Rural health systems change

Much effort has been expended in recent years attempting to reform the Australian health system in order to deliver more efficient and effective systems of care for an ageing and increasingly chronically ill population. Rural health care systems in particular have been a focus of reform programs, and new initiatives such as University Departments of Rural Health, Regional Health Service structures and Commonwealth primary care initiatives have been designed to improve service provision and health status for rural people. However, with these attempts to reform the way rural communities understand and manage their health care, surprisingly little has changed in the day-to-day business of health care in rural and regional areas. Paradoxically, while rural communities have moved to embrace new farming technologies and environmental perspectives along with modern land management practices, revegetation and sustainable production systems, the same enthusiasm for change does not appear to have been kindled in relation to health system reforms. Rural communities, in terms of health care, are still using the equivalent of outmoded farming practices and other environmentally and economically unsustainable approaches to managing their affairs. Why might this be and what can be done to improve the current state of health reform in our rural and regional areas? The paper explores systems change in relation to health reform in rural communities and highlights several strategies for bringing about a functional synthesis of research and health service practice to create a more effective health care system in rural South Australia.

Scaling-up an efficacious school-based physical activity intervention: study protocol for the 'Internet-based professional learning to help teachers support activity in youth' (iPLAY) cluster randomized controlled trial and scale-up implementation evaluat

BACKGROUND: Despite the health benefits of regular physical activity, most children are insufficiently active. Schools are ideally placed to promote physical activity; however, many do not provide children with sufficient in-school activity or ensure they have the skills and motivation to be active beyond the school setting. The aim of this project is to modify, scale up and evaluate the effectiveness of an intervention previously shown to be efficacious in improving children's physical activity, fundamental movement skills and cardiorespiratory fitness. The 'Internet-based Professional Learning to help teachers support Activity in Youth' (iPLAY) study will focus largely on online delivery to enhance translational capacity.

METHODS/DESIGN: The intervention will be implemented at school and teacher levels, and will include six components: (i) quality physical education and school sport, (ii) classroom movement breaks, (iii) physically active homework, (iv) active playgrounds, (v) community physical activity links and (vi) parent/caregiver engagement. Experienced physical education teachers will deliver professional learning workshops and follow-up, individualized mentoring to primary teachers (i.e., Kindergarten - Year 6). These activities will be supported by online learning and resources. Teachers will then deliver the iPLAY intervention components in their schools. We will evaluate iPLAY in two complementary studies in primary schools across New South Wales (NSW), Australia. A cluster randomized controlled trial (RCT), involving a representative sample of 20 schools within NSW (1:1 allocation at the school level to intervention and attention control conditions), will assess effectiveness and cost-effectiveness at 12 and 24 months. Students' cardiorespiratory fitness will be the primary outcome in this trial. Key secondary outcomes will include students' moderate-to-vigorous physical activity (via accelerometers), fundamental movement skill proficiency, enjoyment of physical education and sport, cognitive control, performance on standardized tests of numeracy and literacy, and cost-effectiveness. A scale-up implementation study guided by the RE-AIM framework will evaluate the reach, effectiveness, adoption, implementation, and maintenance of the intervention when delivered in 160 primary schools in urban and regional areas of NSW.

DISCUSSION: This project will provide the evidence and a framework for government to guide physical activity promotion throughout NSW primary schools and a potential model for adoption in other states and countries.

Mental health legislation (civil) in Australia and China: a comparative study

This comparative review of statutory provisions of Australian and Chinese law focuses on accessibility of mental health care, diagnosis, admission and treatment orders for involuntary patients in civil cases as well as discharge procedures. The introduction contextualises the object of the comparative study, including key rights and principles that are used as the basis for analysis. Such factors as different political and legal systems, history, culture, and infrastructure resources of China and Australia form the background for the legal examination. Not surprisingly, these five factors, rather than statutory texts per se, are found to be the most important drivers of each country’s approach to the law of mental health. Two cases, XX v WW [2014] VSC 564 in Australia and Xu Lixin v Xu Canxing, Qingchun Psychiatric Rehabilitation Hospital of Shanghai [2015], known as the Right to Liberty Case, in China illustrate practical differences in legal approach to involuntary treatment. The comparative analysis concludes by identifying the most problematic aspects of the legislation in each country.

