Acceptability of home-assessment post medical abortion and medical abortion in a low-resource setting in Rajasthan, India : Secondary outcome analysis of a non-inferiority randomized controlled trial

Background: Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education. Objective: To investigate women's acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India. Design: Secondary outcome of a randomised, controlled, non-inferiority trial. Setting Outpatient primary health care clinics in rural and urban Rajasthan, India. Population: Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85mg/l and were below 18 years. Methods: Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1: 1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible. Main outcome measures: Women's acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups. Results: 731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001). Conclusion: Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy.

Home truths about home detention

The Victorian Parliament has recently introduced a Bill which implements home detention as a sentencing option. Home detention is an intuitively appealing reform. The logic behind the proposal seems obvious. Prisons are expensive to run. There are too many offenders in prison. So let's take the cost out of prison by turning the homes of offenders into prisons: classic, user-pays, cost-shifting economics. The level of superficial appeal of the argument in favour of home detention is matched only by the depth of the fallacies underpinning some of the fundamental premises. The most basic of which is the assumption that offenders who are candidates for the new sanction should be in detention (of any kind) in the first place. Further, the narrow objective of reducing imprisonment is misguided. It should not be elevated to a cardinal sentencing objective?otherwise total success could be achieved by simply opening the prison gates. There are also other concerns about the appropriateness of home detention. The degree of pain it inflicts in many cases is questionable and it may also violate the principle that punishment should not be inflicted on the innocent. After examining the arguments for and against home detention, this article suggests the approach that should be adopted to achieve enlightened and meaningful sentencing reform.

Home range of the squirrel glider (Petaurus norfolcensis) in a network of remnant linear habitats

Linear strips of natural or semi-natural vegetation are a characteristic feature of rural landscapes throughout the world. Their value for the conservation of fauna in heavily modified landscapes depends on the response of species to the linear shape of the habitat, and the pressures this imposes on population processes and spatial organization. In south-eastern Australia, woodland habitats occupied by the squirrel glider Petaurus norfolcensis, a threatened species of arboreal marsupial, have been preferentially cleared for agriculture leaving only remnants within cleared farmland. In this study, the home range of P. norfolcensis was investigated by radio-tracking 40 gliders within a highly modified landscape where the majority (83%) of remaining wooded habitat occurs as a network of linear strips along roadsides and streams. Individuals were tracked for one to four seasons, resulting in the collection of 4213 independent locational 'fixes'. All fixes of animals were from remnant woodland. Home ranges were elongated and linear, primarily determined by the shape and arrangement of woodland habitat. Seasonal home ranges were small (mean of 1.4–2.8 ha) and ranged between 320 and 840 m long. Small patches of trees in farmland adjacent to the linear habitats were also extensively used. Despite the highly modified landscape structure, home ranges of P. norfolcensis in the linear network were smaller than those estimated from other studies of this species in continuous habitat. The apparent high quality of the linear habitats is attributed to the density of large old trees, which provide foraging and breeding resources, and the productivity of the environment. Linear landscape elements may have a valuable conservation function where they provide resident habitat or enhance landscape connectivity, but their long-term viability is vulnerable to disturbance.

A virtual clinic : telemetric assessment and monitoring for rural and remote areas

This article reports the establishment of a pilot ‘virtual clinic’ in a rural region of Victoria, Australia. Using low-cost videophones that work across ordinary phone lines, together with off-the-shelf (mostly automatic) clinical tools, local volunteers have been trained to mediate a virtual consultation between simulated patients and local GPs. This system has the potential to save long trips into town by such patients since the traditional ‘home visit’ is not feasible, as well as to provide regular home monitoring for those with chronic conditions. This in turn should impact favourably on ambulance deployment, sometimes enabling patients to avoid going to hospital or allowing them to come home sooner than otherwise would be the case, and generally to offer a sense of medical security to those living in isolated regions.

Analysis of the potential and problems of new institutional economics for third world development

Purpose – The aim of this paper is to provide a critical evaluation of the potential of new institutional economics (NIE) in third world development.

Design/methodology/approach – The paper reviews various theories under NIE from both conceptual and empirical perspectives. It then reviews the various definitions of institutions and show that institutions are essential to overcome problems of information and uncertainty.

Findings – The review finds that weak institutions can undermine development and hence governments in developing countries should strengthen their institutions to provide greater scope for efficient functioning of markets. Where the market does not work owing to high transactions costs, traditional institutions of collective action and group decision making can work and hence need to be recognised.

