by two processes: (1) a literature review based on best-practice guidelines in the assessment, treatment and continuity of care for low back pain patients; and (2) consultation with staff and key stakeholders. Stakeholders from both the acute and community sectors comprised the Working Group, who identified central areas of concern to be addressed in the care-pathway, with the goal of preventing chronicity of low back pain and reducing emergency department presentations. The main outcomes achieved include: the development of a new care-coordinator role, which would support a greater focus on integration between acute and community sectors for low back pain patients; identifying the need to screen at-risk patients; implementation of the SCTT (Service Coordination Tool Templates) tool as a system of referral across the acute and community settings; and agreement on the need to develop an evidence-based self-management program to be offered to low back pain patients. The benefits and challenges of implementing this care pathway are discussed.

Community variation in adolescent alcohol use in Australia and the Netherlands

To investigate the cross-national relevance of community health promotion, this paper compared community variation in alcohol use and risk and protective factors for adolescents in Australia (State of Victoria, 2009) and the Netherlands (2007/2008). Multi-level analyses examined community variation in heavy episodic (binge) alcohol use [≥5 drinks in a session ≥once in the prior fortnight (>63 ml of ethanol)] and associations with predictors. Representative community samples of adolescents (12–17 years) were recruited. The participants were 7812 students from 36 Australian communities and 15 082 adolescents from 124 Dutch communities. Predictors included adolescent reports of family, school, peer and neighbourhood environments and community predictors (rural, disadvantage). The overall prevalence of alcohol use prevalence was similar in both nations. Australia had higher use at younger ages and no difference between genders. In the Netherlands older adolescents and males used alcohol at significantly higher rates. Although individual predictors were mostly similar, binge drinking was more strongly associated with poor family management, friends' use of drugs and community disorganization in Australia. Significant community variation in adolescent heavy alcohol use was observed in both countries, but was higher in the Netherlands [inter class correlation 6.1%, (95% CI: 4.5–8.3%)] than Australia (ICC 2.4%, 1.3–4.5%). Youth from rural areas drank at a higher level, especially in the Netherlands. Targeting community level adolescent alcohol use appears feasible in both countries. Although behavioural patterns and risk and protective influences are similar in the Netherlands and Australia, important differences should be taken into account in tailoring community interventions.

The impact of a team-based intervention on the lifestyle risk factor management practices of community nurses: outcomes of the community nursing SNAP trial

Background
Lifestyle risk factors like smoking, nutrition, alcohol consumption, and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care is an appropriate setting to address these risk factors in individuals. Generalist community health nurses (GCHNs) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time. The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practices of GCHNs.

Methods
The trial used a quasi-experimental design involving four generalist community nursing services in NSW, Australia. The services were randomly allocated to either an intervention group or control group. Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessments and interventions. The control group provided usual care. A sample of 129 GCHNs completed surveys at baseline, 6 and 12 months to examine changes in their practices and levels of confidence related to the management of SNAP risk factors. Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice.

Results
Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers. Nurses in the intervention group reported assessing physical activity, weight and nutrition more frequently, as well as providing more brief interventions for physical activity, weight management and smoking cessation. There was little change in referral rates except for an improvement in weight management related referrals. Nurses’ perception of the importance of ‘client and system-related’ barriers to risk factor management diminished over time.

Conclusions
This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practices of GCHNs. Barriers to referral remained. The service model needs to be adapted to sustain these changes and enhance referral.

Low health-related quality of life in school-aged children in Tonga, a lower-middle income country in the South Pacific

Background:
Ensuring a good life for all parts of the population, including children, is high on the public health agenda in most countries around the world. Information about children’s perception of their health-related quality of life (HRQoL) and its socio-demographic distribution is, however, limited and almost exclusively reliant on data from Western higher income countries.

Objectives:
To investigate HRQoL in schoolchildren in Tonga, a lower income South Pacific Island country, and to compare this to HRQoL of children in other countries, including Tongan children living in New Zealand, a high-income country in the same region.

