A qualitative study of primary health care access, barriers and satisfaction among people with mental illness

Research has found that a substantial proportion of individuals with mental illness have high morbidity and mortality rates, and high under-diagnosis of major physical illnesses. Furthermore, people with a mental illness tend not to seek out or utilise health care services. The reasons for the negative attitudes and behaviour towards health care services among this population have not been investigated. This paper presents findings from a study that investigated the health care service needs of people with mental illness (n = 20), and views from health care providers (n = 16) regarding access to these services by people with a mental illness. Results indicated that psychiatric patients identified a range of barriers to their health care usage and low levels of health care satisfaction. These views were shared with health care professionals. Reasons for these findings and strategies to address these problems so that there is better access to health care services for people with mental illness are discussed.

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.

Implementation of evidence into practice : Development of a tool to improve emergency nursing care of acute stroke

Background
Stroke is an increasing global health issue that places considerable burden on society and health care services. An important part of acute stroke management and decreasing stroke-related mortality is preventing complications within the first 24–48 hours. The current climate of prolonged time spent in the Emergency Department (ED) means that many aspects of stroke management are now the responsibility of emergency nurses.

Aims
The aims of this paper are to: i) examine the evidence related to nursing care of acute stroke, ii) identify evidence-based elements of stroke care with most applicability to emergency nursing and iii) use evidence-based stroke care recommendations to develop a guideline for the emergency nursing management of acute stroke.

Results
Emergency nursing care of acute stroke should focus on optimal triage decisions, physiological surveillance, fluid management, risk management, and early referral to specialists.

Conclusions
The role of emergency nurses in stroke care will increase and it is important that emergency nurses deliver evidence-based stroke care in order to optimise patient outcomes. Guidelines and decision support tools for use in emergency nursing must be practical and have high levels of clinical utility for maximum uptake in a busy clinical environment.

Knowledge of late-life depression : an empirical investigation of aged care staff

Objectives: This study examined knowledge of late-life depression among staff working in residential and community aged care settings, as well as their previous training in caring for older people with depression.

Method: A sample of 320 aged care staff (mean age = 42 years) completed a survey questionnaire. Participants included direct care staff, registered nurses and Care Managers from nursing and residential homes and community aged care services.

Results: Less than half of the participating aged care staff had received any training in depression, with particularly low rates in residential care. Although aware of the importance of engaging with depressed care recipients and demonstrating moderate knowledge of the symptoms of depression, a substantial proportion of staff members saw depression as a natural consequence of bereavement, aging or relocation to aged care.

Conclusion: Experience in aged care appears to be insufficient for staff to develop high levels of knowledge of depression. Specific training in depression is recommended for staff working in aged care settings in order to improve the detection and management of late-life depression, particularly among direct carers, who demonstrated least knowledge of this common disorder.

A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population

Background : Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.

Methods : Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.

Results : Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.

Conclusion : Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.

Geelong community's priorities and expectations of public health care

Abstract This thesis set out to achieve the following objectives: (1) To identify the priorities and expectations that the Geelong community has of its public health care system. (2) To determine if there is a common view on the attributes of a just health system. (3) To consider a method of utilising the data in the determination of health care priority setting in Barwon Health. (4) To determine a model of community participation which enables ongoing input into the decision making processes of Barwon Health. The methodology involved a combination of qualitative and quantitative research. The qualitative work involved the use of focus groups that were conducted with 64 members of the Geelong community. The issues raised informed the development of the interview schedule that was the basis of the quantitative study, which surveyed a representative sample of 400 members of the Geelong community. Prior to reporting on this work, the areas of distributive justice, scarcity and community participation in health care were considered. The research found that timely access to public hospitals, emergency care and aged care services were the major priorities; for many people, the cost was less relevant than a quality service. Shorter waiting times and increased staffing levels were strongly supported. Increased taxes were nominated as the best means of financing the health system they sought. Community based services were less relevant than hospital services but health education was supported. An egalitarian approach to resource distribution was favoured although the community was prepared to discriminate in favour of younger people and against older people. There was strong support for the community to be involved in decision making in the public health care system through surveys or focus groups but very little support was given to priorities being determined by politicians, administrators and to a lesser extent, medical professionals.

