Improving supportive care for women with breast cancer in Australia: The challenge of modifying health systems

Although the benefits of many psychosocial support strategies in improving well being in women with breast cancer have been demonstrated, few women receive these programs as part of routine care. This paper provides some recommendations, based on experience in Australia, about how access to evidence-based supportive care strategies might be improved through modification of health systems. It demonstrates the paucity of research about the costs and health service implications of psychosocial support strategies, which is vital to health planning and service delivery change. It outlines the systematic approach taken in Australia to improving psychosocial support nationally by: the development of research reviews; preparation of guidelines about supportive care, implementation of programs to foster the adoption of guidelines through modification of policy, health service delivery and clinician training; and monitoring programs. Coalitions of government, health care professionals and consumers are key to effective lobbying for change. If all women with breast cancer are to receive better supportive care, there is a need for approaches which: refocus the research effort in psycho-oncology; develop more strategic approaches to generating change in health systems and health policy and foster partnerships to advocate for improved resources. Copyright (C) 2003 John Wiley Sons, Ltd.

Adverse Health Effects of Chronic Exposure to Low-Level Cadmium in Foodstuffs and Cigarette Smoke

Cadmium is a cumulative nephrotoxicant that is absorbed into the body from dietary sources and cigarette smoking. The levels of Cd in organs such as liver and kidney cortex increase with age because of the lack of an active biochemical process for its elimination coupled with renal reabsorption. Recent research has provided evidence linking Cd-related kidney dysfunction and decreases in bone mineral density in nonoccupationally exposed populations who showed no signs of nutritional deficiency. This challenges the previous view that the concurrent kidney and bone damage seen in Japanese itai-itai disease patients was the result of Cd toxicity in combination with nutritional deficiencies, notably, of zinc and calcium. Further, such Cd-linked bone and kidney toxicities were observed in people whose dietary Cd intakes were well within the provisional tolerable weekly intake (PTWI) set by the Joint Food and Agriculture Organization/World Health Organization Expert Committee on Food Additives of 1 mug/kg body weight/day or 70 mug/day. This evidence points to the much-needed revision of the current PTWI for Cd. Also, evidence for the carcinogenic risk of chronic Cd exposure is accumulating and Cd effects on reproductive outcomes have begun to emerge.

Introducing evidence-based family assessment and therapy in child and youth mental health services: Applying systemic principles to maintain, sustain and build capacity

The purpose of this article is to overview the context of the mental health service in which we work, and family therapy's status prior to and after the impact of changes wrought by the introduction of the National Mental Health Policy. We then explore some key issues that we think contribute to the persistence of the occlusion of family therapy in child psychiatric services; and the strategies that we developed and are continuing to develop to support change, finally, we describe the use of a family assessment instrument that we believe is central to our change strategy.

A phenomenology of crack abuse

The aim of this dissertation is to identify, describe, and explain the common experiences defining the crack abuser's life-world. Its method is phenomenological. Using basic cybernetic premises, a neurophysiologically oriented phenomenological framework concerning the constitution of thoughts, memories, and perceptions is first written. The framework is designed to hypothetically represent the neuropathology of crack abuse within a perspective that prescinds and describes the constitution, flow, and interdependence of experience. After the framework is written, the dissertation outlines the neuro-psychopharmacology of crack abuse and delimits crack abusers as a specific group within the more general population of cocaine users. It then represents the neuropathology of crack abuse within its phenomenological framework and uses the first-person accounts of forty-two crack dependents to actualize a phenomenological sketch of the crack abuser's life-world. The ethnographies afford the possibility of writing a “thick” description of the crack abuser's daily life—one that communicates the substance, order, and subjective and cultural dimensions of the dependent's defining experiences. ^ The dissertation's goals are successfully realized. The framework written and the ethnographies recorded and transcribed, the dissertation is able to identify, describe, and to a certain extent explain some of the common experiences defining the crack abusers life-world. The dissertation concludes that the crack abuser's life-world is organized around three primary and four secondary experiences. His primary experiences include: (1) an almost complete, yet fleeting, satisfaction of the ego's innate insufficiency and sublime, erotic-like stimulation of its core, (2) a fundamental inclination and expansion of the uniquely oriented euphoria-dysphoria dynamic that vivifies and orients the flow of consciousness, and (3) a change in the ego's innate structure. His secondary experiences include: (a) a characteristic aiming of projects, actions, and conduct toward the procurement and consumption of crack, (b) a denigration in the hold of legitimations and institutionalizations on the thematic field, (c) a strict alignment and a contraction in the scope of logical types pointing to the salient experiences within the stock of knowledge, and (d) for some crack abusers, ontological insecurity, despair, and exhaustion. ^

