People, places and public health : evaluating the benefits of civic environmentalism in an urban local government context

Recent political, economic and social trends pose threats to the sustainability both of ecosystems and of human health. Australia’s environmental management record is poor, and while by international standards Australians enjoy good health, this is variable (AIHW, 2000). Within developed nations, heart disease, depression, alcohol dependence and stroke are major health issues (Mathers et al. 2002). In Australia, mental disorder is the number one contributor to the disease burden (Vos & Mathers 2000). Recent research has highlighted the role of social capital as a key determinant of health (Kawachi et al., 1997). Despite this, Putnam (1995) observes that social connectedness and civic engagement are in decline. People have less time for leisure and for volunteering, as many juggle paid work and caring for children. Anecdotal evidence suggests that engagement in civic environmentalism has human health benefits, relating to a combination of exposure to natural environments and increased social capital (Maller, Brown, Townsend & St. Leger, 2002). This link is supported by Furnass (1996) who defines well-being as including: satisfactory human relationships, meaningful occupation, opportunities for contact with nature, creative expression, and making a positive contribution to human society. Research conducted by Deakin University confirms the efficacy of linking people and places through civic environmentalism for addressing both ecosystem sustainability and human health and wellbeing. The research has included a pilot study to explore the human health benefits of membership of a local parkland ‘Friends’ group, and a more detailed follow-up study. The aims of the pilot study included:- To identify the range of motivations for joining the Friends group;- To document members’ perceptions of the benefits gained from membership of the group;- To assess the potential for Friends groups to be used as an ‘upstream’ health promotion measure.Face-to-face interviews were conducted with eleven members of a ‘Friends’ group in the eastern suburbs of Melbourne. Data was analysed thematically and key findings included:- Motivations: environmental; social; and pragmatic.- General benefits: community belonging; personal satisfaction; learning opportunities; physical activity; and better environment.- Health benefits: physical health; mental health; and social support. There was unanimous support for the use of ‘Friends’ groups as a tool for health promotion.The follow-up study, in the western suburbs of Melbourne, expanded on the pilot study by measuring the group’s social capital and by collecting self-report data on levels of health service usage. Data was collected through face-to-face interviews and a questionnaire. The findings were similar to the pilot study in relation to the motivations, benefits and the health promotion potential of such groups. However, health service usage data highlighted an apparent anomaly: while respondents perceived significant health benefits, some were nevertheless utilising health services at a relatively high level. This poses some questions requiring further exploration: Is this due to the poorer baseline health of the high health service usage members compared with their fellow members? Does involvement in the group offer health benefits that enable people who would otherwise be too unhealthy to participate in community groups to continue such involvement?If this is the case, then we may do well to look to locally-based mechanisms for promoting ecological sustainability as a tool also for promoting human health. Instead of prescribing a pill, connecting people and places through engagement with a local friends group may address our health problems at the same time as addressing local environmental problems.

Cultural diversity and mental health : the relationship between leisure experiences and wellbeing in an ageing Italian community in Australia

One of the population health implications for Australia’s ageing population is that a larger proportion of the Australian community will be retired and have more time for leisure pursuits. Meaningful leisure activities for this group are thought to be a factor in promoting positive mental health. However, a search of health literature revealed a paucity of research on how older adults make use of their leisure time, what meaning these pursuits have to them, and whether their chosen leisure activities are health enhancing and promote wellbeing. Australia’s population is diverse with many cultures represented. As the population ages, mental health workers will be called upon to provide culturally-appropriate mental health services to clients from a range of ethnic groups. Literature on how people of culturally diverse backgrounds understand leisure activities is also limited. This paper reports on a study carried out in an Italian community in a large regional centre. The participants were selected based on the following criteria; aged 65 years and over, born in Italy, independently living in the community, ambulant, and retired from paid workforce. This study explored how a well-elderly group from an ethnic community derived meaning from their leisure activities and how this impacted on their mental health. Establishing the relationship between leisure and mental health in an ageing ethnic community is important because it sheds light on potential intervention strategies that can be used to maintain the mental health of people living independently in the community. Participants were interviewed using semi-structured questions about their perceptions of leisure, the meanings they derived from these activities, and their perceived impact of these activities on their health. Participant observation was also used to add trustworthiness to the data. Themes arising from the interviews and participant observation will be related to the participants’ sense of health. Results also revealed how older Italians engaged in leisure activities. Implications of the research findings will be directed towards mental health practice with older ethnic clients in community settings. The promotion of healthy lifestyles and positive mental health for Australia’s ageing population will also be discussed.

