Population prevalence of personality disorder and associations with physical health comorbidities and health care service utilization: a review

Personality disorder (PD), outcomes of diverse comorbid physical health conditions, and the associated burden on health service resources have seldom been studied at a population level. Consequently, there is limited evidence that might inform a public health approach to managing PD and associated mental and physical disability. A review was conducted of population-based studies examining the prevalence of PD and associations between physical comorbidities and service utilization. The prevalence of any PDs were common (4.4% -21.5%) among populations spanning England, Wales, Scotland, Western Europe, Norway, Australia, and the United States. Preliminary evidence supports associations between PDs from Clusters A and B and physical comorbidities, namely cardiovascular diseases and arthritis. PD appears to increase health care utilization, particularly in primary care. In order to facilitate rational population health planning, further population studies are required.

Patient satisfaction with treatment for alcohol use disorders: comparing patients with and without severe mental health symptoms

BACKGROUND: Previous studies suggest patients with co-occurring alcohol use disorders (AUDs) and severe mental health symptoms (SMHS) are less satisfied with standard AUD treatment when compared to patients with an AUD alone. This study compared patient satisfaction with standard AUD treatment among patients with and without SMHS and explored how standard treatment might be improved to better address the needs of these patients.

METHODS: Eighty-nine patients receiving treatment for an AUD either at an inpatient hospital, outpatient clinic, inpatient detoxification, or residential/therapeutic community services were surveyed. Patient satisfaction with treatment was assessed using the Treatment Perception Questionnaire (range: 0-40). Patients were stratified according to their score on the Depression Anxiety Stress Scale. Forty patients scored in the extremely severe range of depression (score >14) and/or anxiety (score >10) (indicating SMHS) and 49 patients did not. An inductive content analysis was also conducted on qualitative data relating to areas of service improvement.

RESULTS: Patients with SMHS were found to be equally satisfied with treatment (mean =25.10, standard deviation =8.12) as patients with an AUD alone (mean =25.43, standard deviation =6.91). Analysis revealed that being an inpatient in hospital was associated with reduced treatment satisfaction. Patients with SMHS were found to be significantly less satisfied with staffs' understanding of the type of help they wanted in treatment, when compared to patients with AUDs alone. Five areas for service improvement were identified, including staff qualities, informed care, treatment access and continuity, issues relating to inpatient stay, and addressing patients' mental health needs.

CONCLUSION: While findings suggest that AUD treatment services adequately meet the needs of patients with SMHS in treatment, patients with SMHS do feel that staff lack understanding of their treatment needs. Findings have important implications as to how current health care practice might be improved according to the patient's perspective of care.

An `upside-down` view of rural health care

Access to high quality health care services plays an important part in the health of rural communities and individuals. This fact is reflected in efforts by governments to improve the quality of such services through better targeting of funds and more efficient management of services. In Australia, the difficulties experienced by rural communities in attracting and retaining doctors has long been recognized as a contributing factor to the relatively higher levels of morbidity and mortality in rural areas. However, this paper, based on a study of two small rural communities in Australia, suggests that resolving the health problems of rural communities will require more than simply increasing the quality and accessibility of health services. Health and well-being in such communities relates as much to the sense of community cohesion as it does to the direct provision of medical services. Over recent years, that cohesion has diminished, undermined in part by government policies that have fuelled an exodus from small rural communities to urban areas. Until governments begin to take an 'upside-down' perspective, focusing on building healthy communities rather than simply on building hospitals to make communities healthy, the disadvantages faced by rural people will continue to be exacerbated.

Rural nursing and health care reforms : building a social model

This article explores recent shifts in health-care policy and the implications for rural nursing in Australia. Health-care reforms have resulted in the implementation of a 'market forces' ideology, creating tensions between economic imperatives and the need for equity and greater access in rural service delivery. New models of health-service delivery have been developed that have significant implications for the way rural health care is defined, practised and received. The issues surrounding the context of rural nursing practice and service delivery are discussed.

Consumer issues in navigating health care services for type I diabetes

• Despite increasing interest in consumer awareness and participation in health care service delivery, there has been little exploration of consumer views in relation to services for people with type I diabetes. • The purpose of this qualitative exploratory study was to identify strategies people with type I diabetes used to access health services and the barriers they perceived in accessing the services they needed. • Data gathered in semi-structured interviews revealed that consumers experience significant barriers when navigating the health care system. • Three dominant themes were identified. They relate to access to specialist medical skill, to the transition from teenager to young adult and to pre-pregnancy and obstetric care. • Directions for change in service delivery and policy development are discussed.

Ethically defensible decision-making in health care: challenges to traditional practice

The concept of paternalism is deeply entrenched in health care. Decision-making about health care can be extremely difficult at times, and many competing interests may influence the outcomes. However, ethically defensible practice aligns itself with acknowledging the patient's prima facie right to be treated as an autonomous individual. This includes the patient's right to make informed decisions or to decide that other(s), such as the close family, should make decisions on his or her behalf. (author abstract)

Why primary health care offers a more comprehensive approach to tackling health inequities than primary care.

As governments attempt to focus more intently on how to deal with alarming measures of health disadvantage and inequities, a reformist gaze seems to have settled on the primary care sector. Simultaneously, in literature about this area, whether intended or not, primary health care and primary care are terms that are increasingly interchanged. This article argues that the slippage in language is counter-productive, first because it disguises the transformative potential of strategies and approaches that can make the fundamental changes necessary to improve health status, and second because the structures and practices of the primary care sector are not necessarily compatible with notions of comprehensive primary health care. There is much to be lost if primary health care and health promotion are disguised as primary care, and not understood for their capacity to make a difference to health inequities although of course in some circumstances, comprehensive primary health care is interdependent with services provided by primary care. In this article, characteristics of primary care and primary health care are juxtaposed to show that if the strengths and limitations of each model are understood, they can be mobilised in collaborative partnerships to deal more effectively with health inequities, than our system has so far been able to do.

