Re-visioning cultural competence in community health services in Victoria

There are few studies exploring the need to develop and manage culturally competent health services for refugees and migrants from diverse backgrounds. Using data from 50 interviews with service providers from 26 agencies, and focus group discussion with nine different ethnic groups, this paper examines how the Victorian state government funding and service agreements negatively impact on the quest to achieve cultural competence. The study found that service providers have adopted 'one approach fits all' models of service delivery. The pressure and competition for resources to address culturally and linguistically diverse communities' needs allows little opportunity for partnership and collaboration between providers, leading to insufficient sharing of information and duplication of services, poor referrals, incomplete assessment of needs, poor compliance with medical treatment, underutilisation of available services and poor continuity of care. This paper outlines a model for cultural consultation and developing needs-led rather than service-led programs.

Sea search : a community-based citizen science monitoring program for Victoria, Australia, Marine National Parks and Marine Sanctuaries

Community involvement in monitoring Victoria’s Marine Protected Areas (MPAs) engages coastal volunteers in looking after their marine ‘front yards”. The Management Strategy for Victoria’s System of Marine National Parks and Marine Sanctuaries dedicates an entire theme to community engagement with core key performance areas. This includes community participation. The Sea Search community based monitoring program was developed in 2003 to engage volunteers in meaningful ecological data collection for future sustainability of Victoria’s MPAs. Deakin University, an academic institute, and Parks Victoria, the management agency for Victoria’s MPAs, through a research partner program, trialled three different habitat monitoring methodologies. The trails assessed volunteer ability to collect scientific data, and social science aspects for their involvement in a community-based monitoring program. Information collected by volunteers, feeds directly into their local MPA management strategies to address issues such as climate change, introduced pests and human impacts and natural ecological variation.

The Sea Search program addresses the two action programmes, Agenda 21 and the Rio Declaration on Environment and Development, created at the United Nations Earth Summit, held in 1992. Both documents highlight the need for community engagement and capacity building for sustainability, health and integrity of the earth. Involvement in the Sea Search program builds the volunteer’s capacity by learning scientific skills, interacting with other like minded community members, and creating relationships with all organisations involved in the delivery of the program. In this regard, Sea Search is a citizen science program involving all sectors in society by promoting public-interest and research for decision making and planning of Victoria’s system of Marine National Parks and Marine Sanctuaries.

Anything new under the sun? Lessons learned from community based natural resource management

Involving community in natural resource management has occurred under a wide variety of approaches, ideologies and titles over the last 30 odd years, with equally wide variety of outcomes for both the community and natural resource management!. Community Based Natural Resource Management (CBNRM) is now a commonly used and promoted, if not always well defined, approach. Claims about the benefits of CBNRM cover wildlife management and biodiversity, sustainable utilisation and management of natural resources, poverty reduction, increased livelihoods outcomes, improved food security, as well as less material benefits of livelihood diversification, empowerment, increased gender equality, and better institutional relations. There are also some fairly convincing criticisms of CBNRM reflecting on assumptions of the nature of communities, institutional arrangements and both institutional and community expectations. This paper reflects on the changing nature of community engagement in natural resource management, the emergence of CBNRM as an approach and the lessons learned from promoting CBNRM across case studies in the developing world.

Evaluation of a community-based mental health drug and alcohol nurse in the care of people living with HIV/AIDS

There is a growing need for advanced practice mental health and drug and alcohol nursing roles in the care of people living with HIV/AIDS; however, limited publications address these domains. This study evaluated a community-based mental health drug and alcohol nurse role caring for people living with HIV/AIDS (Mental Health D&A Nurse) in a large not-for-profit district nursing organization providing care to people living with HIV/AIDS in an Australian city. Outcomes from a client assessment and 6–8-week follow-up by the Mental Health D&A Nurse are presented as captured by the Depression Anxiety Stress Scales (DASS 21), Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), Health of the Nation Outcome Scales (HONOS) and WHOQoL BREF. Mean scores and caseness were analysed, and significant differences were found on the 'impairment' and 'social problems' subscales of the HONOS. Results of semi-structured interviews with clients describe effective and supportive mental health care and health-promoting education following visits by the Mental Health D&A Nurse. These positive findings support continuing implementation of the role within this community setting and indicate that even greater benefits will ensue as the role develops further. Findings are of interest to clinicians and policy makers seeking to implement similar roles in community-based HIV/AIDS care.

Low back pain and disability in community-based women : prevalence and association factors

Objective: Although low back pain is characterized by both pain and disability, there is a paucity of studies that have concurrently examined risk factors for these features in community-dwelling women. We aimed to investigate the prevalence and identify factors associated with both back pain and disability.