The politics of resistance to workplace cultural diversity education for health service providers : an Australian study

This qualitative study has as its focus an exploration of health service providers' perceptions and experiences of the processes and implications of delivering workplace cultural diversity education for staff. Data were obtained from conducting in-depth individual and focus group interviews with a purposeful sample of 137 healthcare professionals, recruited from over 17 different organizational sites. Participants included cultural diversity educators, ethnic liaison officers, health service managers, nurses, health interpreters, allied health professionals, and community-based ethnic welfare organization personnel working in or with select metropolitan health services in Victoria, Australia. Analysis of the data revealed that workplace cultural diversity education in healthcare is a significant site of resistance and struggle. 'Resistance' was expressed in several forms including: the problematization of resources and staff availability to attend cultural diversity education forums; indifferent failure to recognize cultural imperatives in healthcare; deliberate refusal to recognize cultural imperatives in healthcare; selective recognition of cultural imperatives in healthcare ('facts sheets' only); and the angry rejection of cultural imperatives in healthcare. 'Struggle', in turn, largely involved cultural diversity educators having to constantly 'cajole and convince' (and even manipulate) staff to attend cultural diversity education forums and using a 'velvet glove and iron fist' approach to teaching staff who remained resolute in their resistance when participating in educational forums. An important implication of this study is that the politics of workplace cultural diversity education - and the 'politics of resistance' to such programs - need to be better recognized and understood if the status quo is to be successfully challenged and changed. The need for critical debate and further comparative research on the subject are also highlighted.

The neglect of racism as an ethical issue in health care

Race and racism has been increasingly implicated in known disparities in the health and health care of racial, ethnic and cultural minorities groups. Despite the obvious ethical implications of this observation, racism as an ethical issue per se has been relatively neglected in health care ethics discourse. In this paper consideration is given to addressing the following questions: What is it about racism and racial disparities in health and health care that these command our special moral scrutiny? Why has racism per se tended to be poorly addressed as an ethical issue in health care ethics discourse? And why, if at all, must racism be addressed as an ethical issue in addition to its positioning as a social, political, cultural and legal issue? It is suggested that unless racism is reframed and redressed as a pre-eminent ethical issue by health service providers, its otherwise preventable harmful consequences will remain difficult to identify, anticipate, prevent, manage, and remedy.

Defining dual diagnosis : a qualitative study of the views of health care workers

Background: 'Dual diagnosis' is the term of choice in many countries to describe clients with co-occurring mental health and alcohol and other drug (AOD) issues. However, it is not known if its meaning is consistently represented within and across health care services. This uncertainty has significant implications for referral, consultation and research.
Aim: To obtain information about the way that different health care professionals understand the term 'dual diagnosis'.
Method: Twenty-nine health care workers across five service types (medical, mental health, AOD, dual diagnosis and community health) in Victoria, Australia were interviewed about their understanding of the term 'dual diagnosis'.
Results: The findings indicated that service providers working in AOD and Mental Health had a shared general understanding of what was meant by 'dual diagnosis', despite uncertainties about more specific inclusion criteria. In contrast, medical and community health staff lacked a similar shared understanding, and were more likely to recommend change, but offered no consensus on alternatives.
Conclusion: The results indicate that while the term 'dual diagnosis' has value in efficiently directing attention to the complexity of treatment issues, health practitioners cannot assume it will convey the intended meaning outside mental health or AOD services. Clear articulation of the intended definition may be a necessary requirement in wider health care communication.

Workload capacity measures for estimating allied health staffing requirements

Workforce planning methodologies for the allied health professions are acknowledged as rudimentary despite the increasing importance of these professions to health care across the spectrum of health services settings. The objectives of this study were to (i) identify workload capacity measures and methods for profiling allied health workforce requirements from a systematic review of the international literature; (ii) explore the use of these methods in planning workforce requirements; (iii) identify barriers to applying such methods; and (iv) recommend further action. Future approaches to workforce planning were explored through a systematic review of the literature, interviews with key stakeholders and focus group discussions with representatives from the different professional bodies and health agencies in Victoria. Results identified a range of methods used to calculate workload requirements or capacity. In order of increasing data demands and costliness to implement, workload capacity methods can be broadly classified into four groups: ratio-based, procedure-based, categories of care-based and diagnostic or casemix-based. Despite inherent limitations, the procedure-based measurement approach appears to be most widely accepted. Barriers to more rigorous workforce planning methods are discussed and future directions explored through an examination of the potential of casemix and mixed-method approaches.