Research limitations/implications – The major implications of the paper is that in developing countries, a clear understanding of various institutions such as user groups, inter-linked credit markets, rotational irrigation etc. is needed before they are replaced or modified by other institutions. The main limitations of NIE are that there can be capture by elites of various institutional innovations in rural areas, and that it does not explicitly consider income distribution and uncertainty which are glossed over and hence remain areas for future research.

Originality/value – This paper critically reviews the various institutional environments that developing countries face in addressing development issues.

New institutional economics: it's nature, potential and the future

It is generally accepted that institutional problems have severely constrained development in many countries regardless of significant achievements in technology and other reforms. Both the Old and New Institutional Economics have relevance in understanding the lack of progress in many countries in Asia and Africa. Institutions generally refer to the "framework within which human interactions take place. Two major strands of NIE are the transaction costs and the collective action approach. The NIE implies that traditional rural institutions such as user groups, rotating credit and irrigation associations, interlinked credit etc. are institutions that have emerged in place of the market due to lower transactions costs. The successful management of common property resources such as water, forests, wetlands etc using local arrangements imply that institutions need to be interpreted in broader terms and the simple dichotomy of market or the government is too limited to understand the development process. New thinking is required in developing institutions that are structurally suited for management at the local level. Such an approach will have better chance to succeed compared to a process based upon the market.

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.

Outsourcing in the Australian health sector : the interplay of economics and politics

Purpose – The paper discusses the reasons and approaches used at three health organisations in introducing outsourcing. It specifically answers the question: why have managers of health organisations outsourced some functions in preference to others?

Design/methodology/approach – This research employs a case study method making use of qualitative analysis. The health organisations were chosen first as representatives of their type, and secondly due to the nature of the outsourcing decisions made. The first health organisation operates in the rural sector; the second is a metropolitan network; and the third is a large metropolitan hospital, which, in contrast to the other two case study organisations, had made only one decision to outsource, producing the largest outsourcing contract in health in Australia. Furthermore, this situation was distinctive as the contract was terminated and re-issued to another private sector organisation.

Findings – The reasons for outsourcing varied within and between health organisations. Although generally they were made on the bases of the characteristics of the labour market, employee skill levels and the nature of industrial relations, the perception of what was core, the level of internal management skills, the ability of internal teams to implement change and the relationship between management and staff. Even though cost savings and a downsized labour force resulted, generally these occurred even when services were not outsourced, through the use of other change processes, such as introducing new technology, changing structures and promoting workforce flexibility. The interplay of political reasons and economic effects was evident along with the political nature of the decision-making and processes used. The paper concludes that the power of managers was a moderating factor between the desire for outsourcing and whether outsourcing actually occurred.

Research limitations/implications – Although this research was conducted solely within the health sector it has implications for other public sector bodies and the private sector.

Practical implications – Managerial decision making can be enhanced with the exploration of the full complement of reasons for the outsourcing decision.

Originality/value – The paper has value to both academics researching in the public sector and public sector managers.

Exploring the barriers and enablers to attendance at rural cardiac rehabilitation programs

Objective: The objectives of this study were to: (i) identify local barriers and enablers to the uptake of hospital-based cardiac rehabilitation (CR) programs, and (ii) identify preferred alternatives for the delivery of CR.

Design: A questionnaire administered by local CR coordinators and focus groups facilitated by the research team.

Setting: Six regional hospitals in south-west Victoria offering hospital-based CR programs.

Participants: Patients and their carers referred to and eligible for local CR programs; health professionals working within local CR programs.

Main outcomes measures: CR attendees and decliners demographics, patient and health professional perceived factors which contribute to enabling hospital-based CR attendance, patient and health professional perceived barriers to CR attendance, and receptiveness and preferences for alternative modes of CR delivery.

Results: This study identified distance to travel to hospital-based CR programs the only statistically significant factor in determining uptake of CR. Easy access to transport (63%) and to a lesser extent family support (49%) and work flexibility (43%) were the primary enablers to attendance. Of the 97 study participants, 38% were receptive to alternative CR methods such as programs in outlying communities, evening facility-based programs, home and GP based programs, telephone support and a patient manual/workbook.

Conclusions: The results of this study provide valuable information for designing strategies to increase utilisation and improve patient acceptability of existing hospital-based CR programs. It provides a basis for pilot testing alternative modes of CR program delivery for cardiac patients in rural areas unable to access hospital-based CR.

Responding to rural skills shortages : innovations using vocational education and training

Aims & Rationale/Objectives
To locate, analyse and make accessible innovative models of health training and service delivery that have been developed in response to a shortage of skills.

Methods
Drawing on a synthesis of Australian and international literature on innovative and effective models for addressing health skill shortages, 50 models were selected for further study. Models were also identified from nominations by key health sector stakeholders. Selected models represent diversity in terms of the nature of skill shortage addressed, barriers overcome in developing the model, health care specialisations, and customer groups.