Perioperative mortality rates in Australian public hospitals : the influence of age, gender and urgency

INTRODUCTION: A decline in surgical deaths has been observed in Australia since the introduction of the Australian and New Zealand Audit of Surgical Mortality (ANZASM). The current study was conducted to determine whether the perioperative mortality rate (POMR) has also declined. METHODS: This study is a retrospective review of the POMR for surgical procedures in Australian public hospitals between July 2009 and June 2013, using data obtained from the Australian Institute of Health and Welfare. Operative procedures contained in the Australian Refined Diagnosis Related Groups were selected and the POMR was modelled using urgency of admission, age and gender as explanatory covariates. RESULTS: The POMR in Australian public hospitals reduced by 15.4 % over the 4-year period. The emergency admissions POMR dropped from 1.40 to 1.12 %, and the elective admissions POMR from 0.09 to 0.08 %. The binary logistic regression model used to predict patient mortality showed emergency admissions to have a higher POMR than elective, being more evident at older ages. For emergency admissions, the difference in POMR between females and males increased with age, from about 55 years onwards, with females being lower. For elective surgeries, the difference between males and females was of little practical importance across ages. CONCLUSIONS: The reduction in the POMR in Australia confirms the reduction in surgical deaths reported to ANZASM. Continuing to monitor POMR will be important to ensure the safest surgery in Australia. Further investigations into case-mix will allow better risk adjustment and comparison between regions and time-periods, to facilitate continuous quality improvement.

Dealing with alcohol-related harm and the night-time economy

Alcohol-related problems are a major cause of social disorder and illness in Australia. In particular, problems associated with the night-time economies of urban and regional centres cause substantial community concern and are a considerable drain on police, community and health resources. The estimated cost of alcohol to the community is $15.3 billion, including costs associated with crime, violence, patient treatment, loss of productivity and premature deaths in 2004–05 (Collins 2008). Alcohol has also been identified as a factor in around three quarters of assaults and incidents of offensive behaviour on the street (Buss 1995). Previous research has identified several issues that contribute to the levels of short-term harm associated with risky drinking. These include: excessive consumption at licensed premises, consumption in public areas and lack of transport and security in entertainment precincts (Homel et al. 1992; Graham & Homel 2008).

Drinking in licensed venues is another predictor of harm and public disorder. More than half of offences occurring on the street have been associated with licensed premises in Australia (Buss 1995). A complex range of factors increase risky drinking and associated harms on licensed premises including: aspects of patron mix; levels of comfort, boredom, and intoxication; promotions that cause mass intoxication; and the behaviour of security/bouncers (Homel et al. 1992). Violence has also been shown to be perpetuated by poor venue management, lax police surveillance, lack of transport options for patrons, and inappropriate bureaucratic controls and legislation (Homel et al. 1992). This project aims to provide evidence-based knowledge regarding the implementation and impact of innovative local initiatives directed at alcohol-related harms.

Regional and urban Victorian diabetic youth: clinical and quality-of-life outcomes

Objectives: To compare groups of urban and regional Victorian diabetic children and assess their quality of life, diabetes knowledge, access to services and metabolic control.

Methods: Forty-seven children from three regional Victorian communities (Horsham, Warrnambool and Sale; n = 16, 18 and 13, respectively) were compared with 120 age-, sex- and duration of diabetes-matched children attending the Royal Children's Hospital (RCH) diabetes clinic in Melbourne. Quality of life, diabetes knowledge, use of services, and metabolic control were assessed using the child health questionnaire (CHQ PF-50/CF-80); a diabetes-knowledge questionnaire; access to a diabetes nurse educator (DNE), dietitian and complication screening; and indices of mean HbA1C (values are taken every 3 months in the 'yearly HbA1C'), respectively.

Results: Comparisons of CHQ data showed that regional diabetic youth scored significantly lower on most subscales. The greatest deficits were seen in areas of mental health, self-esteem, parent impact (emotional) and family cohesion. Diabetes knowledge and median yearly HbA1C for patients were not significantly different between the regional and urban centres (8.1%, 8.9%, 8.4% and 8.6% at RCH, Horsham, Warrnambool and Sale, respectively). Patients in regional centres had reportedly less access to team-based diabetes care.

Conclusions: Regional youth in Victoria, with similar levels of metabolic control and diabetes knowledge as their urban counterparts, have a markedly lower quality of life, implying a negative synergy between diabetes and the demands of regional lifestyles.