Design:
A cross-sectional study from Tonga addressing all secondary schoolchildren (11–18 years old) on the outer island of Vava’u and in three districts of the main island of Tongatapu (2,164 participants). A comparison group drawn from the literature comprised children in 18 higher income and one lower income country (Fiji). A specific New Zealand comparison group involved all children of Tongan descendent at six South Auckland secondary schools (830 participants). HRQoL was assessed by the self-report Pediatric Quality of Life Inventory 4.0.

Results:
HRQoL in Tonga was overall similar in girls and boys, but somewhat lower in children below 15 years of age. The children in Tonga experienced lower HRQoL than the children in all of the 19 comparison countries, with a large difference between children in Tonga and the higher income countries (Cohen’s d 1.0) and a small difference between Tonga and the lower income country Fiji (Cohen’s d 0.3). The children in Tonga also experienced lower HRQoL than Tongan children living in New Zealand (Cohen’s d 0.6).

Conclusion:
The results reveal worrisome low HRQoL in children in Tonga and point towards a potential general pattern of low HRQoL in children living in lower income countries, or, alternatively, in the South Pacific Island countries.

A systematic review of the effectiveness of whole-of-community interventions by socioeconomic position

Whole-of-community (WOC) interventions have led to modest reductions in population weight gain. Whether they exhibit differential effectiveness by socioeconomic position (SEP) remains unknown. We aimed to summarize evidence of differential effectiveness of WOC interventions by SEP. Electronic databases and grey literature were searched to identify studies that evaluated the effectiveness of a WOC intervention on behavioural change measures, energy balance behaviours and/or anthropometric outcomes according to any measure of SEP. Interventions were assessed for the following characteristics: structural changes to the environment, number of settings the intervention acted in, presence of community engagement and whether equity was considered in its design. Ten studies were included. Nine reported a greater or equal effect among low SEP groups compared with high SEP groups. These studies commonly featured interventions that incorporated structural changes to the environment, acted across more than three settings and/or employed community engagement. Conclusions did not change when excluding low-quality studies (n = 4). WOC interventions represent an effective and equitable approach for the reduction of population weight. Structural components, a larger number of settings and community engagement were common in equitable WOC interventions and should be considered in the design of future WOC interventions.

Perspectives of clinical handover processes: a multi-site survey across different health professionals

AIMS AND OBJECTIVES: To examine the perspectives of health professionals of different disciplines about clinical handover. BACKGROUND: Ineffective handovers can cause major problems relating to the lack of delivery of appropriate care. DESIGN: A prospective, cross-sectional design was conducted using a survey about clinical handover practices. METHODS: Health professionals employed in public metropolitan hospitals, public rural hospitals and community health centres were involved. The sample comprised doctors, nurses and allied health professionals, including physiotherapists, social workers, pharmacists, dieticians and midwives employed in Western Australia, New South Wales, South Australia and the Australian Capital Territory. The survey sought information about health professionals' experiences about clinical handover; their perceived effectiveness of clinical handover; involvement of patients and family members; health professionals' ability to confirm understanding and to clarify clinical information; role modelling behaviour of health professionals; training needs; adverse events encountered and possibilities for improvements. RESULTS: In all, 707 health professionals participated (response rate = 14%). Represented professions were nursing (60%), medicine (22%) and allied health (18%). Many health professionals reported being aware of adverse events where they noticed poor handover was a significant cause. Differences existed between health professions in terms of how effectively they gave handover, perceived effectiveness of bedside handover vs. nonbedside handover, patient and family involvement in handover, respondents' confirmation of understanding handover from their perspective, their observation of senior health professionals giving feedback to junior health professionals, awareness of adverse events and severity of adverse events relating to poor handovers. CONCLUSIONS: Complex barriers impeded the conduct of effective handovers, including insufficient opportunities for training, lack of role modelling, and lack of confidence and understanding about handover processes. RELEVANCE TO CLINICAL PRACTICE: Greater focus should be placed on creating opportunities for senior health professionals to act as role models. Sophisticated approaches should be implemented in training and education.