The health and nutritional status of multiethnic perimenopausal women

An integrated, dual-phase study design assessed the health and nutritional status and practices of African-American (A-A), Caribbean (A-C), and white non-Hispanic (W-A) women during perimenopause (40–55 years). During Phase I, four focus groups (n = 37) of male and female participants discussed the health and social implications of perimenopause. A conceptual framework for the main study (Phase II) was developed from the focus groups' findings, in concert with the main study's specific aims and objectives. ^ The main study, a cross-sectional survey, quantitatively assessed the health and nutritional status of a convenience sample of 109 women (25 A-A, 31 A-C and 53 W-A), who met specific eligibility criteria. Using seven instruments, sociodemographic, dietary, medical, reproductive health, health practice and anthropometric data were collected. ^ The groups were of comparable age, education, and socioeconomic status (SES). Despite these similarities, statistically significant interethnic nutritional status differences were found. Significantly more total energy and energy from fat were consumed by A-A than W-A and A-C women. Also, significantly more A-A and A-C than W-A women were overweight or obese with android-type weight patterning. ^ Overall, iron and calcium Recommended Dietary Allowances (RDA's) were not met by 35% and 68% of participants, respectively. Iron deficiency anemia was reported by 29% of participants while 33% reported heavier menstrual bleeding. Coupled with suboptimal iron intakes, this is likely to present a serious public health problem. Similarly, increased bone demineralization characteristic of perimenopause, coupled with suboptimal calcium intakes could precipitate another public health problem, osteoporosis. ^ Participants had different expectations about the role of medical care during perimenopause. Significantly more white (57%) than black (38% [A-A and AC]) women sought medical attention for symptoms. Whereas Hormone Replacement Therapy (HRT) was prescribed for 25% of them, only 13% were compliant at enrollment. ^ The trends and statistically significant findings of this study have huge public health policy implications. It is imperative that appropriate policies are formulated to ensure that America's ethnically diverse perimenopausal women have ready access to culturally appropriate care. This would optimize their health outcomes, and enhance their quality of life and productive capacities at this critical juncture of their lives. ^

The effectiveness of an enhanced cognitive behavioral intervention in improving behavioral outcomes related to HIV prevention

This study analyzed outcomes of an enhanced cognitive-behavioral intervention with dually diagnosed severely mentally ill adults. It specifically addressed the improvement of attitudes, skills, self-efficacy to use condoms and the heightening of condom use. The data were analyzed via a randomized three-group repeated measures design composed of the experimental (E-CB), standard care (SC) comparison or a no-treatment control condition as the between-subjects variable and pre-post measure as the within-subjects variable. The E-CB focused on cooperative, application, hands-on, skill-building and role-playing activities for sexual assertiveness, negotiation in risk-taking and proper condom use. The SC comparison, was didactic in its approach and addressed risk-taking and proper condom use in one session, but did not involve application approaches to problem-solving risky situations or condom use. Multiple assessments were conducted at pre-, post- and six months post-intervention. ^ The analysis indicated that the E-CB intervention led to more favorable attitudes toward condoms and to improved and maintained skills regarding their use by participants six months after the intervention compared to the standard care and control groups. No significant improvements in self-efficacy were found. A repeated measures ANOVA conducted on the transformed values of percentage of vaginal condom use indicated no significant differences between the experimental and standard care conditions but both had a significantly higher mean percentage vaginal condom use than the control group, averaged across pre- and six-month post-intervention. No gender differences were seen in attitudes, skills or self-efficacy to use condoms. ^ This study shed light upon the effectiveness of the instructional approach for the enhancement of attitudes, skills and self-efficacy outcomes related to HIV prevention. For heightened effectiveness, future approaches must address multiple factors impacting learning in this population. ^

