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.

Outsourcing in the Australian health sector : the interplay of economics and politics

Purpose – The paper discusses the reasons and approaches used at three health organisations in introducing outsourcing. It specifically answers the question: why have managers of health organisations outsourced some functions in preference to others?

Design/methodology/approach – This research employs a case study method making use of qualitative analysis. The health organisations were chosen first as representatives of their type, and secondly due to the nature of the outsourcing decisions made. The first health organisation operates in the rural sector; the second is a metropolitan network; and the third is a large metropolitan hospital, which, in contrast to the other two case study organisations, had made only one decision to outsource, producing the largest outsourcing contract in health in Australia. Furthermore, this situation was distinctive as the contract was terminated and re-issued to another private sector organisation.

Findings – The reasons for outsourcing varied within and between health organisations. Although generally they were made on the bases of the characteristics of the labour market, employee skill levels and the nature of industrial relations, the perception of what was core, the level of internal management skills, the ability of internal teams to implement change and the relationship between management and staff. Even though cost savings and a downsized labour force resulted, generally these occurred even when services were not outsourced, through the use of other change processes, such as introducing new technology, changing structures and promoting workforce flexibility. The interplay of political reasons and economic effects was evident along with the political nature of the decision-making and processes used. The paper concludes that the power of managers was a moderating factor between the desire for outsourcing and whether outsourcing actually occurred.

Research limitations/implications – Although this research was conducted solely within the health sector it has implications for other public sector bodies and the private sector.

Practical implications – Managerial decision making can be enhanced with the exploration of the full complement of reasons for the outsourcing decision.

Originality/value – The paper has value to both academics researching in the public sector and public sector managers.

Cultural racism, language prejudice and discrimination in hospital contexts : an Australian study

This article explores the idea that racial and ethnic disparities in healthcare may be expressive of unacknowledged practices of cultural racism. In conducting this exploration, the researchers identify, describe and discuss the practice of language prejudice and discrimination by health service providers, discovered serendipitously in the context of a broader study exploring cultural safety and cultural competency in an Australian healthcare context. The original study involved individual and focus groups interviews with 145 participants recruited from over 17 different organisational and domestic home sites. Participants included health service managers, ethnic liaison officers, qualified health interpreters, cultural trainers/educators, ethnic welfare organisation staff, registered nurses, allied health professionals, and healthcare consumers. Participants self-identified as being from over 27 different ethnocultural and language backgrounds.

Analysis of the data revealed that English language proficiency, like skin colour, was used as a social marker to classify, categorise, and negatively evaluate people of non-English speaking backgrounds (NESB) in the contexts studied. Negative evaluations, in turn, were used to justify the exclusion of NESB people from healthcare relationships and resources. Further data analysis revealed that underpinning the negative attitudes and behaviours in hospital domains concerning people who spoke accented English or who did not speak English proficiently were a dislike of difference, fear of difference, intolerance of difference, fear of competition for scarce healthcare resources, repressed hostility toward difference, and ignorance.

Highlighting the implications of language prejudice for the safety and quality care of NESB people, the researchers call for further internationally comparative research and debate on the subject.

Developing a web-based information resource for palliative care : an action-research inspired approach

Background : General Practitioners and community nurses rely on easily accessible, evidence-based online information to guide practice. To date, the methods that underpin the scoping of user-identified online information needs in palliative care have remained under-explored. This paper describes the benefits and challenges of a collaborative approach involving users and experts that informed the first stage of the development of a palliative care website.

Method : The action research-inspired methodology included a panel assessment of an existing palliative care website based in Victoria, Australia; a pre-development survey (n = 197) scoping potential audiences and palliative care information needs; working parties conducting a needs analysis about necessary information content for a redeveloped website targeting health professionals and caregivers/patients; an iterative evaluation process involving users and experts; as well as a final evaluation survey (n = 166).

Results : Involving users in the identification of content and links for a palliative care website is time-consuming and requires initial resources, strong networking skills and commitment. However, user participation provided crucial information that led to the widened the scope of the website audience and guided the development and testing of the website. The needs analysis underpinning the project suggests that palliative care peak bodies need to address three distinct audiences (clinicians, allied health professionals as well as patients and their caregivers).