Utilisation of general practitioner services and achievement of guideline targets by people with diabetes who joined a peer-support program in Victoria, Australia

This paper describes the use of general practitioner (GP) services and achievement of guideline targets by 285 adults with type 2 diabetes in urban and regional areas of Victoria, Australia. Anthropometric and biomedical measures and responses to a self-administered questionnaire were collected. Findings indicate that almost all participants had visited a GP and had had their hypoglycated haemoglobin (HbA1c) measured in the past 6 months; less than one-third had visited a practice nurse. Fifty per cent achieved a HbA1c target of ≤7.0%; 40%, a total cholesterol ≤4.00 mmol/L; 39%, BP Systolic ≤130 mmHg; 51%, BP Diastolic ≤80 mmHg; 15%, body mass index ≤25 kg/m2; and 34% reported a moderately intense level of physical activity, that is, ≥30 min, 5 days a week. However, 39% of individuals achieved at least two targets and 18% achieved at least three of these guideline targets. Regional participants were more likely to report having a management plan and having visited a practice nurse, but they were less likely to have visited other health professionals. Therefore, a more sustained effort that also includes collaborative care approaches is required to improve the management of diabetes in Australia.

Improving Indigenous Access to Early Childhood Services in Urban and Regional Areas

The literature on how to improve Indigenous access to early childhood services consists mainly of program descriptions and documented practice experience, with a limited number of formal program evaluations. Accessible early childhood services fulfil four overlapping dimensions. They are physically accessible; economically accessible (affordable); appropriate (comprehensive and non-discriminatory); and acceptable (respect and acknowledge culture).The literature suggests that there are five types of barriers to accessible early childhood services: individual; program; provider; social and neighbourhood; and cultural.It is not sufficient to just improve access—engagement strategies are also necessary to get families involved in the services that may benefit them.

Which work characteristics predict employee outcomes for the public-sector employee? An examination of generic and occupation-specific characteristics

The wide-ranging changes that have occurred in the public sector over recent years have placed increasing demands on public-sector employees. A survey of employees within a relatively commercially-oriented public-sector organization in Australia was used to test a demand-oriented generic model of employee well-being and a variety of situation-specific variables. The presence of support at work and the amount of control an employee had over their job were found to be key predictors of employee-level outcomes. Perceptions of pay and the perception of a lack of human resources (HR) were also found to predict employee outcome variables. The results emphasize the impact that middle managers and HR managers can have in terms of reducing the detrimental employee effects that can be caused by the introduction of new public management (NPM) and the potential for a positive impact on employees. In particular, public-sector managers can use the design of jobs and the development of social support mechanisms, such as employee assistance programmes, to maintain, if not improve, the quality of working life experienced by their employees. More broadly, this study has found that the job strain model is a useful tool in a public-sector environment and is likely to be of increasing utility with the continuing introduction or consolidation of NPM over time. Managing these issues in the new public sector could be a key means of protecting the key resource of the Australian public sector - the employees.

Rhetorical theory of public relations: opening the door to semiotic and pragmatism approaches

The 2001 Handbook of Public Relations edited by Robert Heath contains a prominent article advocating the use of rhetorical theory or ‘rhetorical enactment rational’ as a fruitful way of advancing theoretical understandings of public relations. In 2004 Heath and Dan Millar edited: Responding to Crisis: A Rhetorical Approach to Crisis Communication. These are the latest excursions into a perspective on public relations reflecting the extensive study of rhetoric in North America. Other examples are Public Relations Inquiry as Rhetorical Criticism (Elwood, 1995); Rhetorical and Critical Approaches to Public Relations (Toth and Heath, 1992); and a chapter Public Relations? No, Relations with Publics: A Rhetorical-Organisational Approach to Contemporary Corporate Communication (Cheney and Dionisopoulos, in Botan and Hazleton (Eds.) 1989).

The conventional notion of rhetoric is argumentation and persuasion stemming from the ancient Greek sophists, such as Aristotle, and from the Romans, particularly Cicero and Quintillion. Rhetoric became a fundamental plank of the trivium of ancient and medieval education: grammar, logic and rhetoric. Then in the 20th century Kenneth Burke, Stephen Toulmin and Chaim Perelman with Lucie Olbrechts-Tyteca extended Aristotle’s suggestion that: “Rhetoric is the counterpart of dialectic” Aristotle (trans. 1991). To use the rhetorical approach to argue that rational discourse cannot describe the world on its own. Instead living, enculturated human beings have to perceive ‘their’ truths. They take a perceptual ‘position’ on reason.

Public relations, is an industry for influencing perceptual ‘positions’. But the study of perception and attempts to influence perception cannot be claimed by rhetorical scholars alone. Semioticians and linguists who take the perspective of linguistic pragmatics also claim this field. This paper takes the example of ‘public relations’ as a focus for the confluence of rhetorical, semiotic and pragmatism approaches to the ‘problematic’ of understanding and truth.