Living positive: Life in community among Puerto Rican men living with HIV in Boston

Negative experiences of stigmatization, discrimination, and rejection are common among people living with HIV in the United States, and particularly when they are also members of a minority group. Some three decades after the first cases of AIDS were identified, people infected with HIV continue to be perceived and characterized negatively. While an HIV/AIDS diagnosis is typically associated with negativity, this study investigates the extent to which collective experiences among HIV-positive people result in healthy responses and positive social adjustment. This study is focused on the ways in which HIV-positive Puerto Rican men in Boston live positive despite being diagnosed with HIV. Rather than wrapping themselves in the social stigma of HIV and the isolation that entails, they participate in processes that affirm themselves and their peers. In so doing, they help generate both healthy and meaningful lives for themselves and others. The study examines the process in which Puerto Rican men living with HIV in Boston participate, promote, and reaffirm an HIV community, la comunidad, as a social entity with a unique culture and identity. This study also investigates how this community influences, supports, and encourages the adoption of positive transformations for living long term with HIV. On the basis of nine months of field research, this qualitative study employed both focus groups and interviews with fifty HIV-positive Puerto Rican men in Boston. These men were recruited, using convenience sampling, from different community-based organizations (CBOs) that provide HIV/AIDS services in Boston. The study finds that HIV-positive Puerto Rican men in Boston build community, not in response to social exclusion, but built on shared positive practices and strategies for living healthy with HIV. These men come together to negotiate and form a unique cultural community expressed in norms, beliefs, and practices that, although centered on HIV, are designed for living healthy. These expressions reaffirm a sense of community in everyday settings and transform the lives of these men with positive behaviors and healthy lifestyles. The findings reveal that this transformation takes place in the context of a community, with the support, encouragement, and at times, policing of others. La comunidad is where the lives of these men are transformed as they learn, adopt, and experience living positive with HIV.

Medical advice, diabetes self-management, and health outcomes of a multi-ethnic population from the National Health and Nutrition Examination Survey 2007--2008

Diabetes self-management, an essential component of diabetes care, includes weight control practices and requires guidance from providers. Minorities are likely to have less access to quality health care than White non-Hispanics (WNH) (American College of Physicians-American Society of Internal Medicine, 2000). Medical advice received and understood may differ by race/ethnicity as a consequence of the patient-provider communication process; and, may affect diabetes self-management. ^ This study examined the relationships among participants’ report of: (1) medical advice given; (2) diabetes self-management, and; (3) health outcomes for Mexican-Americans (MA) and Black non-Hispanics (BNH) as compared to WNH (reference group) using data available through the National Health and Nutrition Examination Survey (NHANES) for the years 2007–2008. This study was a secondary, single point analysis. Approximately 30 datasets were merged; and, the quality and integrity was assured by analysis of frequency, range and quartiles. The subjects were extracted based on the following inclusion criteria: belonging to either the MA, BNH or WNH categories; 21 years or older; responded yes to being diagnosed with diabetes. A final sample size of 654 adults [MA (131); BNH (223); WNH (300)] was used for the analyses. The findings revealed significant statistical differences in medical advice reported given. BNH [OR = 1.83 (1.16, 2.88), p = 0.013] were more likely than WNH to report being told to reduce fat or calories. Similarly, BNH [OR = 2.84 (1.45, 5.59), p = 0.005] were more likely than WNH to report that they were told to increase their physical activity. Mexican-Americans were less likely to self-monitor their blood glucose than WNH [OR = 2.70 (1.66, 4.38), p<0.001]. There were differences among ethnicities for reporting receiving recent diabetes education. Black, non-Hispanics were twice as likely to report receiving diabetes education than WNH [OR = 2.29 (1.36, 3.85), p = 0.004]. Medical advice reported given and ethnicity/race, together, predicted several health outcomes. Having recent diabetes education increased the likelihood of performing several diabetes self-management behaviors, independent of race. ^ These findings indicate a need for patient-provider communication and care to be assessed for effectiveness and, the importance of ongoing diabetes education for persons with diabetes.^

Norm-based comparison of SF -12 physical and mental health scale scores for a sample of employees of Broward County