Conclusion : Web developers should pay close attention to the content, language, and accessibility needs of these groups. Given the substantial cost associated with the maintenance of authoritative health information sites, the paper proposes a more collaborative development in which users can be engaged in the definition of content to ensure relevance and responsiveness, and to eliminate unnecessary detail. Access to volunteer networks forms an integral part of such an approach.

Does self-management lead to sustainable health benefits in people with arthritis? A 2-year transition study of 452 Australians.

Objective: To evaluate the Arthritis Self-Management Course (ASMC) when applied in a nationwide context.

Methods: Four hundred fifty-two people who participated in the ASMC across Australian states took part in a longitudinal followup study. ASMC is a 6 week, 2 h group educational program designed to assist people with chronic illness to better manage their condition. Measures of program effectiveness included health status and service utilization. Data were collected on 3 occasions: before intervention (baseline) and 6 months and 2 years after the program.

Results: Several indicators of health status showed improvement at 6 months following the ASMC. These included reduction in pain (4%; p < 0.001), fatigue (3%; p < 0.01), and health distress (12%; p < 0.001) as well as increase in self-efficacy (6%; p < 0.001). Increased self-efficacy was a significant predictor of positive change in health status. Health-related behaviors such as aerobic exercise also increased, with the proportion of people who did little or no exercise decreasing by up to 8%. These changes were sustained at 2 years. There was an increase in use of analgesics at 6 months and an increase in use of nonsteroidal antiinflammatory drugs at 2 years. No changes in healthcare utilization (physician visits, allied health visits, and hospitalizations) were observed.

Conclusion: The ASMC is a widely applied program in which participants benefit through a reduction in pain, fatigue, and health distress. Although the absolute changes in health status are small, the low cost and wide application of the intervention suggests the program may have a substantial public health effect.

Health care provider and consumer understandings of cultural safety and cultural competency in health care : an Australian study

There is increasing recognition in Australia that racial and ethnic minority groups experience significant disparities in health and health care compared with the average population and that the Australian health care system needs to be more responsive to the health and care needs of these groups. The paper presents the findings of a year long study that explored what providers and recipients of health care know and understand about the nature and implications of providing culturally safe and competent health care to minority racial and ethnic groups in Victoria, Australia. Analysis of the data obtained from interviewing 145 participants recruited from over 17 different organizational sites revealed a paucity of knowledge and understanding of this issue and the need for a new approach to redress the status quo.

Barriers to care for depressed older people : perceptions of aged care among medical professionals

The current study evaluated barriers to detection of depression among older people. Focus groups were conducted with 21 professional carers, 4 nurses, 10 general practitioners, and 7 aged care managers. The results demonstrated that care for older people is primarily focused on physical care. Further, staff resources, a lack of continuity of care, multiple co-morbidities, reluctance by older people to discuss depression, negative attitudes among carers, as well as a lack of skills all contributed to a failure to detect and treat depression. The implications of these findings for training programs for professional carers are discussed.

Leaving the bush : why did they do it?

The demand for allied health professionals (AHPs) in rural areas is increasing due to changes in lifestyle, disease and disability of the population. Recruitment and retention of AHPs in rural Australia is an issue that continues to challenge policy makers. However, recent initiatives from the Commonwealth Government have focused on boosting the rural health workforce through grants that support education and training, expand health services and increase the number of rural and remote clinical placements. In addition to this funding, suggested restructure of the current allied health service delivery model is gaining much attention. Although this funding and organisational reform is much needed and welcomed, the changing nature of allied health work, increasing demand, and shortages across most rural areas highlight the need for research to address the complexities associated with recruitment and retention of these professionals.

Gaining insight into the experiences of rural AHPs can assist with enhancing government funded recruitment and retention programs and developing sustainable and efficient workforce policies. This study hopes to build on our previous research that implies recruitment is enhanced when retention is optimal, since AHPs are willing to recommend their workplace. Therefore, the factors that influence retention are just as valid and important as the factors that influence recruitment, but many of the existing workforce models have solely focused on recruitment.4 Additionally, these models do not adequately address issues regarding rural employment, they are difficult to implement, and costly to sustain.