Development of a professional practice audit questionnaire for mental health nursing in Aotearoa/New Zealand

This paper reports the three-stage development of a professional practice audit questionnaire for mental health nursing in Aotearoa/New Zealand. In Study 1, clinical indicator statements (n = 99) generated from focus group data, which were considered to be unobservable in the nursing documentation in consumer case notes, were included in a three-round Delphi process. Consensus of ratings occurred for the mental health nurse and academic participants (n = 7) on 83 clinical indicator statements. In Study 2, the clinical indicator statements (n = 67) that met importance and consensus criteria were incorporated into a questionnaire, which was piloted at a New Zealand mental health service. The questionnaire was then modified for use in a national field study. In Study 3, the national field study, registered mental health nurses (n = 422) from 11 New Zealand District Health Board mental health services completed the questionnaire. Five categories of nursing practice were identified: professional and evidence-based practice; consumer focus and reflective practice; professional development and integration; ethically and legally safe practice; and culturally safe practice. Analyses revealed little difference in the perceptions of nurses from different backgrounds regarding the regularity of the nursing practices. Further research is needed to calibrate the scores on each clinical indicator statement with behaviour in clinical practice.

Effects of financial disadvantage on use and non-use of after hours care in Australia

Policy addressing the provision of primary care after hours (AH) is currently in flux because of concerns about equity of access and cost. In this study we examine the effects of socioeconomic disadvantage on access to AH care and episodes of not seeking AH care when needed among users and non-users of AH care. The effects of health on these relationships were also explored. The total sample consisted of 5538 users of AH care and 891 non-users of AH care who were randomly selected for telephone interviews. Factors determining AH care included accessibility that is structural barriers to use of care such as distance and transport, as well as affordability and availability. Logistic regression was used to determine the impact of financial disadvantage on episodes of not seeking AH care. Barriers to use of AH care and household health were subsequently added to the models to assess their impact. The results suggested that there were inequities in access to AH care but these were a function of barriers to AH care use rather than financial disadvantage per se. Accessibility and availability were significant barriers to use of AH clinics among both user and non-user samples. Affordability was only a significant barrier among users of AH care. The study suggests that policy aimed at reducing these barriers may effectively address inequities in AH care but that to be optimally effective policy change would also need to be accompanied by changes in consumer awareness.

Intervening to improve health indicators among Australian farm families

The Sustainable Farm Families project (http://www.sustainablefarmfamilies.org.au/) was a 3-year demonstration and education project designed to influence farmer behavior with respect to family health and well-being among cropping and grazing farmers in Victoria, New South Wales, and South Australia, Australia. The project was conducted by the Western District Health Service, Hamilton, Australia, in partnership with farmers; Farm Management 500 (peer discussion group); the Victorian Farmers Federation; Royal Melbourne Institute of Technology; and Land Connect. During the 3 years of the project, 128 farmers—men (70) and women (58)—were enrolled. The project utilized a combination of small group workshops, individualized health action plans, and health education opportunities to encourage farm safety and health behavior changes and to elicit sustained improvements in the following health indicators: body mass index (BMI), total cholesterol, fasting blood glucose, and blood pressure. Mean changes in these health indicators were analyzed using repeated measures analysis of variance (ANOVA) and McNemar's test compared the proportion of individuals with elevated indicators. Among participants with elevated values at baseline, the following average reductions were observed: BMI 0.44 kg/m2 (p = .0034), total cholesterol 48.7 mg/dl (p < .0001), blood glucose 10.1 mg/dl (p = .0016), systolic blood pressure 12.5 mm Hg (p < .0001), and diastolic blood pressure 5.0 mm Hg (p = .0007). The proportion of participants with elevated total cholesterol at baseline decreased after 24 months (p < .001). Such findings suggest that proactive intervention by farmer associations, rural health services, and government agencies may be an effective vehicle for promoting voluntary farm safety and health behavior change while empowering farm families to achieve measurable reductions in important health risk factors.

Building capacity for rural health : the role of boundary crossers in coalition maturity for partnerships with external agents

The concept of partnership has entered policy rhetoric and is urged as good practice in a variety of domains including health. Rural communities tend to have fewer resources available for the provision of services such as health than their metropolitan counterparts, and so could be expected to benefit from partnerships with external agencies. Indicators of coalition maturity for working in partnership with external agents in order to build stronger communities are distilled from the group development and partnership research literature and considered in the light of the experiences of the University Department of Rural Health in community engagement. The chapter draws on experiences of two rural community coalitions working to plan and negotiate health service provision. The coalitions were analysed against the indicators. A key indicator of maturity and readiness for working in partnership with external agents is related to the behaviour of ‘boundary crossers’. Boundary crossers are defined as people who move freely between two or more domains and who understand the values, cultures and language, and have the trust, of both. Domains can be within a community or be the community and an external sector. Community health professionals, especially those in senior positions, often act as boundary crossers between the community and broader domains such as regional/state health services or policy, although other community members can fill the role. Other key indicators of coalition maturity for working in partnership with external agents include local leadership that empowers the community, a willingness of community coalitions to take risks and mould opportunities to meet their vision, and a culture of critical reflection and evaluation of past actions.