Decision making in health care: limitations of the substituted judgement principle

The substituted judgement principle is often recommended as a means of promoting the self-determination of an incompetent individual when proxy decision makers are faced with having to make decisions about health care. This article represents a critical ethical analysis of this decision-making principle and describes practical impediments that serve to undermine its fundamental purpose. These impediments predominantly stem from the informality associated with the application of the substituted judgement principle. It is recommended that the principles upon which decisions are made about health care for another person should be transparent to all those involved in the process. Furthermore, the substituted judgement principle requires greater rigour in its practical application than currently tends to be the case. It may be that this principle should be subsumed as a component of advance directives in order that it fulfils its aim of serving to respect the self-determination of incompetent individuals.

`This was a great project!`: reflections on a `successful` mental health promotion project in a remote Indigenous school

Issue addressed: The complexities encountered in an Indigenous community when a white project support team assisted a school (Bwgcolman on Palm Island, Queensland) to implement MindMatters, a centralised, national project aiming to promote the psychosocial health of young Australians through the development of a comprehensive, school- based mental health promotion program. Approach: The MindMatters consortium offered pilot schools curriculum materials, professional development for staff, funding and ongoing support at a local level in return for their participation in the project. The support team flew to the island on two occasions to provide support. Conclusion: Whether or not MindMatters constituted a community project at Bwgcolman is debatable. Nevertheless, the project at Bwgcolman was considered a 'success' by key players since initial aims identified by the school were tangible (eg, professional development, curriculum development) and met in a way that the school could take ownership of. Additionally, behavioural management policy was implemented in a manner that was cognisant of a history of coercive relations with Indigenous communities. So what?: It is important in the telling of the success story at Bwgcolman that even though MindMatters endeavoured to be culturally sensitive, it was nevertheless a centralist mental health promotion program. Future mental health promotion initiatives need to be aware that the approach of the support team in attempting to hand back some community control at the local level may have played a role in the school succeeding.

Straddling the pathway from paediatrician to mainstream health care : transition issues experienced in disability care

Objective: To identify the strengths and limitations of health care and related services provided to young adults with a disability during the period of transition from the care of a paediatrician to the mainstream health system.
Design: A descriptive design was used to address the study objectives.
Setting: Barwon and south-western region of Victoria.
Subjects: Twelve focus group discussions, with young adults with a disability, carers of young adults with a disability and health care service providers. Each focus group involved eight to 10 participants.
Results: The findings revealed a number of problems with the transition period. All participants acknowledged the supportive, coordinating role of the paediatrician. In the absence of this type of role, carers felt they lacked the knowledge and support to manage the adolescent with a disability. Communication problems between all service providers were identified as being problematical. The general lack of continuity of care between providers made it difficult for individuals to negotiate the transition period and increased the burden of care on carers.
Conclusion: There is a need for policy makers to address these transition problems and develop appropriate services that improve the situation for young adults with a disability and their carers.
What is already known: It is well documented that the transition period from paediatrician to adult health care services is problematic for the young adult with a disability and their carer. The difficulties experienced are attributed to poor communication between service providers and a lack of continuity of care.
What does this study add: This study provides insights from a number of different consumer and health care professionals' perspectives. The findings identify service delivery gaps and a need to develop health care services that could assist the young adult with the disability negotiate this transition from the paediatric services to mainstream health care services in rural and regional settings in Victoria.

Clinical nurses` response to an environment of health care reform and organizational restructuring

The aim of this paper is to provide an explanation for clinicians' undisputed acceptance of change. This will be performed by examining the process of organizational restructuring across three analytical levels – the macro, meso and micro; identifying the consequences of restructuring for clinical nurses' performance; and evaluating organizational restructuring using a micro-political theoretical framework.

The transition from pediatric to adult health care services for young adults with a disability : an ethical perspective

Young children with disabilities and their carers or parents tend to form a long-term dependent relationship with a paediatrician throughout childhood At some stage when the young person with a disability reaches early adulthood, the relationship is severed This paper draws upon recent research undertaken by the authors that describes the difficulties experienced by young people with disabilities as they go through the transition from paediatric care to adult mainstream health care services. The purpose of this article is to present the argument that the dependent, paternalistic relationship that tends to exist between young people with disabilities (and/or their carers) and paediatricians throughout childhood does not facilitate the successful negotiation of adult mainstream health care services, nor optimally promote the well-being of these young people with disabilities. It is proposed that the promotion of autonomy (or self-determination) via a well planned transition program will increase the likelihood that young adults with disabilities and/or their carers will be empowered to successfully negotiate the current mainstream health care system in Australia, and will enhance the well-being of young adults with disabilities.

Towards critical social work practice in mental health: a review

Progressive social work perspectives that draw on both critical theories and postmodern thought, provide highly relevant and appropriate frameworks to inform social work practice in the mental health field. Despite this, the literature overviewed indicates that the majority of social work practice conducted in mental health settings reflects an uncritical embrace of the medical model of psychiatric illness, and therefore largely neglects social work approaches which utilize critical principles. The following article explores the possibilities for applying a critical model of social work practice to the mental health field, and argues the necessity for social workers to actively engage with critical practice, even in medically dominated settings, to effectively work towards the espoused social justice ethics and mission of the social work profession.