Tantalus and the tyranny of territory : pursuing the dream of parity in rural and metropolitan population health outcomes through primary health care programs

Many health professionals and rural health academics are motivated by the challenge of achieving equitable access to health care in rural communities with the implicit vision that fairer access to services might ultimately lead to more equitable health outcomes for people living in rural and remote settings. The purpose of this paper is to put the issue of rural and urban health outcome parity into perspective and assess recent progress towards achieving the ultimate goal of improving rural health status. I will also explore ways in which rural communities might increase their access to and use of primary health care revenue in the future to improve community health outcomes. While some improvements have been achieved across the rural health system in recent times, the fundamental problem of maintaining infrastructure to service community needs in rural areas remains as daunting as ever. Extensive evidence has now been assembled to show that rural people generally enjoy a much lower standard of health care, health outcomes and life expectancy than their urban cousins. The question underlying all of this evidence, however, is... must this always be so? Is it possible to redress the current inequities between rural and urban populations and could new primary health care initiatives, such as the Enhanced Primary Care (EPC) program, be vehicles for achieving more equitable health care arrangements and health outcomes for people living in rural communities?

Effective recruitment and retention strategies in community health programs

Issue addressed: 

Building health promoting work settings : identifying the relationship between work characteristics and occupational stress in Australia

Occupational stress is a serious threat to the health of individual workers, their families and the community at large. The settings approach to health promotion offers valuable opportunities for developing comprehensive strategies to prevent and reduce job stress. However, there is evidence that many workplace health promotion programs adopt traditional, lifestyle-oriented strategies when dealing with occupational stress, and ignore the impact that the setting itself has on the health of employees. The aim of the present study was to address two of the barriers to adopting the settings approach; namely the lack of information on how psycho-social work characteristics can influence health, and not having the confidence or knowledge to identify or address organizational-level issues. A comprehensive occupational stress audit involving qualitative and quantitative research methods was undertaken in a small- to medium-sized public sector organization in Australia. The results revealed that the work characteristics ‘social support’ and ‘job control’ accounted for large proportions of explained variance in job satisfaction and psychological health. In addition to these generic variables, several job-specific stressors were found to be predictive of the strain experienced by employees. When coupled with the results of other studies, these findings suggest that work characteristics (particularly control and support) offer valuable avenues for creating work settings that can protect and enhance employee health. The implications of the methods used to develop and complete the stress audit are also discussed.

Program, agency and effect sustainability in health promotion

ISSUE ADDRESSED: Achieving sustainability is often considered a key objective of health promotion efforts despite a lack of consensus as to what sustainability is.

MATERIAL: A review of the international health promotion literature was conducted to identify understandings of sustainability in health promotion.

RESULTS:Three distinct understandings of sustainability in respect of programs, health promotion agencies and program effects were identified.

CONCLUSIONS: Despite a strong emphasis on program sustainability in the health promotion field, clear criteria for why programs should be continued is required rather than assuming that it is the best option. Arguably more important than the maintenance of either programs or the agencies which support them is the ability to produce sustainable program effects.

A proposed smart-card solution for Australian health services : the problems encountered

This case study describes the experience of a state government health department in evaluating the use of smart card technology to redesign health benefits programs for the disabled in Australia. The social and political context of the system is explained in detail, and the potential benefits and risks accruing to the government, health care intermediaries and the community are examined.

Development of a collaborative model to improve school health promotion in the Netherlands

In recent decades, school health promotion programs have been developing into whole-school health approaches. This has been accompanied by a greater understanding among health promoters of the core-business of schools, namely education, and how health promotion objectives can be integrated into this task. Evidence of the positive impact of school health promotion on health risk behavior of students is increasing. This article focuses on the processes and initial results of developing a collaborative model tailored for whole-school health in the Netherlands, named schoolBeat. The Dutch situation is characterized by fragmentation, a variety of health and welfare groups supporting schools, and a lack of sound integrated youth policies. A literature review, observations, and stakeholder consultation provided a clear picture of the current situation in school health promotion, and factors limiting a comprehensive and needs-based approach to school health. This revealed that a health promotion team within a school is fundamental to an effective approach to tailored school health promotion. A respected member of school staff should chair this team. To strengthen the link with the school care team, the school care coordinator should be a member of both teams. To provide coordinated support to all schools in a region, participating organizations decided to share advisory tasks. These tasks are included in the regular health promotion work of their staff. This means working with one advisor representing all school-health organizations per school, and using a comprehensive overview of possible support and projects promoting health. Empowering schools in needs assessments and comprehensive school health promotion is an important element of the developed approach. This article concludes with an examination of emerging issues in evaluating collaborative school health support during the first 18 months of development, and implementation and future perspectives regarding sustainable collaboration and quality improvement.

