Ethical decision making and health care managers : developing managerial profiles based on ethical frameworks and other influencing factors

Whether the community is looking for “scapegoats” to blame, or seeking more radical and deeper causes, health care managers are in the firing line whenever there are woes in the health care sector. The public has a right to question whether ethics have much influence on the everyday decision making of health care managers. This thesis explores, through a series of published papers, the influence of ethics and other factors on the decision making of health care managers in Australia. Critical review of over 40 years of research on ethical decision making has revealed a large number of influencing factors, but there is a demonstrable lack of a multidimensional approach that measures the combined influences of these factors on managers. This thesis has developed an instrument, the Managerial Ethical Profile (MEP) scale, based on a multidimensional model combining a large number of influencing factors. The MEP scale measures the range of influences on individual managers, and describes the major tendencies by developing a number of empirical profiles derived from a hierarchical cluster analysis. The instrument was developed and refined through a process of pilot studies on academics and students (n=41) and small-business managers (n=41), and then was administered to the larger sample of health care managers (n=441). Results from this study indicate that Australian health care managers draw on a range of ethical frameworks in their everyday decision making, forming the basis of five MEPs (Knights, Guardian Angels, Duty Followers, Defenders, and Chameleons). Results from the study also indicate that the range of individual, organisational, and external factors that influence decision making can be grouped into three major clusters or functions. Cross referencing these functions and other demographic data to the MEPs provides analytical insight into the characteristics of the MEPs. These five profiles summarise existing strengths and weaknesses in managerial ethical decision making. Therefore identifying these profiles not only can contribute to increasing organisational knowledge and self-awareness, but also has clear implications for the design and implementation of ethics education and training in large scale organisations in the health care industry.

Associations between perception of wellness and health-related quality of life, comorbidities, modifiable lifestyle factors and demographics in older Australians

Aim: The associations between perceived wellness and health-related quality of life, comorbidities and modifiable lifestyle factors in older adults were explored. Methods: Self-administered questionnaires including the Perceived Wellness Survey and the 36-Item Short Form of the Medical Outcomes Study version two were distributed to 328 community-living adults aged 65 years and over. Results: Results showed positive associations between perception of wellness and health-related quality of life. General health (r(249) = 0.66, P < 0.01), vitality (r(249) = 0.59, P < 0.01) and mental health (r(249) = 0.52, P < 0.01) had the strongest association; and social functioning (r(249) = 0.3, P < 0.01) and pain (r(249) = 0.36, P < 0.01) the lowest. Perceived wellness was influenced by hearing, mobility, memory, chronic disease, exercise, gambling and single status. Conclusion: The study identified that perceived wellness in older adults is a multidimensional construct.

Dose response relationships between physical activity, walking and health-related quality of life in mid-age and older women

Background Although physical activity is associated with health-related quality of life (HRQL), the nature of the dose-response relationship remains unclear. This study examined the concurrent and prospective dose-response relationships between total physical activity (TPA) and (only) walking with HRQL in two age cohorts of women. Methods Participants were 10,698 women born in 1946-1951 and 7,646 born in 1921-1926, who completed three mailed surveys for the Australian Longitudinal Study on Women's Health. They reported weekly TPA minutes (sum of walking, moderate, and vigorous minutes). HRQL was measured with the Medical Outcomes Study Short-Form 36 Health Status Survey (SF-36). Linear mixed models, adjusted for socio-demographic and health-related variables, were used to examine associations between TPA level (none, very low, low, intermediate, sufficient, high, and very high) and SF-36 scores. For women who reported walking as their only physical activity, associations between walking and SF-36 scores were also examined. Results Curvilinear trends were observed between TPA and walking with SF-36 scores. Concurrently, HRQL scores increased significantly with increasing TPA and walking, in both cohorts, with increases less marked above sufficient activity levels. Prospectively, associations were attenuated although significant and meaningful improvements in physical functioning and vitality were observed across most TPA and walking categories above the low category. Conclusion For women in their 50s-80s without clinical depression, greater amounts of TPA are associated with better current and future HRQL, particularly physical functioning and vitality. Even if walking is their only activity, women, particularly those in their 70s-80s, have better health-related quality of life.