This chapter analyses the impact of boundary crossing behaviour on community readiness and partnerships with external agents that are intended to build rural community capacity to plan and negotiate health service provision. It is argued that the characteristics and modus operandi of boundary crossers who are members of rural community coalitions affect the level of maturity of the coalitions and community readiness to work with external agents. An understanding of the characteristics and modus operandi of boundary crossers provides valuable insights for external agents in designing their approach to partnerships that build rural community capacity for health.

Building capacity for rural health : the role of boundary crosser and the impact of their behaviours on community readiness partnerships

The concept of partnership has entered policy rhetoric and is urged as good practice in a variety of domains including health. Rural communities tend to have fewer resources available for the provision of services such as health than their metropolitan counterparts, and so could be expected to benefit from partnerships with external agencies. Indicators of coalition maturity for working in partnership with external agents in order to build stronger communities are distilled from the group development and partnership research literature and considered in the light of the experiences of the University Department of Rural Health in community engagement. The chapter draws on experiences of two rural community coalitions working to plan and negotiate health service provision. The coalitions were analysed against the indicators. A key indicator of maturity and readiness for working in partnership with external agents is related to the behaviour of ‘boundary crossers’. Boundary crossers are defined as people who move freely between two or more domains and who understand the values, cultures and language, and have the trust, of both. Domains can be within a community or be the community and an external sector. Community health professionals, especially those in senior positions, often act as boundary crossers between the community and broader domains such as regional/state health services or policy, although other community members can fill the role. Other key indicators of coalition maturity for working in partnership with external agents include local leadership that empowers the community, a willingness of community coalitions to take risks and mould opportunities to meet their vision, and a culture of critical reflection and evaluation of past actions.

This chapter analyses the impact of boundary crossing behaviour on community readiness and partnerships with external agents that are intended to build rural community capacity to plan and negotiate health service provision. It is argued that the characteristics and modus operandi of boundary crossers who are members of rural community coalitions affect the level of maturity of the coalitions and community readiness to work with external agents. An understanding of the characteristics and modus operandi of boundary crossers provides valuable insights for external agents in designing their approach to partnerships that build rural community capacity for health.

Rural Health Week Tasmania 2007

Aims & Rationale/Objectives
To raise the awareness of health issues in rural Tasmania, the work of rural health professionals and community volunteers

Methods
A partnership initiative between the University Department of Rural Health and the Department of Health and Human Services attracted $64,000 sponsorship from government and private sector. It established 28 regional groups which organised local activities and awards for a community volunteeer and a health professional. Regional groups were surveyed about their planning process for rural health week, the activities held, their outcomes and future intentions.

Principal Findings
Regional groups were partnerships of local organisations. Activities had a preventative focus. They included cooking, bike rides, dances, manual handling, health checks, community art, suicide prevention.Events attracted up to 300 participants. There were 48 nominations for the 2 awards, which were perceived to have raised the profile of health professionals and volunteers. Activities that attracted most participation were fun runs and health expos. Most used their understanding of community needs when deciding on activities. Only a small number relied on formal health needs analyses. Groups varied in their assessment of how well the activities they organised actually met needs. Half the group members had not worked together previously. All but 3 intend to work with others in the future. Most group members learnt more about health programs and other professionals in their community.

Implications
Raised profile of health services and role of health professionals and volunteers in rural Tasmania.
Increased range of ongoing health promoting activities. Better planned and coordinated activities.

Our health in our hands : building effective community partnerships for rural health service provision

This paper reports findings from a study in two small Tasmanian rural communities that examined the process of developing and sustaining partnerships between health services and their communities. It identifies a generic framework for partnership development that appears to be common to partnerships, regardless of their purpose or of partners involved. The framework comprises ten predictors or indicators of effectiveness, and a sequential nine-stage partnership development process. Integral to the framework are social capital, and the leadership practices of health service and community leaders. The influence of context on the partnership development process is also examined, with reference to historical precedent, age or maturity of the partnership, and community readiness.