Public reporting of nursing home quality of care : Lessons from the United States experience for Canadian policy discussion

While the demand for continuing care services in Canada grows, the quality of such services has come under increasing scrutiny. Consideration has been given to the use of public reporting of quality data as a mechanism to stimulate quality improvement and promote public accountability for and transparency in service quality. The recent adoption of the Resident Assessment Instrument (RAI) throughout a number of Canadian jurisdictions means that standardized quality data are available for comparisons among facilities across regions, provinces and nationally. In this paper, we explore current knowledge on public reporting in nursing homes in the United States to identify what lessons may inform policy discussion regarding potential use of public reporting in Canada. Based on these findings, we make recommendations regarding how public reporting should be progressed and managed if Canadian jurisdictions were to implement this strategy.

Lesbian and gay experiences of primary care in one borough in North London, UK

This paper reports the findings of a research study which explored the experiences of lesbians and gay men in relation to primary care services in general practice in a multiracial borough in North London, UK. The research took a qualitative approach and used several methods including a literature review, interviews with stakeholders (n = 6), focus group discussions (n = 27) and completion (n = 42) of a survey distributed to lesbians and gay men locally. The process facilitated the development of a grounded theory. The important themes to emerge were finding a GP and coming out, sexual health issues, mental health issues and communication with the GP. Given the high level of mobility among this population, there were problems in maintaining continuity of care, and a lack of protocols to facilitate the sharing of knowledge between patients and practitioners while reducing reliance on heterosexual assumptions. There were clear differences between the treatment of women and men in relation to sexual health, and neither approach could be said to be patient centred or inclusive of diversity of need. The fact that many informants accessed alternative sources of healthcare indicated that they were concerned to promote and maintain their health and wellbeing in a holistic manner. The lack of transparent protocols within general practice inhibited some informants from being as open and honest about their sexuality with their GPs as they were with their families or their employers. The findings highlight (1) the need for organisational development within primary care to improve sensitivity to the needs of lesbians and gay men; (2) the value of research to engage with the social experiences of lesbians and gay men; (3) the importance of engaging with the differing experiences of lesbians and gay men in relation to sexual health concerns.

Maternity care experiences of Asia ethnic minorities in rural Tasmania, Australia : a mixed methods study

When migrating to Australia Asian women bring with them birthing cultural beliefs and practices, many of which are different from the Australian medical and cultural understanding of reproduction. Such cultural differences may result in conflicts between clients and health care providers especially when the migrants have a poor knowledge of English. The research investigates the maternity care experiences of Asian migrants in Tasmania. The barriers that Asian migrants face in accessing maternity care services and the factors that affect their views towards maternity care were also explored. A mix of quantitative and qualitative methods was employed. Ten women from different ethnic minorities were invited to semi-structured interviews. The qualitative data were analysed using grounded theory. Findings from the interviews were utilized to design a survey questionnaire. Of the 150 survey questionnaires posted, 121 questionnaires were returned. Descriptive statistics and Chi-square tests of independence were used to analyse the quantitative data. Asian migrants followed some traditional practices such as having good rest and eating hot food during the postpartum month. However, they tended to adapt or disregard traditional practices that were no longer applicable in the new environment including the practices of not washing or having a shower. Support is vital for women recovering after childbirth to prevent postnatal depression. Two main barriers migrant women face in accessing health care are language and cultural barriers. Country of origin, partner’s ethnicity, religion and length of stay in Australia are factors that shape the migrants’ views and attitudes towards and experience of maternity care. Providing interpreting services, social support for migrant women and improving the cross-cultural training for healthcare providers are recommended to improve available maternal care services. The factors that affect migrants’ view on maternity care should be taken into account when providing maternity care for Asian migrant women.