Scandals, public inquiries and health professional regulation

Since 1980 there has been an increasing incidence of the use of public inquiries as a process through which scandals raising patient safety and health care quality concerns can be subject to highly public scrutiny. The use of public inquiries and their impact on the governance of health or social systems, especially around issues of patient or client safety, has been examined by a number of commentators (Butler and Drakeford 2003, Masso and Eager 2009, Stanley and Manthorpe 2004, Walshe and Higgins 2002) but public inquiries into scandals in the health system also raise a question about the impact of these inquiries on public perceptions about the adequacy of the various mechanisms for health professional regulation...

School nurses and health education : the classroom experience.

Objective: The aim of the study is to explore school nurses’ experience of health education. Design: A qualitative approach; phenomenology was used to answer the question. Method: Sixteen participants were recruited through purposeful and snowball sampling. Participants undertook an audio-recorded interview which was transcribed and analysed. Results: Five themes represent school nurses’ experience of health education. Within these five themes, three issues were identified by the participants as having a negative impact on their experience of health education. These were: (1) feeling unwanted by the school; (2) not supported by the school hierarchy; and (3) a lack of role definition. Conclusion: These three issues provide important insight into school nurses’ experience of health education and have implications for other school nurses and professionals in the school environment.

Barriers and facilitators to diabetes self-management: Perspectives of older community dwellers and health professionals in China

Little is known about self-management among people with Type 2 diabetes living in mainland China. Understanding the experiences of this target population is needed to provide socioculturally relevant education to effectively promote self-management. The aim of this study was to explore perceived barriers and facilitators to diabetes self-management from both older community dwellers and health professionals in China. Four focus groups, two for older people with diabetes and two for health professionals, were conducted. All participants were purposively sampled from two communities in Shanghai, China. Six barriers were identified: overdependence on but dislike of western medicine, family role expectations, cuisine culture, lack of trustworthy information sources, deficits in communication between clients and health professionals, and restriction of reimbursement regulations. Facilitators included family and peer support, good relationships with health professionals, simple and practical instruction and a favourable community environment. The findings provide valuable information for diabetes self-management intervention development in China, and have implications for programmes tailored to populations in similar sociocultural circumstance.

Socioeconomic status and health outcomes in a developing country

Although the relationship between socioeconomic status (SES) and health is well documented for developed countries, less evidence has been presented for developing countries. The aim of this paper is to analyse this relationship at the household level for Fiji, a developing country in the South Pacific, using original household survey data. To allow for the endogeneity of SES status in the household health production function, we utilize a simultaneous equation approach where estimates are achieved by full information maximum likelihood. By restricting our sample to one, relatively small island, and including area and district hospital effects, physical geography effects are unpacked from income effects. We measure SES, as permanent income which is constructed using principal components analysis. An alternative specification considers transitory household income. We find that a 1% increase in wealth (our measure of permanent income) would lead to a 15% decrease in the probability of an incapacitating illness occurring intra-household. Although the presence of a strong relationship indicates that relatively small improvements in SES status can significantly improve health at the household level, it is argued that the design of appropriate policy would also require an understanding of the various mechanisms through which the relationship operates.

The Cuban Revolution and Internationalism: Structuring Education and Health

The Capacity to Share is the first book to document how Cubans share their highly developed educational services with other low-income states, especially those in Africa, Latin America, and the Caribbean. A variety of international and Cuban authors break new ground in presenting this research. They investigate the experiences of people who have studied in Cuba on scholarships from the Cuban government, the implications for their home countries, and the work of Cuban teachers and administrators to support education in other countries. The authors discuss how the Cuban "solidarity" approach prioritizes global educational cooperation for mutual support, rather than imposing conditional aid. The book offers original and unusual insights into issues of culture, education, aid, development, and change as they relate to low-income states.

