An evaluation of the effect of an educational intervention for Australian social workers on competence in delivering brief cognitive behavioural strategies : a randomised controlled trial

Background Broad community access to high quality evidence-based primary mental health care is an ongoing challenge around the world. In Australia one approach has been to broaden access to care by funding psychologists and other allied health care professionals to deliver brief psychological treatments to general practitioners' patients. To date, there has been a scarcity of studies assessing the efficacy of social worker delivered psychological strategies. This study aims to build the evidence base by evaluating the impact of a brief educational intervention on social workers' competence in delivering cognitive behavioural strategies (strategies derived from cognitive behavioural therapy). Methods A randomised controlled trial design was undertaken with baseline and one-week follow-up measurement of both objective and self-perceived competence. Simulated consultations with standardised depressed patients were recorded on videotape and objective competence was assessed by blinded reviewers using the Cognitive Therapy Scale. Questionnaires completed by participants were used to measure self-perceived competence. The training intervention was a 15 hour face-to-face course involving presentations, video example consultations, written materials and rehearsal of skills in pairs. Results 40 Melbourne-based (Australia) social workers enrolled and were randomised and 9 of these withdrew from the study before the pre training simulated consultation. 30 of the remaining 31 social workers (97%) completed all phases of the intervention and evaluation protocol (16 from intervention and 14 from control group). The intervention group showed significantly greater improvements than the control group in objective competence (mean improvement of 14.2 (7.38-21.02) on the 66 point Cognitive Therapy Scale) and in subjective confidence (mean improvement of 1.28 (0.84-1.72) on a 5 point Likert scale). On average, the intervention group improved from below to above the base competency threshold on the Cognitive Therapy Scale whilst the control group remained below. Conclusions Social workers can attain significant improvements in competency in delivering cognitive behavioural strategies from undertaking brief face to face training. This is relevant in the context of health reforms that involve social worker delivery of evidence based psychological care. Further research is required to assess how these improvements in competence translate into performance in practice and clinical outcomes for patients.

Job stress as a preventable upstream determinant of common mental disorders: a review for practitioners and policy-makers

There is growing recognition of the important role of mental health in the workforce and in the workplace. At the same time, there has been a rapid growth of studies linking job stress and other psychosocial working conditions to common mental disorders, and a corresponding increase in public concern media attention to job stress and its impact upon worker health and well-being. This article provides a summary of the relevant scientific and medical literature on this topic for practitioners and policy-makers. It presents a primer on job stress concepts, an overview of the evidence linking job stress and common mental disorders, a summary of the intervention research on ways to prevent and control job stress, and a discussion of the strengths and weakness of the evidence base. We conclude that there is strong evidence linking job stress and common mental disorders, and that it is a substantial problem on the population level. On a positive note, however, the job stress intervention evidence also shows that the problem is preventable and can be effectively addressed by a combination of work- and worker-directed intervention.

An integrated approach to workplace mental health : an Australian feasibility study

We developed and implemented an integrated workplace mental health promotion intervention combining job stress reduction with a workplace mental health literacy program. The intervention was evaluated using an uncontrolled design, with organizationorganisation-wide census employee surveys of working conditions and mental health literacy pre-intervention, followed by a 1-year action planning and intervention period, then a post-intervention survey. All employees were invited to be surveyed, and all respondents were included in analysis, independent of participation in intervention activities or employment status (44% response rate at baseline, 37% at final). No significant changes were observed in the targeted psychosocial working conditions – job control, job demands, and social support at work. In contrast, significant improvements in some aspects of mental health literacy were observed, particularly in helping behaviours. Acknowledging the limitations of this being an uncontrolled pilot study, our results suggest that it is feasible to integrate job stress and mental health literacy intervention, as well as evidence of sustained improvements in mental health literacy and the need for more intensive and sustained efforts to improve psychosocial working conditions.

An application of an extended effort-reward imbalance model to police absenteeism behaviour

Purpose – Frequent absences from work can be highly disruptive, whilst also potentially indicating problematic working conditions that can lead to increased withdrawal behaviour. The purpose of this paper is to test the predictive capability of an expanded effort-reward imbalance model on employee absenteeism within the context of policing.

Design/methodology/approach – Three separate reward systems are identified by the effort-reward imbalance model. In this study, the authors assessed these individual components for their contribution to officer withdrawal behaviour in the form of absenteeism frequency. Data were gathered from a sample of operational officers (n=553) within a large Australian police agency.

Findings – Findings indicate that there was a strong influence of social rewards such as social support and recognition in the workplace on officer absenteeism rates. Low workload was associated with a higher frequency of absenteeism suggesting a potential underloading effect. There were a number of significant interactions providing support for the effort-reward imbalance mechanism and the separation of the reward construct. Security rewards were particularly influential and significantly moderated the relationship between effort and absenteeism.