Intervention for depression among palliative care patients and their families : a study protocol for evaluation of a training program for professional care staff

Background: Clinical depression is highly prevalent yet under-detected and under-treated in palliative care settings and is associated with a number of adverse medical and psychological outcomes for patients and their family members. This article presents a study protocol to evaluate a training intervention for non-physician palliative care staff to improve the recognition of depression and provide support for depressed patients and their family members. Details of the hypotheses and expected outcomes, study design, training program development and evaluation measures are described.
Methods and Design: A randomised controlled trial will be implemented across two palliative care services to evaluate the “Training program for professional carers to recognise and manage depression in palliative care settings”. Pre-, post- and three-month follow-up data will be collected to assess: the impact of the training on the knowledge, attitudes, self-efficacy and perceived barriers of palliative care staff when working with depression; referral rates for depression; and changes to staff practices. Quantitative and qualitative methods, in the form of self-report questionnaires and interviews with staff and family members, will be used to evaluate the effectiveness of the intervention.
Discussion: This study will determine the effectiveness of an intervention that aims to respond to the urgent need for innovative programs to target depression in the palliative care setting. The expected outcome of this study is the validation of an evidence-based training program to improve staff recognition and appropriate referrals for depression, as well as improve psychosocial support for depressed patients and their family members.

Coproduction in practice : participatory action research to develop a model of community aged care

Coproduction has become synonymous with innovative approaches to public service delivery in European Union countries as well as in Australia. Coproduction has the potential to bring together individuals, communities, and organisations in a process to collaboratively develop new models and services which improve public services. Yet, Australian policy makers and practitioners who would like to deploy coproduction within the context of older adult social care can only draw on a handful of papers and reports that could guide implementation. This paper fills this gap by reporting on the implementation of a multi-stakeholder coproduction approach to the development of a consumer directed care model for older people with complex health issues. The paper describes and critically highlights methodological challenges encountered during the 12 month-long participatory action research phase of a larger project involving older people with complex care needs, their carers, and government and non-government stakeholders. The paper outlines key considerations regarding (1) the involvement of older people with complex needs, (2) collaboration with industry partners, (3) engagement of government representatives, and (4) reflects on implementing participatory research projects within a context of outsourcing and interlinked supply chains. While not all challenges encountered could be resolved, the coproduction approach was successful in bringing together a wide range of stakeholders with competing agendas in an iterative process geared to resolve a plethora of concerns raised by older people, carers and services providers. This paper provides an example for others seeking to use coproduction and participatory methods to provide person-centred care services for older people.

It's here! Are we ready? Five case studies of health promotion practices that address climate change from within Victorian health care settings

Issue addressed: Climate changes and environmental degradation caused by anthropogenic activities are having an irrefutable impact on human health. The critical role played by health promotion in addressing environmental challenges has a history in seminal charters − such as the Ottawa Charter for Health Promotion − that explicitly link human well-being with the natural environment. The lack of documented practice in this field prompted an investigation of health promotion practice that addresses climate change issues within health care settings.

Methods: This qualitative study involved five case studies of Victorian health care agencies that explicitly identified climate change as a priority. Individual and group interviews with ten health promotion funded practitioners as well as document analysis techniques were used to explore diverse practices across these rural, regional and urban health care agencies.

Results: Health promotion practice in these agencies was oriented toward: active and sustainable transport; healthy and sustainable food supply; mental health and community resilience; engaging vulnerable population groups such as women; and organisational development.

Conclusion: Despite differences in approach, target population and context, the core finding was that health promotion strategies, competencies and frameworks were transferable to action on climate change in these health care settings.

Detecting and managing depressed patients : palliative care nurses' self-efficacy and perceived barriers to care

Background: Depression is a highly prevalent yet under-recognized and under-treated psychiatric illness in patients receiving palliative care. Nurses are the front-line health care professionals in these settings and are well-positioned to detect depressive symptoms and initiate pathways to care. Previous research suggests, however, that nurses' confidence and skills in relation to this task are low, and there appear to be a number of barriers within these settings that may impede nurses' engagement in this process.

Methods: To further investigate these factors, a quantitative study was carried out with 69 palliative care nurses from three palliative care services in Australia.

Results: A number of issues were identified, including the need for further training in the signs and symptoms of depression, issues around discussing depression with patients and their family members, and difficulty differentiating depressive symptoms from grief.

Conclusion: These findings provide insight into specific areas in which palliative care nurses would benefit from further training to improve detection rates for depression in this vulnerable population.

Gender differences in financial barriers to primary health care in New Zealand

Gender differences in health status and use of health care services have been established in the developed world; less attention, however, has been paid to gender differences in financial barrier to primary health care. Such barrier, however, represent potentially avoidable mortality and morbidity. This paper aims to examine gender differences in financial barrier to primary health care in New Zealand.