Observing the behaviour and interactions of adults with congenital deafblindness living in community residences

Background Adults with congenital deafblindness (CDB) have received little attention from researchers. In this study we examined the nature of interactions between adults with CDB and the staff who mediate their support, and investigated the reliability of an observation coding system, originally designed for observing adults with severe intellectual disability.

Method The behaviours of 9 adults with CDB, including their interactions with support staff from 2 community residences, were recorded and subsequently coded by 2 observers.

Results Interrater reliability, measured using Cohen's k, was variable across the coding system. Adults with CDB were predominantly observed to be disengaged, with few observations of engagement according to the coding schedule's definition of engagement. Interactions between the residents and support staff were rare.

Conclusion The introduction of interventions designed for staff to promote resident engagement in social interaction is recommended.

Implementation of the nurse practitioner role within a Victorian healthcare network : an organisational perspective

Objective
This paper presents a discussion of the development of a framework to implement and sustain the nurse practitioner (NP) role within one health service designed to strengthen the capacity of the health system and which could be readily transferable to other health services.
Setting
Eastern Health (EH) is a multi‑campus tertiary health care organisation servicing a population of approximately 800,000 people in the east and outer eastern suburbs of Melbourne, Australia. EH is committed to advancing the nursing profession and exploring innovative, research based models of practice that are responsive to the needs of the community it serves.
Primary argument
The Framework documents the processes of providing a new career pathway for advanced practice nurses that incorporates education and training, and utilises current evidenced‑based practice guidelines to define and promote the scope of practice.
Conclusion
Strong organisational support to facilitate interdisciplinary and multidisciplinary learning opportunities assists integration of the NP role into the healthcare team. Role clarity will assist interprofessional teams to understand and value the role NPs provide.

Assessing and managing old age psychiatric disorders in community practice

A shortage of specialised facilities means that general practitioners have a prominent role in community care of the elderly with mental illness.

A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency

Background
Change agency in its various forms is one intervention aimed at improving the effectiveness of the uptake of evidence. Facilitators, knowledge brokers and opinion leaders are examples of change agency strategies used to promote knowledge utilization. This review adopts a realist approach and addresses the following question: What change agency characteristics work, for whom do they work, in what circumstances and why?

Methods
The literature reviewed spanned the period 1997-2007. Change agency was operationalized as roles that are aimed at effecting successful change in individuals and organizations. A theoretical framework, developed through stakeholder consultation formed the basis for a search for relevant literature. Team members, working in sub groups, independently themed the data and developed chains of inference to form a series of hypotheses regarding change agency and the role of change agency in knowledge use.

Results
24, 478 electronic references were initially returned from search strategies. Preliminary screening of the article titles reduced the list of potentially relevant papers to 196. A review of full document versions of potentially relevant papers resulted in a final list of 52 papers. The findings add to the knowledge of change agency as they raise issues pertaining to how change agents’ function, how individual change agent characteristics effect evidence-informed health care, the influence of interaction between the change agent and the setting and the overall effect of change agency on knowledge utilization. Particular issues are raised such as how accessibility of the change agent, their cultural compatibility and their attitude mediate overall effectiveness. Findings also indicate the importance of promoting reflection on practice and role modeling. The findings of this study are limited by the complexity and diversity of the change agency literature, poor indexing of literature and a lack of theory-driven approaches.

Conclusion
This is the first realist review of change agency. Though effectiveness evidence is weak, change agent roles are evolving, as is the literature, which requires more detailed description of interventions, outcomes measures, the context, intensity, and levels at which interventions are implemented in order to understand how change agent interventions effect evidence-informed health care.

Community-onset Escherichia coli infection resistant to expanded- spectrum cephalosporins in low-prevalence countries

Background
By global standards the prevalence of community onset expanded-spectrum cephalosporin resistant Escherichia coli (ESC-R-EC) remains low in Australia and New Zealand. Of concern, our countries are in a unique position with high extramural resistance pressure from close population and trade links to Asia-Pacific neighbours with high ESC-R-EC rates. We aim to characterize the risks and dynamics of community onset ESC-R-EC in our low-prevalence region.

