Challenges in health services and health systems research

The relationship between emerging trends in healthcare systems and the consequent research priorities will be explored.

Governments and policy makers in developed countries are increasingly focused on the management of chronic disease, reflecting demographic changes and shifts in the burden of disease. Systems of quality improvement and reward are increasingly based on performance in chronic disease management. There is some evidence that countries with well-developed systems of primary care, such as Australia, achieve better health outcomes at less cost. In the past 15 years, almost all developed countries have undergone some type of health care reform. There has been a major focus on reducing costs; often involving shifting services from secondary to primary care. While there are few international comparisons, most suggest a complex relationship between the strength of primary care within the overall health services system and good performance, particularly with regard to lower costs of care and particularly relevant measures of health.

Aims for 21st century health systems
What, then, are the issues which are shaping contemporary general practice in developed countries? There are several imperatives: Safety, effectiveness, patient-centredness, timeliness, efficiency and equity. A study by the Nuffield Trust (Dargie, 1999) projected the shape of healthcare for the first fifteen years of this century. The study identified six issues that need to be addressed in the process of formulating health systems policies:

• Peoples’ expectations and financial sustainability
• Demography and ageing
• Information and knowledge management
• Scientific advance and new technology
• Workforce education and training
• Systems performance and quality (efficiency, effectiveness, economy
and equity)

Each of these six issues requires innovative thinking and priority setting on the part of the health sector, such as the delivery of health services in new and creative ways. Furthermore, there is a clear need for a finely tuned research, development and evaluation strategies to match these goals.

Health risk behaviours and health care needs among people with psychiatric illness

This paper presents findings from two studies. Study 1 explored differences between people with psychiatric illness (PPI) (N=144) and the general population (N=151) in levels of low-fat diet, exercise and smoking. Study 2 investigated barriers and health care needs of PPI (N=60). The prevalence of overweight, cigarette smoking and sedentary lifestyle were significantly greater among PPI than the general population. Major predictors were limited social support, knowledge of correct dietary principles, lower self-efficacy, psychiatric symptomatology and various psychotropic drugs. The findings demonstrated that PPI over-used medical services but under-used preventive services due to inaccessibility, lower satisfaction and knowledge of services.

Where pain = no gain : perspectives on sport, exercise and health, c. 1850-1920

A common perspective today is that sportspeople must train and compete to a level of exertion beyond the ‘pain threshold’ if they are to succeed; a view that has given rise to the popular expression ‘No Pain, No Gain’. Indeed, a common aphorism is that the health and quality of life of individuals and of the wider population is positively correlated with the frequency and vigour of physical exercise. In the period when modern sports were taking on their present characteristics (approximately 1850-1920), the prevailing opinions about the health and well-being effects of exercise were far more cautious, however. While the benefits of moderate exercise for physical and mental well-being went without question, too great an exertion was considered to be as risky as too little, causing ‘strain’ with the potential to inflict lasting and potentially fatal damage, including mental and physical complaints as diverse as neuralgia and ‘athletes’ heart’. The supposedly more strenuous sports, such as football, athletics and rowing, and the training required for them came under particular scrutiny in medical and popular discourses. This paper, an exercise in historical sociology, examines these discourses to demonstrate how advice about the risks on health of participating in sports and of too little or too much exercise more generally, was informed by prevailing physiological models and the interpretation of these within the medical profession and the wider population. The data sources include medical journals and texts, and sports training manuals from the period under investigation.

Discrepancy between expected and actual child support payments : predicting the health and health-related quality of life of children living in low-income, single-parent families

Objective Although the amount and frequency of child support payments received by single parents are often erratic and fluctuate, no study to date has quantitatively explored how the discrepancy between expected and actual payments relates to child health. This study aims to examine whether the discrepancy between expected and actual child support payments predicts a range of child health outcomes, including global health, health-related quality of life, involvement in activities and parental psychological distress.

Methods This study used results from the Longitudinal Study of Australian Children, which included a sample of parents of children aged 4–5 years (n = 4983). The questionnaire was completed by the parent who spent the most time with the child and knew the child best. From the 4983 families, 332 low-income single parents reliant on welfare with a formal or informal child support order in place were identified.

Results After controlling for income, the discrepancy between expected and actual child support predicted school functioning, conduct problems, total mental health problems and involvement in activities. Discrepancy between expected and actual child support payments did not predict the remaining health-related quality of life domains, mental health domains, global child health or parental psychosocial distress.

Conclusion This was the first study to examine how the discrepancy between expected and actual child support payments relates to child health, providing important data on the effectiveness of the child support system for children's well-being. These findings highlight the potential impact of the discrepancy on school functioning, conduct problems, total mental health problems and involvement in activities.