Research limitations/implications – Differential effects of occupational rewards were identified in the study, indicating that there are significant opportunities for expansion of the effort-reward imbalance model along with opportunities for HRM practitioners in terms of employee recognition and remuneration programmes. This research was focused on a specific sample of operational officers, therefore should be expanded to include multiple occupational groups.

Originality/value – This paper considers and expanded model of worker strain and contributes a longitudinal assessment of the association between perceived effort and reward systems and worker absenteeism.

Approaches to population health care : the emerging context!

This paper provides a review of recent developments in population-based approaches to community health and explores the origins of the population health concept and its implications for the operation of health service management. There is a growing perception among health professionals that the key to improving health outcomes will be the implementation of integrated and preventive population-based resource management rather than investment in systems that respond to crises and health problems at the acute end of the service provision spectrum only. That is, we will need increasingly to skew our community health and welfare investments towards preventive care, education, lifestyle change, self-management and environmental improvement if we are to reduce the rate of growth in the incidence of chronic disease and mitigate the impact of these diseases upon the acute health care system. While resources will still need to be devoted to the treatment and management of physical trauma, infectious diseases, inherited illness and chronic conditions, it is suggested we could reduce the rate at which demand for these services is increasing at present by managing our environment and communities better, and through the implementation of more effective early intervention programs across particular population groups. Such approaches are known generally as population health management, as opposed to individual or illness - based health management' or even public health - and suggest that health systems might productively focus in the future on population level causation and not just upon disease-specific problems or illness management after the fact. Population health approaches attempt to broaden our understanding of causation and manage health through an emphasis on the health of whole populations and by building healthy communities rather than seeing "health care" as predominantly about illness management or responses to health crises. The concept also presupposes the existence of cleaner and healthier environments, clean water and food, and the existence of vibrant social contexts in which individuals are able to work for the overall good of communities and, ultimately, of each other.

Gaps in understanding health and engagement with healthcare providers across common long-term conditions: a population survey of health literacy in 29 473 Danish citizens

OBJECTIVES: To (1) quantify levels of subjective health literacy in people with long-term health conditions (diabetes, cardiovascular disease, chronic obstructive pulmonary disease, musculoskeletal disorders, cancer and mental disorders) and compare these to levels in the general population and (2) examine the association between health literacy, socioeconomic characteristics and comorbidity in each long-term condition group.

DESIGN: Population-based survey in the Central Denmark Region (n=29,473). MAIN

OUTCOME MEASURES: Health literacy was measured using two scales from the Health Literacy Questionnaire (HLQ): (1) Ability to understand health information and (2) Ability to actively engage with healthcare providers.

RESULTS: People with long-term conditions reported more difficulties than the general population in understanding health information and actively engaging with healthcare providers. Wide variation was found between disease groups, with people with cancer having fewer difficulties and people with mental health disorders having more difficulties in actively engaging with healthcare providers than other long-term condition groups. Having more than one long-term condition was associated with more difficulty in engaging with healthcare providers and understanding health information. People with low levels of education had lower health literacy than people with high levels of education.

CONCLUSIONS: Compared with the general population, people with long-term conditions report more difficulties in understanding health information and engaging with healthcare providers. These two dimensions are critical to the provision of patient-centred healthcare and for optimising health outcomes. More effort should be made to respond to the health literacy needs among individuals with long-term conditions, multiple comorbidities and low education levels, to improve health outcomes and to reduce social inequality in health.

Population health and wellbeing: identifying priority areas for Victorian children

Background
Population health information, collected using soundly-designed methodologies, is essential to inform policy, research, and intervention programs. This study aimed to derive policy-oriented recommendations for the content of a health and wellbeing population survey of children 0–12 years living in Victoria, Australia.

Results
Qualitative interviews were conducted with 54 academic and policy stakeholders, selected to encompass a wide breadth of expertise in areas of public health and inter-sectoral organisations relevant to child health outcomes, including universities, government and non-government agencies across Victoria. These stakeholders were asked to provide advice on strategic priorities for child health information (data) using a structured interview technique. Their comments were summarised and the major themes were extracted. The priority areas of health and wellbeing recommended for regular collection include obesity and its determinants, pregnancy and breastfeeding, oral health, injury, social and emotional health and wellbeing, family environment, community, health service utilisation, illness, and socioeconomic position. Population policy questions for each area were identified.