Methods
A case-control methodology was used. Patients with ESC-R-EC or susceptible E. coli isolated from blood or urine were recruited at six geographically dispersed tertiary hospitals in Australia and New Zealand. Epidemiological data was prospectively collected and bacteria were retained for analysis.

Results
In total, 182 patients (91 cases and 91 controls) were recruited. Multivariate logistic regression identified risk factors for ESC-R amongst E. coli including birth on the Indian subcontinent (OR=11.13, 2.17-56.98, p=0.003), urinary tract infection in the past year (per infection OR=1.430, 1.13-1.82, p=0.003), travel to South East Asia, China, Indian subcontinent, Africa and the Middle East (OR=3.089, 1.29-7.38, p=0.011), prior exposure to trimethoprim+/-sulfamethoxazole &/or an expanded-spectrum cephalosporin (OR=3.665, 1.30-10.35, p=0.014) and healthcare exposure in the previous six months (OR=3.16, 1.54-6.46, p=0.02).

Amongst our ESC-R-EC the blaCTX-M ESBLs was dominant (83% of ESC-R-EC), and the worldwide pandemic clone ST-131 was frequent (45% of ESC-R-EC).

Conclusion
In our low prevalence setting, ESC-R amongst community onset E. coli may be associated with both ‘export’ from healthcare facilities into the community and direct ‘import’ into the community from high-prevalence regions.

Community views on responding to a local asbestos disease epidemic : implications for policy and practice

The Latrobe Valley region of Victoria, Australia, has the highest rate of asbestos disease in the state due to extensive past use of asbestos in the power industry. Current responses to asbestos disease epidemics in Australia and internationally are dominated by medical, scientific, legal and government perspectives. The voices and perspectives of those most directly affected – exposed and diseased workers, their families and communities – are relatively rarely heard.A qualitative interview study was conducted to determine what people in the Latrobe Valley community think could or should be done following their own asbestos disease epidemic. Analysis identified several themes. Notably, these represent a sophisticated community understanding of issues that is largely consistent with state-of-the-art occupational health and public health knowledge.Some themes are well known already, eg the need for fair and timely compensation, adequate healthcare facilities and services, and more education. Others point to neglected possibilities, such as the need for reconciliation and social healing to complement the dominant individual medico-legal focus. Employer suppression of hazard information and denial of asbestos-related disease in past decades continues to have a profound effect on people's views in the present. Reconciliation in some form, eg acknowledgement of or apology for past wrongs, was identified as a necessary first step in developing new and better policy and practice responses; action in this regard has important implications for the implementation and effectiveness of other policy and practice interventions. Further, a need for substantive community participation in the development of policy and practice responses – currently lacking – was identified. Findings suggest that community is an under-recognised and under-utilised resource in responding to a local asbestos disease epidemic.The Latrobe Valley situation is a microcosm of the broader Australian and international story. It offers insights on the perspectives of those most affected by asbestos issues, how such people and their views can be used to strengthen current policy and practice responses, and how their participation is essential to building comprehensive public and social health responses to this global problem.

Evaluating health services with point of service feedback: perspectives and experiences of patients, staff and community volunteers in an inpatient rehabilitation facility

PURPOSE: To determine patient, staff and community volunteer opinions and experiences of point of service feedback (POSF) in an inpatient rehabilitation facility. METHOD: Participants were recruited by purposeful sampling. Two researchers conducted in-depth semi-scripted interviews with patients, staff or volunteers until no new issues emerged. Manually transcribed interview data underwent thematic analysis that grouped information into categories of related information. RESULTS: Twenty patients, 26 staff from 10 different professional groups, and 2 community volunteers were interviewed. Patient and volunteer data were grouped into five main categories: patients wanted their voice heard and acted on; patients could be positively and negatively affected by POSF; patients could be reluctant to evaluate staff; patients preferred POSF to post-discharge mailed questionnaires; and patients' feedback was influenced by the data collector. Staff wanted: feedback to help them improve the patient experience; and feedback that was trustworthy, usable and used. Staff believed that the feedback-collector influenced patients' feedback and affected how feedback could be used. CONCLUSIONS: Patients, staff and community volunteers identified issues that determine the appropriateness and usefulness of POSF. Policy and practise should address the preferences, needs and experiences of health service users and providers so that POSF produces maximum benefits for both patients and health services. Implications for Rehabilitation POSF can enhance patients' experiences of inpatient rehabilitation by providing a mechanism to be heard and communicating that patients are valued; care must be exercised with patients who find giving feedback stressful. Collecting POSF is most beneficial when coupled with methods to efficiently and effectively respond to feedback. POSF requires interpretation in light of its limitations including patients' ability to accurately and unreservedly communicate their experiences. Who collects POSF requires careful consideration; community volunteers have both advantages and disadvantages.