Design: A questionnaire was mailed to 542 women from a community-based research database. Detailed demographic data were collected, including participants' menopause, relationship, and employment status. Point and period prevalence estimates for back pain were derived. Participants were classified based on pain intensity and disability scores calculated from the Chronic Pain Grade Questionnaire, and factors associated with high levels of pain and disability were examined.

Results: A total of 506 (93.4%) women completed the questionnaire. More than 90% of participants had experienced low back pain, with 75.1% and 22.5% reporting pain in the past 12 months and currently, respectively. Seven percent of women reported a high level of disability and 16% reported high-intensity pain. Women with higher levels of disability were more likely to have a higher body mass index and to have pain currently, whereas those with greater pain intensity were more likely to be younger, have a higher body mass index, not be employed outside the home, drink alcohol, and have current pain.

Conclusions: Low back pain is a common problem for community-based women. A high body mass index and current pain were factors independently associated with both high pain intensity and disability. Longitudinal investigation is required to determine the predictive nature of these factors and their potential role in preventing pain and disability.

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.

Economic analysis of a community-based falls prevention program

Objectives: To undertake a cost–benefit analysis of ‘Stay on Your Feet’, a community-based falls prevention program targeting older people at all levels of risk in New South Wales, Australia. Hospital separations were monitored in the intervention region, a control region and for the state of New South Wales as a whole. Changing admission patterns over the intervention period were used to assess the impact of the program.

Methods: Cost–benefit analysis compared the costs of the program with two estimates of savings from avoided hospital admissions. The first compared the cost of hospital admissions in the intervention region to a control region of similar demographics, while the second compared hospital utilization in the intervention region with the state of New South Wales as a whole using falls-related hospital diagnosis related group (DRG) codes.

Results: The total direct costs of the program were estimated at A$781 829. Both methods identified clear overall net benefits ranging from A$5.4 million for avoided hospitalizations alone to A$16.9 million for all avoided direct and indirect costs. The confidence intervals around these estimates were small. The average overall benefit to cost ratio for the intervention as a whole was 20.6:1.

Conclusions: These findings suggest that well-designed community-based interventions targeting falls prevention among older people are highly cost effective and a wise investment for all levels of government. The models used are conservative and are likely to underestimate the real benefit of the intervention, which may have lasted for some time beyond the life of the program.

Community-based environmental education : government and community, economics and environment

This thesis contends that government focus on policy implicitly defines community education as a means of overcoming barriers to government-initiated change, rather than as an input to governmental decision-making. The role of education is thus viewed as instrumentalist rather than as dialectical in nature. I argue that this role has been reinforced and driven by economic rationalism, as a mechanism related to scientific theory and practice. The thesis addresses the role of government in non-institutional community-based environmental education. Of interest is environmental education under the dominance of economic rationalism and as expressed in government-derived policy, in its own right, and as enacted in two government funded animal management projects. The main body of data, then, includes a review of some contemporary environmental policies and two case studies of 'policy in practice'. Chapter One provides an overview of environmentalism as it has emerged as part of the discourse of Western political systems. Recognised as part of this change is a move to environmentalism embued with the rhetoric of economic theory. The manifestation of this change can be seen in an emphasis on management for the natural environment's use as a resource for humans. Education under this arrangement is valued in terms of its ability to support initiatives that are perceived as economically viable and economically advantageous, maintaining centralised control of decision-making and serving the interests of those who profit from this arrangement. Government-derived environmental policies are presented in Chapter Two. They provide evidence of the conjoining of environment with economic rationalism and the adoption of a particular stance which is both utilitarian and instrumentalist. Emerging from this is an understanding of the limitations placed on environmental debates that do not respond to complex understandings of context and instead support and legitimate centralisation of decision-making and control. Chapter Three presents an argument for an historical approach to environmental education research to accommodate contextual dimensions, as well as scientific, economic and technical dimensions, of the subject under study. An historical approach to research, inclusive of biographical, intergenerational and geographical histories, goes some way to providing an understanding of current individual and collective responses to policy enactment within the two study sites. It also responds to the concealing of history which results from the reduction of environmental debates to economic terms. With this in mind, Chapters Four and Five provide two historical case studies of 'policy in practice'. Chapter Four traces the workings of a rabbit control project in the Sutton Grange district of Victoria and Chapter Five provides an account of a mouse plague project in the Wimmera and Mallee regions of Victoria. The Sutton Grange rabbit project is organised and controlled by district landholders while the Wimmera and Mallee mouse project is organised and controlled by representatives from a scientific organisation and a government agency. Considered in juxtaposition, the two case studies enable an analysis of two somewhat different expressions of the 'role of government'. Chapter Six investigates the competing processes of community participation in governmental decision-making and Australia's system of representative democracy, Despite a call for increased community participation, the majority of policies remain dominated by governmental rhetoric and ideology underpinned by a belief in impartiality. The primacy of economics is considered in terms of government and community interaction, with specific reference to the emergence of particular conceptual constructions, such as cost-benefit analysis, that support this dominance. Of specific importance to this thesis is the argument that economic theory is essentially anthropocentric and individualist and, thus, necessarily marginalises particular conceptions of environment that are non-anthropocentric and non-individualistic. Finally, Chapter Six examines two major interrelated tensions; those of central interests and community interests, and economic rationalism and environmentalist. Chapter Seven looks at examples of theories and practices that fall outside the rationality determined by scientistic knowledge. It is clear from the examination of environmental policy within this thesis that the role ascribed to environmental education is instrumentalist. The function of education is often to support, promote and implement policy and its advocated practices. It is also clear from the examination of policy and advocated processes that policy defines community education as a means of manifesting change as determined by policy, rather than as an input to governmental decision-making. The domination of scientific, economic and technocratic processes (and legitimation of processes) allows only for an instrumentalist approach to education from government. What is encouraged by government through the process of change is continuity rather than reform. It promotes change that will not disrupt the governing hegemony. Particular perspectives and practices, such as a critical approach to education, are omitted or considered only within the unquestioned rationale of the dominant worldview. Chapter Seven focuses on the consequence of government attention to policy which implicitly defines community education as a means of overcoming barriers to change, rather than as an input to governmental decision-making. Finally a list of recommendations is put forward as a starting point to reconstruct community-based environmental education. The role considered is one that responds to, and encourages engagement in, debates which expose disparate views, assumptions and positions. Community ideology must be challenged through the public practices of communication and understanding, decision-making, and action. Intervention is not on a level that encourages a preordinate outcome but, rather, what is encouraged is elaborate consideration of disparate views and rational opinions, and the exposure of assumptions and interests behind ideological positions.