In order to make policy recommendations on recruitment and retention in Australia, this paper aims to explore the experiences of AHPs who resigned from rural employment

Opting in and opting out: a grounded theory of nursings contribution to inpatient rehabilitation

Aim: To develop a grounded theory of nursing’s contribution to patient rehabilitation from the perspective of nurses working in inpatient rehabilitation.

Design: Grounded theory method, informed by the theoretical perspective of symbolic interactionism, was used to guide data collection and analysis, and the development of a grounded theory.

Setting: Five inpatient rehabilitation units in Australia.

Participants: Thirty-five registered and 18 enrolled nurses participated in audio-taped interviews and/or were observed during periods of their everyday practice.

Findings: The analysis revealed a situation whereby nurses made decisions about when to ‘opt in’ and when to ‘opt out’ of inpatient rehabilitation. This occurred on two levels: with their interaction with patients and allied health professionals, and when faced with negative system issues that impacted on their ability to contribute to patient rehabilitation. The primary contribution nurses made to inpatient rehabilitation was working directly with patients, enabling them to self-care. Nurses coached patients when their decisions about ‘opting in’ and ‘opting out’ were based on assessment of the person in their particular context. In contrast, the nurses mostly distanced themselves from system-based problems, ‘opting out’ of addressing them. They did this not to make their working lives easier, but more manageable.

Conclusion: System-based problems impacted negatively on the nurses’ ability to deliver comprehensive rehabilitation care. As a consequence, some nurses felt unable to influence the care and they withdrew professionally to make their work lives more manageable.

Preventing falls among older people : current practice and attitudes among community pharmacists

Objective: Falls among older people are a major cause of injury and death in Australia Urgent action is required if we are to stem the .epidemic' increase in falls as our population ages. This paper describes current practice and attitudes of community pharmacists in Northern Rivers, New South Wales, in relation to preventing falls. .. Method: Comm~typhannacists in the Northern Rivers area ofNew South Wales were surveyed to detennine their current activities to reduce the risk of falls in older clients and to gauge awareness of the successful 1992-96 falls prevention program- 'Stay on Your Feet'. Results: Response rate was 79% (53/67). Seventy-two per cent reported that they urge 'most' or 'almost all' older clients to bring in out-of-date medications for disposal, 66% give them falls prevention advice at least 'sometimes', 57% refer at least 'some' older clients to allied health practitioners for assessment or treatment of falls risk. and 92% are interested in receiving more written information regarding falls prevention. Conclusion: The fmdings suggest that while community pharmacists are both ready and keen to play a role in future falls prevention initiatives. their current involvement varies considerably. Specific ways in which they might further help to reduce falls are: regularly checking the potential of client. medications to connibute to falls. giving more verbal or written advice, promoting 'falls safe' products, referring older clients to allied health practitioners for assessment or treatment of falls risk, and training staff [Q provide falls prevention advice

What's needed to increase research capacity in rural primary health care

The aim of this study is to identify ways to build research capacity within primary health. A consultation was undertaken in late 2004 using a combination of a one-page survey and a guided meeting format, in a primary health setting in rural NSW. Most (81.3%) of the 134 individuals consulted were part of an Area Health Service, with 12.7% from non-government settings. Most (80.6%) were clinicians, with a third (31.5%) nurses, 8.3% in medicine, and the remainder from a range of allied health professions. Eleven organisations were represented. The main  outcome measures were identification of support needs, processes to enhance research engagement, and barriers and enablers to clinicians’ research  involvement. The results showed that popular delivery modes for research training and support were courses and “one-to- one” advice. Writing topics were generally more popular than others. Common barriers were time and technology issues. A key enabler was a discipline-specific focus. This is one of few rural Australian  consultations on research needs in primary health conducted with a diverse  range of clinicians at the clinician level. It will direct future research capacity  building efforts towards maximising face-to-face discipline specific options and  minimising technology use.