In the new health paradigm, the connotation of health has extended beyond the measures of morbidity and mortality to include wellness and quality of life. Comprehensive assessments of health go beyond traditional biological indicators to include measures of physical and mental health status, social role-functioning, and general health perceptions. To meet these challenges, tools for assessment and outcome evaluation are being designed to collect information about functioning and well-being from the individual's point of view.^ The purpose of this study was to profile the physical and mental health status of a sample of county government employees against U.S. population norms. A second purpose of the study was to determine if significant relationships existed between respondent characteristics and personal health practices, lifestyle and other health how the tools and methods used in this investigation can be used to guide program development and facilitate monitoring of health promotion initiatives.^ The SF-12 Health Survey (Ware, Kosinski, & Keller, 1995), a validated measure of health status, was administered to a convenience sample of 450 employees attending one of nine health fairs at an urban worksite. The instrument has been utilized nationally which enabled a comparative analysis of findings of this study with national results.^ Results from this study demonstrated that several respondent characteristics and personal health practices were associated with a greater percentage of physical and/or mental scale scores that were significantly "worse" or significantly "better" than the general population. Respondent characteristics that were significantly related to the SF-12 physical and/or mental health scale scores were gender, age, education, ethnicity, and income status. Personal health practices that were significantly related to SF-12 physical and/or mental scale scores were frequency of vigorous exercise, presence of chronic illness, being at one's prescribed height and weight, eating breakfast, smoking and drinking status. This study provides an illustration of the methods used to analyze and interpret SF-12 Health Survey data, using norm-based interpretation guidelines which are useful for purposes of program development and collecting information on health at the community level. ^

Health changes in Hispanic older adults in a Spanish arthritis self -management education program

Arthritis is the most common chronic condition affecting older people and is a major cause of limited activity. Arthritis education programs in English have demonstrated a positive impact on health but these programs have not reached the Hispanic communities where arthritis is the leading cause of disability. Minorities, such as Hispanics, have traditionally been reluctant to pursue self-help programs, and have been identified as an under-served population in terms of medical care. This study examined the effectiveness of one community health adult education program targeting Hispanic older adults with arthritis, the Spanish Arthritis Self Management Education Program (SASMEP), by evaluating changes in the participants' general health, pain, disability, self-efficacy, health perceptions, frequency of physician visits, and exercise. A pre and post control group experimental design and analyses of covariance were used to determine the pre and post differences in health status and health behaviors for a group participating in the SASMEP and a group who did not using gender and age as covariates. A repeated measures design was also used, and repeated measures analyses of variance and post hoc tests were done on health status and health behavior data collected pre, post and one-year post education to determine long-term differences. ^ Results indicated the participants' health status significantly improved in general health, significantly decreased in pain, and significantly decreased in arthritic disability immediately following the education. Self-efficacy and health perceptions increased for both groups but not significantly. The participants' health behaviors showed significantly fewer physician visits and significantly increased time spent performing stretching and strengthening exercise and time spent performing aerobic exercise. No group differences were found in the frequency of arthritis physician visits. ^ The improvements seen immediately after the SASMEP participation were not reflected in the post one-year scores. No significant differences were found for the participants' health status or health behaviors one year following the education. Health status and health behaviors did not return below baseline scores after one year suggesting the participants' health, although not improved, did not deteriorate. Therefore, the SASMEP education provided short-term health benefits for older Hispanic adults with arthritis, but not long-term health benefits. ^

Putting Adequate Financial and Human Resources in Healthcare for Effective Universal Health Coverage in Kenya: Lessons and Experiences from China

In recent years, most low and middle-income countries, have adopted different approaches to universal health coverage (UHC), to ensure equity and financial risk protection in accessing essential healthcare services. UHC-related policies and delivery strategies are largely based on existing healthcare systems, a result of gradual development (based on local factors and priorities). Most countries have emphasized on health financing, and human resources for health (HRH) reform policies, based on good practices of several healthcare plans to deliver UHC for their population.

Health financing and labor market frameworks were used, to understand health financing, HRH dynamics, and to analyze key health policies implemented over the past decade in Kenya’s effort to achieve UHC. Through the understanding, policy options are proposed to Kenya; analyzing, and generating lessons from health financing, and HRH reforms experiences in China. Data was collected using mixed methods approach, utilizing both quantitative (documents and literature review), and qualitative (in-depth interviews) data collection techniques.

