Negotiating collective and individual agency : a qualitative study of young women's reproductive health in rural India

The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.

Amalgamation of health services in South-West Victoria: reinvention or survival?

In Australia 'the hospital' has long been considered the cornerstone of small, rural health services. However, this premise has been altered significantly by the introduction of casemix loading and diagnostic-related groups that promote a rationalised output-based model of management. In the light of these changes, many rural health services have struggled to reinvent themselves by establishing a range of service models such as Multi-purpose Service (MPS) and Health Streams, while maintaining traditional models (i.e. bush nursing centres, nursing homes and aged-care facilities). These changes are about survival. This paper analyses one such case in south-west Victoria, the Macarthur and District Community Outreach Service, and compares the outcomes with other similar Victorian rural health research projects. Particular attention is paid to the nature of the health services, the management of change and the proposed health outcomes for the local rural communities. In conclusion, it is argued that this study adds to the body of knowledge surrounding the construction of models of community health and development programming, These models impact upon future rural and remote area initiatives throughout Australia.

The role and theoretical evolution of knowledge translation and exchange in public health

Background There is an increased emphasis in public health research on effective models and strategies to support knowledge translation (KT), the exchange, synthesis and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users. In other words, KT can be seen as an acceleration of the knowledge cycle—an acceleration of the natural transformation of knowledge into use (Canadian Institutes of Health Services Research. Knowledge Translation Strategy, 2004). The most recent conceptualizations consider the complexities of public health decision-making. The role of practitioners and communities is increasingly considered.

Methods We identify, describe and discuss the theoretical underpinnings of KT and recommend a way forward to build the evidence for more effective practice.

Results Theoretical perspectives increasingly influence research on KT in public health. A range of innovative work is being conducted to explore methods for KT using practical tools, often with the support of government.

Conclusions KT describes a crucial and to date under-developed element of the research process. There is an important gap in theoretically informed empirical studies of effectiveness of proposed approaches in public health, health promotion and preventive medicine, and thus much of the debate remains abstract. There is clearly an urgent policy need to establish the effectiveness of KT models in a range of contexts. This must include both the consideration of development and the utilization of knowledge.

The health and well-being of adolescents: a school-based population study of the self-report child health questionnaire

Purpose: To evaluate a new generic measure of adolescent health status, the self-report version of the Child Health Questionnaire (CHQ), and provide population-based data. Furthermore, we aimed to examine the impact of common adolescent illness and health concerns on their health and well-being.

Methods: A stratified, two-stage, random cluster sampling design was used to obtain a cross-sectional sample of subjects through schools. A written questionnaire included the 80-item 12-scale self-report CHQ and items measuring health concerns, illnesses/health conditions, and sociodemographics.

Results: A total of 2361 adolescents participated (response rate of 70%). Reliability was high: Tests of internal consistency and discriminant validity reported 90% of item-scale correlations >.4; all scales had Cronbach alpha coefficients >.7. Adolescents with illnesses/conditions or health concerns reported lower scores and larger differences for content-related scales, supporting content and construct validity. Statistically significant age and gender trends were observed for Mental Health, Self-Esteem, General Health, and Family Cohesion scales. Health status worsened as health concerns increased (X2 linear trend, p = .00) with deterioration in health of 5–20% on all scales for emotional health concerns (40% of sample).

Conclusions: The self-report CHQ is a reliable and seemingly valid measure of health and well-being for adolescent health research, although additional measures may be required where scales have high ceiling values. The significantly lower scores reported by adolescents with illness and/or health concerns lend support to the use of standardized health measures and longitudinal research to further examine the impact of adolescent comorbidities and their causal determinants.

New money for mental health : will it make things better for rural and remote Australia?

New Australian government funding for the Better Outcomes in Mental Health Care initiative is a significant step forward for mental health, with general practitioners now able to offer direct referrals to psychologists, social workers, occupational therapists and Aboriginal health workers. Incentives for better teamwork between GPs and other mental health professionals have been introduced, but may have unintended consequences, including an exacerbation of workforce shortages in rural and remote areas. Possible solutions to these shortages include rural scholarships for students in the mental health professions; recruitment and retention of students coordinated by university departments of rural health; better access to continuing professional development; and federally funded rural positions and additional financial incentives for rural mental health practitioners.

Cervical cancer services for Indigenous Women: Advocacy, Community-Based Research and Policy Change in Australia

Collaborative research undertaken in the state of Queensland, Australia, resulted in major changes in cervical cancer screening and treatment for Indigenous women. Guided by an Indigenous statewide reference group and with an Indigenous researcher playing a lead role, qualitative data were collected using interviews, focus groups, and larger community meetings; and case studies were conducted with health workers and community members from diverse rural, remote and urban communities, to explore the different cultural and structural factors affecting understanding and awareness of cervical cancer and Indigenous women's use of and access to health services for screening, diagnosis and treatment. These data were supplemented by an analysis of clinical data and health service checklists. We discuss the methodology and summarize the key social and structural factors that discourage women from presenting for screening or returning for follow-up. These include women's misunderstanding of cervical cancer screening, fear of cancer, distrust of health services, poor recall and follow-up systems, and the economic and social burden to women presenting for treatment. We describe how the research process and subsequent activities provided Indigenous women with a vehicle for their own advocacy, resulting in important policy and program changes.

Understanding environmental influences on walking - Review and research agenda

Background
Understanding how environmental attributes can influence particular physical activity behaviors is a public health research priority. Walking is the most common physical activity behavior of adults; environmental innovations may be able to influence rates of participation.