Labour, social and health outcomes of immigrants in Australia : effects of language proficiency using the IV approach

Language has been of interest to numerous economists since the late 20th century, with the majority of the studies focusing on its effects on immigrants’ labour market outcomes; earnings in particular. However, language is an endogenous variable, which along with its susceptibility to measurement error causes biases in ordinary-least-squares estimates. The instrumental variables method overcomes the shortcomings of ordinary least squares in modelling endogenous explanatory variables. In this dissertation, age at arrival combined with country of origin form an instrument creating a difference-in-difference scenario, to address the issue of endogeneity and attenuation error in language proficiency. The first half of the study aims to investigate the extent to which English speaking ability of immigrants improves their labour market outcomes and social assimilation in Australia, with the use of the 2006 Census. The findings have provided evidence that support the earlier studies. As expected, immigrants in Australia with better language proficiency are able to earn higher income, attain higher level of education, have higher probability of completing tertiary studies, and have more hours of work per week. Language proficiency also improves social integration, leading to higher probability of marriage to a native and higher probability of obtaining citizenship. The second half of the study further investigates whether language proficiency has similar effects on a migrant’s physical and mental wellbeing, health care access and lifestyle choices, with the use of three National Health Surveys. However, only limited evidence has been found with respect to the hypothesised causal relationship between language and health for Australian immigrants.

Aboriginal and Torres Strait Islander people in Australia, education and health literacy

Health literacy is a vital tool to build health knowledge and enable empowerment in health decision making at a community and individual level. There are different views of what constitutes health literacy with the most inclusive addressing broadly the skills and competencies required “to seek out, comprehend, evaluate, and use health information and concepts to make informed choices, reduce health risks, and increase quality of life” (Zarcadoolas 2005). Poor health literacy has been shown to impact health seeking behaviour, access and awareness to preventive health.

Study protocol : establishing good relationships between patients and health care providers while providing cardiac care. Exploring how patient-clinician engagement contributes to health disparities between indigenous and non-indigenous Australians in South Australia

Abstract Background: Studies that compare Indigenous Australian and non-Indigenous patients who experience a cardiac event or chest pain are inconclusive about the reasons for the differences in-hospital and survival rates. The advances in diagnostic accuracy, medication and specialised workforce has contributed to a lower case fatality and lengthen survival rates however this is not evident in the Indigenous Australian population. A possible driver contributing to this disparity may be the impact of patient-clinician interface during key interactions during the health care process. Methods/Design: This study will apply an Indigenous framework to describe the interaction between Indigenous patients and clinicians during the continuum of cardiac health care, i.e. from acute admission, secondary and rehabilitative care. Adopting an Indigenous framework is more aligned with Indigenous realities, knowledge, intellects, histories and experiences. A triple layered designed focus group will be employed to discuss patient-clinician engagement. Focus groups will be arranged by geographic clusters i.e. metropolitan and a regional centre. Patient informants will be identified by Indigenous status (i.e. Indigenous and non-Indigenous) and the focus groups will be convened separately. The health care provider focus groups will be convened on an organisational basis i.e. state health providers and Aboriginal Community Controlled Health Services. Yarning will be used as a research method to facilitate discussion. Yarning is in congruence with the oral traditions that are still a reality in day-to-day Indigenous lives. Discussion: This study is nestled in a larger research program that explores the drivers to the disparity of care and health outcomes for Indigenous and non-Indigenous Australians who experience an acute cardiac admission. A focus on health status, risk factors and clinical interventions may camouflage critical issues within a patient-clinician exchange. This approach may provide a way forward to reduce the appalling health disadvantage experienced within the Indigenous Australian communities. Keywords: Patient-clinician engagement, Qualitative, Cardiovascular disease, Focus groups, Indigenous

A cross-discipline and collaborative approach to identifying the predictors of environmentally friendly and health protective behaviour