The problems in Kenya are substantial: high levels of out-of-pocket health expenditure, slow progress in expanding health insurance among informal sector workers, inefficiencies in pulling of health are revenues, inadequate deployed HRH, maldistribution of HRH, and inadequate quality measures in training health worker. The government has identified the critical role of strengthening primary health care and the National Hospital Insurance Fund (NHIF) in Kenya’s move towards UHC. Strengthening primary health care requires; re-defining the role of hospitals, and health insurance schemes, and training, deploying and retaining primary care professionals according to the health needs of the population; concepts not emphasized in Kenya’s healthcare reforms or programs design. Kenya’s top leadership commitment is urgently needed for tougher reforms implementation, and important lessons from China’s extensive health reforms in the past decade are beneficial. Key lessons from China include health insurance expansion through rigorous research, monitoring, and evaluation, substantially increasing government health expenditure, innovative primary healthcare strengthening, designing, and implementing health policy reforms that are responsive to the population, and regional approaches to strengthening HRH.

Understandings of transnational families in debates on Migration and development

International migration sets in motion a range of significant transnational processes that connect countries and people. How migration interacts with development and how policies might promote and enhance such interactions have, since the turn of the millennium, gained attention on the international agenda. The recognition that transnational practices connect migrants and their families across sending and receiving societies forms part of this debate. The ways in which policy debate employs and understands transnational family ties nevertheless remain underexplored. This article sets out to discern the understandings of the family in two (often intermingled) debates concerned with transnational interactions: The largely state and policydriven discourse on the potential benefits of migration on economic development, and the largely academic transnational family literature focusing on issues of care and the micro-politics of gender and generation. Emphasizing the relation between diverse migration-development dynamics and specific family positions, we ask whether an analytical point of departure in respective transnational motherhood, fatherhood or childhood is linked to emphasizing certain outcomes. We conclude by sketching important strands of inclusions and exclusions of family matters in policy discourse and suggest ways to better integrate a transnational family perspective in global migration-development policy.

Psychology and Social Work: Applied Perspectives

Successful social work practice is underpinned by knowledge, theories and research findings from a range of related disciplines, key amongst which is psychology. This timely book offers a grounded and engaging guide to psychology s vital role at the heart of contemporary social work practice. The book skilfully addresses some of the central theoretical developments in psychology from an applied perspective, and explains how these make essential contributions to the methods and theory base of social work in ways that foster critical evaluation and promote best practice. Written by two authors with extensive backgrounds in psychology and social work respectively as well as a deep understanding of the intersections of the two this book delivers a unique synthesis of perspectives and approaches, focusing on their application to the lives of individuals and families. Each chapter contains reflective points and case studies based on contemporary practice realities which are related to the Professional Capabilities Framework for Social Workers and also to the Health and Care Professions Council s Standards of Proficiency. Times have never been more challenging for social work and this book will be an invaluable source of professional support within the ever-more complex psychological worlds where social work takes place. Table of Contents 1. Introduction: The place of psychological knowledge and research in social work training and practice 2. Signposts from Developmental Psychology on Human Development over the Life Course 3. Perspectives from Clinical and Counselling Psychology on Mental Health and Illness 4. Perspectives from Social and Community Psychology: Understanding values, attitudes, diversity and community change 5. Health Psychology: Understanding health, illness, stress and addiction 6. Organizational Psychology: Understanding the individual and the organization in the social work structure 7. Forensic Psychology: Understanding criminal behaviour and working with victims of crime 8. Conclusion References Index

Social Return on Investment: Valuing Health Outcomes or Promoting Economic Values?

Interventions and activities that influence health are often concerned with intangible outcomes that are difficult to value despite their potential significance. Social Return on Investment is an evaluation framework that explores all aspects of change and expresses these in comparable terms. It combines qualitative narratives and quantitative measurements with a financial approach to enable outcomes that can otherwise be overlooked or undervalued to be incorporated appropriately. This article presents Social Return on Investment as an effective tool for supporting the development of a holistic appreciation of how interventions impact on the health and well-being of individuals, communities and societies.