Geelong community's priorities and expectations of public health care

Abstract This thesis set out to achieve the following objectives: (1) To identify the priorities and expectations that the Geelong community has of its public health care system. (2) To determine if there is a common view on the attributes of a just health system. (3) To consider a method of utilising the data in the determination of health care priority setting in Barwon Health. (4) To determine a model of community participation which enables ongoing input into the decision making processes of Barwon Health. The methodology involved a combination of qualitative and quantitative research. The qualitative work involved the use of focus groups that were conducted with 64 members of the Geelong community. The issues raised informed the development of the interview schedule that was the basis of the quantitative study, which surveyed a representative sample of 400 members of the Geelong community. Prior to reporting on this work, the areas of distributive justice, scarcity and community participation in health care were considered. The research found that timely access to public hospitals, emergency care and aged care services were the major priorities; for many people, the cost was less relevant than a quality service. Shorter waiting times and increased staffing levels were strongly supported. Increased taxes were nominated as the best means of financing the health system they sought. Community based services were less relevant than hospital services but health education was supported. An egalitarian approach to resource distribution was favoured although the community was prepared to discriminate in favour of younger people and against older people. There was strong support for the community to be involved in decision making in the public health care system through surveys or focus groups but very little support was given to priorities being determined by politicians, administrators and to a lesser extent, medical professionals.

Effectiveness of a community-based osteoporosis education and self-management course : a wait list controlled trial

Summary : Osteoporosis is an increasing burden on individuals and health resources. The Osteoporosis Prevention and Self-Management Course (OPSMC) was designed to assist individuals to prevent and manage osteoporosis; however, it had not been evaluated in an Australian setting. This randomised controlled trial showed that the course increased osteoporosis knowledge.
Introduction and hypothesis : Osteoporosis is a major and growing public health concern. An OPSMC was designed to provide individuals with information and skills to prevent or manage osteoporosis, but its effectiveness has not previously been evaluated. This study aimed to determine whether OPSMC attendance improved osteoporosis knowledge, self-efficacy, self-management skills or behaviour.
Materials and methods : Using a wait list randomised controlled trial design, 198 people (92% female) recruited from the community and aged over 40 (mean age = 63) were randomised into control (n = 95) and intervention (n = 103) groups. The OPSMC consists of four weekly sessions which run for 2 h and are led by two facilitators. The primary outcome were osteoporosis knowledge, health-directed behaviour, self-monitoring and insight and self-efficacy.
Results : The groups were comparable at baseline. At 6-week follow-up, the intervention group showed a significant increase in osteoporosis knowledge compared with the control group; mean change 3.5 (p < 0.001) on a measure of 0–20. The intervention group also demonstrated a larger increase in health-directed behaviour, mean change 0.16 (p < 0.05), on a measure of 0–6.
Conclusion : The results indicate that the OPSMC is an effective intervention for improving understanding of osteoporosis and some aspects of behaviour in the short term.