Sources of stress in impoverished neighbourhoods : insights into links between neighbourhood environments and health

Objective : We consider associations between individual, household and area-level characteristics and self-reported health.
Method : Data is taken from baseline surveys undertaken in 13 socio-economically disadvantaged neighbourhoods in Victoria (n=3,944). The neighbourhoods are sites undergoing Neighbourhood Renewal (NR), a State government initiative redressing place-based disadvantage.
Analysis :This focused on the relationship between area and compositional factors and self-reported health. Area was coded into three categories; LGA, NR residents living in public housing (NRPU) and NR residents who lived in private housing (NRPR). Compositional factors included age, gender, marital status, identifying as a person with a disability, level of education, unemployment and receipt of pensions/benefits.
Results : There was a gradient in socio-economic disadvantage on all measures. People living in NR public housing were more disadvantaged than people living in NR private housing who, in turn, were more disadvantaged than people in the same LGA. NR public housing residents reported the worst health status and LGA residents reported the best.
Conclusions : Associations between compositional characteristics of disability, educational achievement and unemployment income and poorer self-reported health were shown. They suggested that area characteristics, with housing policies, may be contributing to differences in self-reported health at the neighbourhood level.
Implications : The clustering of socio-economic disadvantage and health outcomes requires the integration of health and social support interventions that address the circumstances of people and places.

Islamic religiosity, subjective well-being, and health

The aim of this paper is to explore the relationship between Islamic religiosity and satisfaction with a diverse range of life and health domains, in a sample of 2909 participants (1446 males, 1463 females) from Algeria. Factor analysis of the Islamic Religiosity Scale (IRS) indicates that it measures Religiosity as a multidimensional construct with two useful factors: Religious Practice and Religious Altruism. Religiosity at some level is ubiquitous through this sample, and it has a strong positive relationship with Subjective Well-Being (SWB). Moreover, this relationship is relatively unaffected by health deficiencies, even though such deficiencies generally have a negative influence on SWB scores. These findings are discussed in terms of the social context of Algeria.

Walking and cycling to school : predictors of increases among children and adolescents

Background
Little is known about what happens to active commuting as children get older, and less is known about influences on changes in this behavior. This study examined predictors of increases in children's and adolescents' active commuting (walking or cycling) to/from school over a 2-year period.
Methods
Participants were initially recruited and assessed in 2001. Follow-up data were collected in 2004 and 2006 and analyzed in 2008. Participants were 121 children (aged 9.1±0.34 years in 2004) and 188 adolescents (aged 14.5±0.65 years in 2004) from Melbourne, Australia. Parents and adolescents reported their perceptions of individual-level factors and of the neighborhood social and physical environment. Weekly active commuting (walking or cycling) to/from school, ranging from 0 to 10 trips/week was also proxy- or self-reported at the initial measurement and again 2 years later. Logistic regression analyses examined predictors of increases in active commuting over time.
Results
Children whose parents knew many people in their neighborhood were more likely to increase their active commuting (OR=2.6; CI=1.2, 5.9; p=0.02) compared with other children. Adolescents whose parents perceived there to be insufficient traffic lights and pedestrian crossings in their neighborhood were less likely to increase their active commuting over 2 years (OR=0.4; CI=0.2, 0.8; p=0.01), whereas adolescents of parents who were satisfied with the number of pedestrian crossings were more likely to increase their active commuting (OR=2.4; CI=1.1, 5.4; p=0.03) compared with other adolescents.
Conclusions
Social factors and physical environmental characteristics were the most important predictors of active commuting in children and adolescents, respectively.

Predictors of the attitudinal and health outcomes of aged care nurses

This study examines the predictive capacity of the Demand-Control-Support (DCS) model in combination with organizational justice variables on attitudinal- and health-related outcomes for aged care nurses. Multiple regression analyses of aged care nurses (n=168) from a medium to large Australian healthcare organization. The DCS model explains the largest amount of variance across both the attitudinal and health outcomes with 27% of job satisfaction and 44% of organizational commitment, and 33% of psychological distress and 35% of wellbeing, respectively. Additional variance was explained by the justice variables for job satisfaction, organizational commitment and psychological distress. The addition of the organizational justice variables to the DCS model proved to be a valuable step in understanding the work conditions of aged care nurses. The inclusion of curvilinear effects clarified the potentially artefactual nature of certain interaction variables. The results provide practical implications for managers of aged care nurses in developing and maintaining levels of job control, support and fairness, as well as monitoring levels of job demands. The results particularly highlight the importance of the nurses’ supervisor.

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.