Health promotion and evaluation - a programmatic approach

Health promotion has evolved significantly in the past twenty years. Its emphasis has shifted from relatively simple monocausal models focused on behavioural risk factors to a greater emphasis on broader social determinants of health. Single method, single risk factor interventions have increasingly been replaced with multiformat, multiple risk factor interventions and extended campaigns, with whole-of-govemment implications. Health promotion structures have developed from ad hoc single shot activity to large dedicated agencies with continuing responsibilities and a wide ambit.

The development of health promotion research and evaluation has followed these trends. The early epidemiology studies linked behavioural risks such as smoking, diet and physical activity with systemic conditions such as cancer and cardiovascular disease. A raft of small and large scale intervention studies aimed at demonstrating that these behavioural risk factors could be modified and that modification would lead to improved health outcomes followed with mixed results.

More recent evidence suggests that behavioural risks are not the onIy social factors that influence health outcomes. There is now strong evidence that social determinants such as income, education and employment have highly significant direct effects on health outcomes, which are not mediated by behavioural risks, and that behavioural risks are also correlated with these broader determinants.

Health promotion now operates in a variety of ways at different scales and different levels of the health system (and the wider social system). The goals of health promotion, and the measures that assess whether a project, campaign, or general strategy has met its goals, differ accordingly.

Arguably, where local, state and federal governments begin to coordinate their efforts systematically across settings, intervention strategies, health action areas and population groups, health promotion becomes more
programmatic, sustainable and effective. A programmatic approach also integrates knowledge generation, the development of health promotion capacity, practice and evaluation together.

However, programmatic approaches to health promotion are comparatively new. Only recently have governments begun to develop and resource
comprehensive and sustained health promotion programs that address a range of health issues using multiple intervention strategies. The scope of a more programmatic approach and its functions and purposes is still developing.

Although evaluation has a key role to play in this respect, the development of programmatic strategies for health promotion has generally outpaced evaluation theory and practice. While we now have reasonable technologies for measurement of behavioural risks and individual attitudinal and cognitive influences on them, strategies to evaluate organisational and community interventions are still emerging.

Similarly, while new approaches to evaluate small scale community and organisational interventions have been developed, comprehensive models to monitor and evaluate health promotion programs and strategies across multiple intervention sites over extended periods have not yet emerged. Nor have we resolved the methodological problems of teasing out the relative contribution of different intervention strategies to observed change in health outcomes.

More programmatic approaches to health promotion require a more programmatic approach to health promotion evaluation. This paper represents an issues based examination of the evidence base for a more programmatic health promotion and the evaluation issues that arise

The sustainable farm families project: changing farmer attitudes to health

Farm health and safety has focussed on strategies such as injury prevention, audits and fulfilling legislative responsibilities. We know farmer injuries mask deeper health issues such as higher rates of cancer, suicides, cardiovascular disease and stress. The relationship between occupational health and safety and farming family health has not been investigated by other researchers either nationally or internationally. The Sustainable Farm Families (SFF) project attempts to make this connection in order to address the unacceptable rates of premature death, higher morbidity and injury on Australian farms.

The SFF focuses on the human resource in the triple bottom line and is working with farmers, families, industry, and university to collaboratively address and improve the health and well being of farming families. Based on a model of extension that engages farming families as active learners where they commit to healthy living and safe working practices the SFF is proving to be an effective model for engaging communities in learning and change. Health education and information is delivered to farming families using a workshop format with participants reporting positive impacts on their farming business. The SFF project sits across generations and sexes and has a high level of support with the overwhelming majority of participants saying they would recommend the program to others.

This paper discusses the progress of the research outlining the design of the project, the delivery and extension processes used to engage 321 farming families to date. The paper presents key learning’s on intersectoral collaboration, engaging farmers and families in health and the future for this project extending into agricultural industries across the nation.