Conclusion
In contrast to previous population survey programs nationally and internationally, this study sought to extract contemporary policy-oriented domains for inclusion in a strategic program of child health data collection, using a stakeholder consultation process to identify key domains and policy information needs. The outcomes are a rich and relevant set of recommendations which will now be taken forward into a regular statewide child health survey program.

The role of workplace health promotion in addressing job stress

The enormous human and economic costs associated with occupational stress suggest that initiatives designed to prevent and/or reduce employee stress should be high on the agenda of workplace health promotion (WHP) programmes. Although employee stress is often the target of WHP, reviews of job stress interventions suggest that the common approach to combating job stress is to focus on the individual without due consideration of the direct impacts of working conditions on health as well as the effects of working conditions on employees' ability to adopt and sustain ‘healthy’ behaviours. The purpose of the first part of this paper is to highlight the criticisms of the individual approach to job stress and to examine the evidence for developing strategies that combine both individual and organizational-directed interventions (referred to as the comprehensive approach). There is a risk that WHP practitioners may lose sight of the role that they can play in developing and implementing the comprehensive approach, particularly in countries where occupational health and safety authorities are placing much more emphasis on identifying and addressing organizational sources of job stress. The aim of the second part of this paper is therefore to provide a detailed description of what the comprehensive approach to stress prevention/reduction looks like in practice and to examine the means by which WHP can help develop initiatives that address both the sources and the symptoms of job stress.

Gatekeeping or redressing social exclusion : expectations on social work educators in relation to incarcerated students

Until recently, the author was in Scotland, where professional registration in social work extends to students and involves criminal record checks prior to acceptance into a course of study. She is now teaching at Deakin University in Australia, which places a high priority on making higher education available to persons and groups who have traditionally been excluded, both through the provision of courses through off campus (distance education) study mode and an innovative and culturally sensitive mode of provision for indigenous Australians. One result of our attempts to redress social exclusion is that, on occasion, we discover that some of our students are incarcerated. There are important logistical issues which may emerge as a consequence of accepting prisoners into a program of social work education. However, it would seem that the inclusion of prisoners is symbolic of a fundamental difference in philosophy with programmes of social work education in countries where there is a strong expectation that social work educators act as gatekeepers to the profession, especially in respect of students with criminal convictions. This in tum reflects an expectation among social work educators in Australia that it may be more appropriate for professional associations or registration bodies to determine whether or not a graduate with a criminal record is suitable for employment as a professional social worker. In some settings, a prior criminal record is not a barrier to being an effective service provider, as well as international differences in understandings of the social work role and employment
destinations of social work graduates.

Predictors of job strain and intention to quit in a reorganised Australian workforce

This study examined the role of working conditions in predicting the psychological health, job satisfaction, organisational commitment and intention to quit of employees working in an industry sector that had undergone large-scale organisational change. The working conditions were assessed using an augmented job strain model- whereby job demand, job control and social support had been augmented by industry-specific stressors - and the psychological contract model. The results of regression analyses indicate that social support was predictive of all of the outcome measures. Job control and the honouring of psychological contracts were both predictive of job satisfaction and commitment, Furthermore, job satisfaction and organisational commitment were found to mediate the relationship between working conditions and intention to quit. Collectively, these findings suggest that strategies aimed at combating the negative effects of organisational change could be enhanced by addressing several variables represented in the models - particularly social support, job control and psychological contracts.

Sources of well-being and commitment of staff in the Australian Disability Employment Services

This study examined the role of working conditions in predicting the psychological health, job satisfaction and organisational commitment of personnel responsible for helping people with disabilities gain employment in the mainstream Australian labour market. The working conditions were assessed using two theories: the Job Strain Model (job demand, social support and job control) and Psychological Contract Theory (unwritten reciprocal obligations between employers and employees). In the case of the Job Strain Model, the generic dimensions had been augmented by industry-specific sources of stress. A cross-sectional survey was undertaken in June and July 2005 with 514 staff returning completed questionnaires (representing a response rate of 30%). Comparisons between respondents and non-respondents revealed that on the basis of age, gender and tenure, the sample was broadly representative of employees working in the Australian disability employment sector at that time. The results of regression analyses indicate that social support was predictive of all of the outcome measures. Job control and the honouring of psychological contracts were both predictive of job satisfaction and commitment, while the more situation-specific stressors - treatment and workload stressors - were inversely related to psychological health (i.e. as concern regarding the treatment and workload stressors increased, psychological health decreased). Collectively, these findings suggest that strategies aimed at combating the negative effects of large-scale organisational change could be enhanced by addressing several variables represented in the models - particularly social support, job control, psychological contracts and sector-specific stressors.