Folate fortification : a case study of public health policy-making

This thesis investigates the use of scientific evidence in the process of making public health policy. A case study located within a food regulation setting is used. The aim is to test theory against this case study. The outcome is a theoretical understanding of the use of scientific evidence in the policy-making process in a food regulation setting. Food regulation can influence food composition and food labelling and thereby affect the population's dietary intake. Frequently there are contested values, beliefs, ideologies and interests among stakeholders regarding the use of food regulation as a policy instrument to effect public health outcomes. The protection of public health and safety, taking into account evidence based practice, is generally employed by food regulators as the priority objective during the policy-making process to adjudicate among the competing expectations of stakeholders. However, this policy objective has not been clearly defined and is vulnerable to interpretation and application. The process by which folate fortification policy was made in Australia, in response to epidemiological evidence of a relationship between folate intake during the periconceptional period and reduced risk of neural tube defects, was analysed as a case study of the policy-making process. The folate fortification policy created a precedent for both food fortification and subsequently health claims policy in Australia. A social constructivist method was used to analyse the case study. The method involved deconstructing the food regulatory system into three levels; decision-making process; procedural; and political environment. Data aligned with each level of analysis was collected from 22 key informant interviews, documentary sources, field notes and surveys of both a random sample of the Australian population's knowledge of folate and use of folic acid-containing supplements (n = 5422), and the implementation of folate fortified food products into stores (n = 60). The insights that emerged from each of the three levels of analysis were assessed iteratively to identify a pattern of interrelationships associated with the policy-making process within the food regulatory system. The identified pattern was interpreted against existing theory to gain a theoretical understanding of the public health policy-making process in this political setting. The central argument of this thesis extends Sabatier and Jenkins-Smith's Advocacy Coalition Framework theory to a food regulation setting. The argument is that within the contemporary political climates of neoliberalism and globalisation, a coalition between corporate interests and the values of scientists with a positivist-reductionist approach to public health research is privileged so as to invoke certain scientific evidence to, in turn, legitimise food regulation policy decisions. The theory will help to inform policy-makers about how and why the public health policy objective in a food regulation setting is interpreted and applied. This will contribute to improving policy practice intended to effect public health outcomes. It is concluded that irrespective of the quantity and quality of the scientific evidence that is being made available, scientific evidence cannot be assumed to speak for itself Policy-making is an inherently political and value-laden process and the potential for politically motivated interpretation and application of otherwise value-neutral scientific evidence can undermine the investment in its generation. From this perspective, evidence based practice, far from liberating policy-making from political influence, can itself become part of the problem rather than the solution. Nevertheless, rational evidence based practice is an ideal to strive for and a series of recommendations is proposed to help make the use of evidence in current food regulation policy processes more transparent and democratic.

Grounded theory of nursing's contribution to inpatient rehabilitation

There is growing awareness of the benefits of rehabilitation both in Australia and overseas. While the provision of rehabilitation services is not new, recognition of this type of health service as an integral part of health care has been linked to changes in the provision of acute care services, advances in medical technology, improvements in the management of trauma and an ageing population. Despite this, little attention has been paid to nursing's contribution to patient rehabilitation in Australia. The aim of this grounded theory study, therefore, was to collect and analyse nurses' reports of their contributions to patient rehabilitation and to describe and analyse contextual factors influencing that contribution. Data were collected during interviews with registered and enrolled nurses working in five inpatient rehabilitation units in New South Wales and during observation of the nurses' everyday practice. A total of 53 nurses participated in the study, 35 registered nurses and 18 enrolled nurses. Grounded theory, informed by the theoretical perspective of symbolic interactionism, was used to guide data analysis, the ongoing collection of data and the generation of a substantive theory. The findings revealed six major categories. One was an everyday problem labelled incongruence between nurses' and patients' understandings and expectations of rehabilitation. Another category, labelled coaching patients to self-care, described how nurses independently negotiated the everyday problem of incongruence. The remaining four categories captured conditions in the inpatient context which influenced how nurses could contribute to patient rehabilitation. Two categories, labelled segregation: divided and dividing work practices between nursing and allied health and role ambiguity, were powerful in shaping nursing's contribution as they acted individually and synergistically to constrain nursing's contribution to patient rehabilitation. The other two categories, labelled distancing to manage systemic constraints and grasping the nettle to realise nursing's potential, represent the mutually exclusive strategies nurses used in response to segregation and role ambiguity. From exploration of the relationship between the six categories, the core category and an interactive grounded theory called opting in and opting out emerged. In turn, this grounded theory reveals nursing's contribution to inpatient rehabilitation as well as contextual conditions constraining that contribution. The significance of these findings is made manifest through their contribution to the advancement of nursing knowledge and through implications for nursing practice and education, rehabilitation service delivery and research.