Background. As a society, our interaction with the environment is having a negative impact on human health. For example, an increase in car use for short trips, over walking or cycling, has contributed to an increase in obesity, diabetes and poor heart health and also contributes to pollution, which is associated with asthma and other respiratory diseases. In order to change the nature of that interaction, to be more positive and healthy, it is recommended that individuals adopt a range of environmentally friendly behaviours (such as walking for transport and reducing the use of plastics). Effective interventions aimed at increasing such behaviours will need to be evidence based and there is a need for the rapid communication of information from the point of research, into policy and practice. Further, a number of health disciplines, including psychology and public health, share a common mission to promote health and well-being. Therefore, the objective of this project is to take a cross-discipline and collaborative approach to reveal psychological mechanisms driving environmentally friendly behaviour. This objective is further divided into three broad aims, the first of which is to take a cross-discipline and collaborative approach to research. The second aim is to explore and identify the salient beliefs which most strongly predict environmentally friendly behaviour. The third aim is to build an augmented model to explain environmentally friendly behaviour. The thesis builds on the understanding that an interdisciplinary collaborative approach will facilitate the rapid transfer of knowledge to inform behaviour change interventions. Methods. The application of this approach involved two surveys which explored the psycho-social predictors of environmentally friendly behaviour. Following a qualitative pilot study, and in collaboration with an expert panel comprising academics, industry professionals and government representatives, a self-administered, Theory of Planned Behaviour (TPB) based, mail survey was distributed to a random sample of 3000 residents of Brisbane and Moreton Bay Region (Queensland, Australia). This survey explored specific beliefs including attitudes, norms, perceived control, intention and behaviour, as well as environmental altruism and green identity, in relation to walking for transport and switching off lights when not in use. Following analysis of the mail survey data and based on feedback from participants and key stakeholders, an internet survey was employed (N=451) to explore two additional behaviours, switching off appliances at the wall when not in use, and shopping with reusable bags. This work is presented as a series of interrelated publications which address each of the research aims. Presentation of Findings. Chapter five of this thesis consists of a published paper which addresses the first aim of the research and outlines the collaborative and multidisciplinary approach employed in the mail survey. The paper argued that forging alliances with those who are in a position to immediately utilise the findings of research has the potential to improve the quality and timely communication of research. Illustrating this timely communication, Chapter six comprises a report presented to Moreton Bay Regional Council (MBRC). This report addresses aim's one and two. The report contains a summary of participation in a range of environmentally friendly behaviours and identifies the beliefs which most strongly predicted walking for transport and switching off lights (from the mail survey). These salient beliefs were then recommended as targets for interventions and included: participants believing that they might save money; that their neighbours also switch off lights; that it would be inconvenient to walk for transport and that their closest friend also walks for transport. Chapter seven also addresses the second aim and presents a published conference paper in which the salient beliefs predicting the four specified behaviours (from both surveys) are identified and potential applications for intervention are discussed. Again, a range of TPB based beliefs, including descriptive normative beliefs, were predictive of environmentally friendly behaviour. This paper was also provided to MBRC, along with recommendations for applying the findings. For example, as descriptive normative beliefs were consistently correlated with environmentally friendly behaviour, local councils could engage in marketing and interventions (workshops, letter box drops, internet promotions) which encourage parents and friends to model, rather than simply encourage, environmentally friendly behaviour. The final two papers, presented in Chapters eight and nine, addresses the third aim of the project. These papers each present two behaviours together to inform a TPB based theoretical model with which to predict environmentally friendly behaviour. A generalised model is presented, which is found to predict the four specific behaviours under investigation. The role of demographics was explored across each of the behaviour specific models. It was found that some behaviour's differ by age, gender, income or education. In particular, adjusted models predicted more of the variance in walking for transport amongst younger participants and females. Adjusted models predicted more variance in switching off lights amongst those with a bachelor degree or higher and predicted more variance in switching off appliances amongst those on a higher income. Adjusted models predicted more variance in shopping with reusable bags for males, people 40 years or older, those on a higher income and those with a bachelor degree or higher. However, model structure and general predictability was relatively consistent overall. The models provide a general theoretical framework from which to better understand the motives and predictors of environmentally friendly behaviour. Conclusion. This research has provided an example of the benefits of a collaborative interdisciplinary approach. It has identified a number of salient beliefs which can be targeted for social marketing campaigns and educational initiatives; and these findings, along with recommendations, have been passed on to a local council to be used as part of their ongoing community engagement programs. Finally, the research has informed a practical model, as well as behaviour specific models, for predicting sustainable living behaviours. Such models can highlight important core constructs from which targeted interventions can be designed. Therefore, this research represents an important step in undertaking collaborative approaches to improving population health through human-environment interactions.