Interventions to improve cultural competency in healthcare: a systematic review of reviews

Cultural competency is a recognized and popular approach to improving the provision of health care to racial/ethnic minority groups in the community with the aim of reducing racial/ethnic health disparities. The aim of this systematic review of reviews is to gather and synthesize existing reviews of studies in the field to form a comprehensive understanding of the current evidence base that can guide future interventions and research in the area.

Cost-effectiveness of whole-of-community obesity prevention programs: an overview of the evidence

Whole-of-community obesity prevention programs that impact on multiple players and promote community capacity show promise as an important strategy in the fight against global obesity. This paper reviews the economic evaluation literature of multifaceted, community based obesity prevention programs. There are few cost effectiveness studies. Whilst results to date are encouraging, there is considerable uncertainty surrounding the long term results given the lack of evidence regarding sustainability of program effect and a consequent reliance on economic modeling to fill the gaps. More empirical studies of longer duration are needed to demonstrate the longer term effectiveness and cost effectiveness of these programs, and to facilitate identification of the elements necessary for their sustainability.

Adherence to therapeutic guidelines for patients with community-acquired pneumonia in Australian hospitals

Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality, particularly in elderly patients, and is associated with a considerable economic burden on the healthcare system. The combination of high incidence and substantial financial costs necessitate accurate diagnosis and appropriate management of patients admitted with CAP. This article will discuss the rates of adherence to clinical guidelines, the use of severity scoring tools and the appropriateness of antimicrobial prescribing for patients diagnosed with CAP. The authors maintain that awareness of national and hospital guidelines is imperative to complement the physicians' clinical judgment with evidence-based recommendations. Increased use of pneumonia severity assessment tools and greater adherence to therapeutic guidelines will enhance concordant antimicrobial prescribing for patients with CAP. A robust and multifaceted educational intervention, in combination with antimicrobial stewardship programs, may enhance compliance of CAP guidelines in clinical practice in Australia.

Barriers and enablers to healthcare access and use among Arabic-speaking and Caucasian English-speaking patients with type 2 diabetes mellitus: a qualitative comparative study

OBJECTIVE: The objective of this study was to explore the decision-making processes and associated barriers and enablers that determine access and use of healthcare services in Arabic-speaking and English-speaking Caucasian patients with diabetes in Australia. STUDY SETTING AND DESIGN: Face-to-face semistructured individual interviews and group interviews were conducted at various healthcare settings-diabetes outpatient clinics in 2 tertiary referral hospitals, 6 primary care practices and 10 community centres in Melbourne, Australia. PARTICIPANTS: A total of 100 participants with type 2 diabetes mellitus were recruited into 2 groups: 60 Arabic-speaking and 40 English-speaking Caucasian. DATA COLLECTION: Interviews were audio-taped, translated into English when necessary, transcribed and coded thematically. Sociodemographic and clinical information was gathered using a self-completed questionnaire and medical records. PRINCIPAL FINDINGS: Only Arabic-speaking migrants intentionally delayed access to healthcare services when obvious signs of diabetes were experienced, missing opportunities to detect diabetes at an early stage. Four major barriers and enablers to healthcare access and use were identified: influence of significant other(s), unique sociocultural and religious beliefs, experiences with healthcare providers and lack of knowledge about healthcare services. Compared with Arabic-speaking migrants, English-speaking participants had no reluctance to access and use medical services when signs of ill-health appeared; their treatment-seeking behaviours were straightforward. CONCLUSIONS: Arabic-speaking migrants appear to intentionally delay access to medical services even when symptomatic. Four barriers to health services access have been identified. Tailored interventions must be developed for Arabic-speaking migrants to improve access to available health services, facilitate timely diagnosis of diabetes and ultimately to improve glycaemic control.