Gender and health promotion: A multisectoral policy approach

Women and men are different as regards their biology, the roles and responsibilities that society assigns to them and their position in the family and community. These factors have a great influence on causes, consequences and management of diseases and ill-health and on the efficacy of health promotion policies and programmes. This is confirmed by evidence on male–female differences in cause-specific mortality and morbidity and exposure to risk factors. Health promoting interventions aimed at ensuring safe and supportive environments, healthy living conditions and lifestyles, community involvement and participation, access to essential facilities and to social and health services need to address these differences between women and men, boys and girls in an equitable manner in order to be effective. The aim of this paper is to (i) demonstrate that health promotion policies that take women's and men's differential biological and social vulnerability to health risks and the unequal power relationships between the sexes into account are more likely to be successful and effective compared to policies that are not concerned with such differences, and (ii) discuss what is required to build a multisectoral policy response to gender inequities in health through health promotion and disease prevention. The requirements discussed in the paper include i) the establishment of joint commitment for policy within society through setting objectives related to gender equality and equity in health as well as health promotion, ii) an assessment and analysis of gender inequalities affecting health and determinants of health, iii) the actions needed to tackle the main determinants of those inequalities and iv) documentation and dissemination of effective and gender sensitive policy interventions to promote health. In the discussion of these key policy elements, we use illustrative examples of good practices from different countries around the world.

Health promotion and evaluation - a programmatic approach

Health promotion has evolved significantly in the past twenty years. Its emphasis has shifted from relatively simple monocausal models focused on behavioural risk factors to a greater emphasis on broader social determinants of health. Single method, single risk factor interventions have increasingly been replaced with multiformat, multiple risk factor interventions and extended campaigns, with whole-of-govemment implications. Health promotion structures have developed from ad hoc single shot activity to large dedicated agencies with continuing responsibilities and a wide ambit.

The development of health promotion research and evaluation has followed these trends. The early epidemiology studies linked behavioural risks such as smoking, diet and physical activity with systemic conditions such as cancer and cardiovascular disease. A raft of small and large scale intervention studies aimed at demonstrating that these behavioural risk factors could be modified and that modification would lead to improved health outcomes followed with mixed results.

More recent evidence suggests that behavioural risks are not the onIy social factors that influence health outcomes. There is now strong evidence that social determinants such as income, education and employment have highly significant direct effects on health outcomes, which are not mediated by behavioural risks, and that behavioural risks are also correlated with these broader determinants.

Health promotion now operates in a variety of ways at different scales and different levels of the health system (and the wider social system). The goals of health promotion, and the measures that assess whether a project, campaign, or general strategy has met its goals, differ accordingly.

Arguably, where local, state and federal governments begin to coordinate their efforts systematically across settings, intervention strategies, health action areas and population groups, health promotion becomes more
programmatic, sustainable and effective. A programmatic approach also integrates knowledge generation, the development of health promotion capacity, practice and evaluation together.

However, programmatic approaches to health promotion are comparatively new. Only recently have governments begun to develop and resource
comprehensive and sustained health promotion programs that address a range of health issues using multiple intervention strategies. The scope of a more programmatic approach and its functions and purposes is still developing.

Although evaluation has a key role to play in this respect, the development of programmatic strategies for health promotion has generally outpaced evaluation theory and practice. While we now have reasonable technologies for measurement of behavioural risks and individual attitudinal and cognitive influences on them, strategies to evaluate organisational and community interventions are still emerging.

Similarly, while new approaches to evaluate small scale community and organisational interventions have been developed, comprehensive models to monitor and evaluate health promotion programs and strategies across multiple intervention sites over extended periods have not yet emerged. Nor have we resolved the methodological problems of teasing out the relative contribution of different intervention strategies to observed change in health outcomes.

More programmatic approaches to health promotion require a more programmatic approach to health promotion evaluation. This paper represents an issues based examination of the evidence base for a more programmatic health promotion and the evaluation issues that arise

Understanding health : a determinants approach

This work introduces students to the variety of approaches to old and new public health, by placing them in the broader context of conditions and structures in society. Practical in its approach, this introductory text features a wide range of examples and case studies.

Using critical ethnography to explore issues in health promotion

In this article, the author outlines the need for a critical research method in the field of health promotion to explore the determinants of health. These determinants, including healthy child development, employment and working conditions, and education, for example, underlie many of the health issues that individuals experience. They are, in turn, influenced by nebulous factors such as patterns of inequality, and cultural norms, which are difficult to research using conventional methodologies. The author provides an overview of critical ethnography as a method for health promotion research. She describes specific data collection and analysis techniques, with the addition of critical discourse analysis to add scope to ethnographic findings. She concludes with an overview of the congruence between critical ethnography and health promotion research, including a discussion of the differences between critical ethnography and participatory action research.