Method
Review of studies on relationships of objectively assessed and perceived environmental attributes with walking. Associations with environmental attributes were examined separately for exercise and recreational walking, walking to get to and from places, and total walking.

Results
Eighteen studies were identified. Aesthetic attributes, convenience of facilities for walking (sidewalks, trails); accessibility of destinations (stores, park, beach); and perceptions about traffic and busy roads were found to be associated with walking for particular purposes. Attributes associated with walking for exercise were different from those associated with walking to get to and from places.

Conclusions
While few studies have examined specific environment–walking relationships, early evidence is promising. Key elements of the research agenda are developing reliable and valid measures of environmental attributes and walking behaviors, determining whether environment–behavior relationships are causal, and developing theoretical models that account for environmental influences and their interactions with other determinants.

Communication outside the humanities in media 'effect' research

This paper draws on the case study of a recent review of research literature on the influences (harms and benefits) on children and families of electronic media content and usage, undertaken on behalf of a Federal regulatory body (Australian Communications and Media Authority) by a multidisciplinary research team. Recent critiques of psychological studies of children and media have challenged the positivist social sciences to look outside of their own disciplinary warrants and to fully answer cultural studies critiques of ‘media effects’ research. Making connections outside the humanities in this case study involved making the rationales of communications and cultural studies methodologies available to those policy makers who normally may not consider such findings to be evidence-based or policy relevant. But it also involved providing a historical and institutional contextualization of positivist social and medical science findings, a contextualization not enabled by the underlying warrants and discourses of these disciplines. This paper focuses on those sections of the case study project concerned with psychological research on the effects of violent media and epidemiological and public health research on childhood obesity.

Have the health services reoriented at all?

Recently, I had an opportunity to observe the workings of the health care system from the inside. I was admitted to a mixed surgical ward in an Australian public hospital with a mysterious ailment. My personal health required acute promotion.

My participant observation research demonstrated that the calls for action in the Ottawa Charter are still urgent. The Charter, twenty three years ago, stated

The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health.

The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components.

Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services which refocuses on the total needs of the individual as a whole person.

Building collaborative partnerships: a key to increasing Indigenous Victorian peoples' access to country

This article reports on a qualitative research study undertaken with Indigenous government employees to explore ways in which Indigenous communities can access programs involving caring for Country' (knowledge, responsibility and inherent right to protect the traditional natural landscape) on their traditional land and, in so doing. improve their health. Factors that optimise such nature-based projects are the capacity of their intention to build relationships, consultation. transparency, consistency, education and training between Indigenous communities. government and the general public. Government agencies need to develop strategies where partnership and collaboration are effective with Indigenous communities and within the agencies themselves, in order to resolve controversial issues surrounding access to Country.

Folate fortification : a case study of public health policy-making

This thesis investigates the use of scientific evidence in the process of making public health policy. A case study located within a food regulation setting is used. The aim is to test theory against this case study. The outcome is a theoretical understanding of the use of scientific evidence in the policy-making process in a food regulation setting. Food regulation can influence food composition and food labelling and thereby affect the population's dietary intake. Frequently there are contested values, beliefs, ideologies and interests among stakeholders regarding the use of food regulation as a policy instrument to effect public health outcomes. The protection of public health and safety, taking into account evidence based practice, is generally employed by food regulators as the priority objective during the policy-making process to adjudicate among the competing expectations of stakeholders. However, this policy objective has not been clearly defined and is vulnerable to interpretation and application. The process by which folate fortification policy was made in Australia, in response to epidemiological evidence of a relationship between folate intake during the periconceptional period and reduced risk of neural tube defects, was analysed as a case study of the policy-making process. The folate fortification policy created a precedent for both food fortification and subsequently health claims policy in Australia. A social constructivist method was used to analyse the case study. The method involved deconstructing the food regulatory system into three levels; decision-making process; procedural; and political environment. Data aligned with each level of analysis was collected from 22 key informant interviews, documentary sources, field notes and surveys of both a random sample of the Australian population's knowledge of folate and use of folic acid-containing supplements (n = 5422), and the implementation of folate fortified food products into stores (n = 60). The insights that emerged from each of the three levels of analysis were assessed iteratively to identify a pattern of interrelationships associated with the policy-making process within the food regulatory system. The identified pattern was interpreted against existing theory to gain a theoretical understanding of the public health policy-making process in this political setting. The central argument of this thesis extends Sabatier and Jenkins-Smith's Advocacy Coalition Framework theory to a food regulation setting. The argument is that within the contemporary political climates of neoliberalism and globalisation, a coalition between corporate interests and the values of scientists with a positivist-reductionist approach to public health research is privileged so as to invoke certain scientific evidence to, in turn, legitimise food regulation policy decisions. The theory will help to inform policy-makers about how and why the public health policy objective in a food regulation setting is interpreted and applied. This will contribute to improving policy practice intended to effect public health outcomes. It is concluded that irrespective of the quantity and quality of the scientific evidence that is being made available, scientific evidence cannot be assumed to speak for itself Policy-making is an inherently political and value-laden process and the potential for politically motivated interpretation and application of otherwise value-neutral scientific evidence can undermine the investment in its generation. From this perspective, evidence based practice, far from liberating policy-making from political influence, can itself become part of the problem rather than the solution. Nevertheless, rational evidence based practice is an ideal to strive for and a series of recommendations is proposed to help make the use of evidence in current food regulation policy processes more transparent and democratic.