Three key learnings: (1) The increased health risks faced by farmers and their families need social and political attention. (2) Joint ownership and collaborative partnerships where all partners have a key role within the development and delivery of the project to their relevant representative groups enables resources to be shared and encourages greater in-kind support to augment funding received. (3) Farming families are keen to understand more about their health and farmers who participate in health education programs based around industry collaboration with high levels of individual participation will engage with health professionals and obtain an improved health status if programs are presented to them in personally engaging and relevant ways

Paving pathways : shaping the public health workforce through tertiary education

Public health educational pathways in Australia have traditionally been the province of Universities, with the Master of Public Health (MPH) recognised as the flagship professional entry program. Public health education also occurs within the fellowship training of the Faculty of Public Health Medicine, but within Australia this remains confined to medical graduates. In recent years, however, we have seen a proliferation of undergraduate degrees as well as an increasing public health presence in the Vocational Education and Training (VET) sector. Following the 2007 Australian Federal election, the new Labour government brought with it a refreshing commitment to a more inclusive and strategic style of government. An important example of this was the 2020 visioning process that identified key issues of public health concern, including an acknowledgment that it was unacceptable to allocate less than 2% of the health budget towards disease prevention. This led to the recommendation for the establishment of a national preventive health agency (Australia: the healthiest country by 2020 National Preventative Health Strategy, Prepared by the Preventative Health Taskforce 2009). The focus on disease prevention places a spotlight on the workforce that will be required to deliver the new investment in health prevention, and also on the role of public health education in developing and upskilling the workforce. It is therefore timely to reflect on trends, challenges and opportunities from a tertiary sector perspective. Is it more desirable to focus education efforts on selected lead issues such as the “obesity epidemic”, climate change, Indigenous health and so on, or on the underlying theory and skills that build a flexible workforce capable of responding to a range of health challenges? Or should we aspire to both? This paper presents some of the key discussion points from 2008 - 2009 of the Public Health Educational Pathways workshops and working group of the Australian Network of Public Health Institutions. We highlight some of the competing tensions in public health tertiary education, their impact on public health training programs, and the educational pathways that are needed to grow, shape and prepare the public health workforce for future

Health-related empowerment in cancer: validity of scales from the health education impact questionnaire

Empowerment refers to an individual's feelings of being able to manage the challenges of the cancer experience and of having a sense of control over one's life. However, empowerment questionnaires that have been validated for the cancer setting are lacking. The objective of this study was to validate scales from the Health Education Impact Questionnaire (heiQ), which assesses the effects of health education programs among individuals with chronic conditions. The heiQ scales Social integration and support, Health service navigation, Constructive attitudes and approaches, Skill and technique acquisition, and Emotional distress were identified as key dimensions of empowerment for the cancer context.

Mental health diversion courts: a two year recidivism study of a South Australian mental health court program.

The need to develop specialized judicial processes to deal with offenders with mental illnesses is now widely recognized and has led to the introduction of mental health court diversion programs around the world. At present, however, there is only limited evidence from which to assess the impact of these initiatives. This paper describes the South Australian model of diversion, with specific reference to the relationship between identified participant characteristics, program compliance rates, and re-offending outcomes. The results of a two-year recidivism study suggest that involvement with the program has a positive impact on recidivism, but that this is independent from the individual's level of success in the program. Lower risk offenders were more likely to achieve successful outcomes than those in the higher risk categories. The implications of these results, as well the factors that might inform the ongoing development of mental health court programs, are discussed.

Higher adherence to the Australian dietary guidelines is associated with better mental health status among Australian adult first-time mothers

Background: Mental health disorders are a leading cause of disability worldwide, including in first-time mothers. Understanding the associations between diet and depressive symptoms could assist in improving mental health status in this group. Objective: Our aim was to determine the association between diet quality, fruit, vegetable, and fish consumption and depressive symptoms in first-time mothers aged 19 to 45 years.

Design: We analyzed cross-sectional, baseline data (3 months postpartum) from the Melbourne InFANT (Infant Feeding, Activity, and Nutrition Trial) Extend Program.

Participants/setting: Participants were first-time Australian mothers aged 19 to 45 years from the Geelong and Melbourne regions of Victoria, Australia (n=457).

Main outcome measures: A self-administered, 137-item food frequency questionnaire assessed dietary intake over the past year. Adherence to the 2013 Australian Dietary Guidelines was assessed using the Dietary Guideline Index as a measure of diet quality. Depressive symptoms were determined using the Center for Epidemiologic Studies Depression Scale.

Statistical analysis performed: Relationships between diet quality, fruit, vegetable, and fish intake and depressive symptoms were investigated using linear regression adjusted for relevant covariates (age, smoking status, sleep quality, education, physical activity status, and body mass index).

Results: Better diet quality, as indicated by a higher score on the Dietary Guideline Index, was associated with lower depressive symptoms after adjusting for relevant covariates (β=-.034; 95% CI -.056 to -0.012). There were no other associations between dietary intake and depressive symptoms.

Conclusions: Adherence to the Australian Dietary Guidelines was associated with better mental health status among first-time mothers. Further research, including longitudinal and intervention studies, are required to determine causality between dietary intake and depressive symptoms, which might help inform future public health nutrition programs for this target group.