Principal Findings
Rural and remote areas have become home to a set of innovative service delivery models. Models identified encompass local, regional and state/national responses. Local responses are usually single health service-training provider partnerships. Regional responses, the most numerous, tend to have a specific focus, such as training young people. A small number of holistic state or national responses, eg the skills ecosystem approach, address multiple barriers to health service provision. Typical barriers include unwillingness to risk-take, stakeholder differences, and entrenched workplace cultures. Enhancers include stakeholder commitment, community acceptance, and cultural fit.

Discussion
Of particular interest is increasing numbers of therapy assistants to help address shortages of allied health professionals, and work to formalise their training, and develop standards of practice and policy. Other models likely to help address skill shortage amongst VET health workers focus on recruiting, supporting and training employees from a range of disadvantaged target groups, and on providing career paths with opportunities for staff to expand their skills. Such models are underpinned by nationally recognised qualifications, but each solution is targeted to a particular context in terms of the potential workforce and local need.

NGOs, enterprise and rural development

Non-Government Welfare Organisations (NGOs) in rural areas have traditionally relied upon the state for a large part of their revenue which in turn provides the state with the capacity to impose strict monitoring and evaluation. However the tightening of state funding has either forced NGOs to stretch their own resource to the limit or to become more enterprising and innovative in their desire to provide people with access to an ever increasing range of community-based services and opportunities for connection with their local communities. The term that is often used for these new approaches is ‘social enterprise’ that has been defined as a business with primarily social objectives whose surpluses are principally reinvested for that purpose in the business or the community, rather than being driven by the need to maximise profit for shareholders and owners’ . It is most often seen as an interface between public and private sector, being part of neither but engaging closely with both through partnerships, stakeholding and joint ventures as well as through complex trading and contracting relationships.

Such broad definitions however do not give much guidance to how particular NGOs can shift to a social enterprise model and still remain within their chosen missions. It is the very processes of re-imagining and reforming their enterprise that is a vital element in moving to a successful social enterprise practice. Accordingly this project focuses on two NGOs in different parts of the world (Brophy Family and Youth Services in Warrnambool. Australia and Aberdeen Foyer in Aberdeen, Scotland) that have developed (and are developing) new ways of approaching their roles as service providers and early intervention agents for youth in their local areas. Since both organisations have faced (and are facing) issues associated with depleting state allocated resources they are attempting to break new ground in the ways in which they redevelop their work with youth. Both agencies are leading the way in developing a broader approach that draws together disparate element of a social enterprise model. The project analyses the processes used by these two agencies to develop as social enterprises and how likeminded agencies can use the model for capability enhancement.

Lay healing practices in the household

This thesis explores the power-knowledge relationship underlying lay healing practices in the household; a non-traditional area of study in public health. Lay knowledge continues to be discounted as illegitimate and !non-expert' by policymakers, health professionals and academics. Given the absence of theory on lay knowledge and decision-making, an eclectic theoretical approach was undertaken in this study. Theory is drawn from medical anthropology, sociology of the body, health economics, gender studies, social theory, psychology, nursing, ethics, philosophy and history of medicine in order to contribute to and advance debate. Operating within the genre of a 'multi-sited ethnography' (working across different sites), methods for data collection included 'anthropology at home' by undertaking fieldwork in Geelong, Victoria, Australia. I conducted interviews and focus group discussions with, and administered a questionnaire to, 98 participants who are parents of young children. They were recruited via primary schools and snowball sampling. The quantitative data presents a socio-demographic 'picture' of 78 women and 20 men (representing 98 households) from urban, rural and coastal areas of the region. The qualitative data contains case studies as well as narratives, analysed for their content and discourses. Additional methods included maintenance of a 'reflexive journal', inter-sectoral consultations and public health policy analysis. Research findings indicate laypeople's conceptualisations of the body, self, health and illness rest upon a notion of the embodied self and health that is physical, mental and spiritual. Lay people have a substantial knowledge base on health and ill-health that derives from many sources, is both generalised and specialised, and is set within the context of everyday life. Laypeople make diagnoses and treat illness and injury within the household. They also exercise substantial agency in determining their choice of healer(s) for therapeutic intervention and management of ill-health outside the household. This study has substantial implications for public health in terms of healers' clinical practices, research and policy.

Solar lanterns or solar home lighting systems – community preferences in East Timor

Access to electrification in rural areas of East Timor is extremely limited with as few as 5% of rural households connected to electricity. The government of East Timor intends to increase rural access to electricity significantly in the coming decade. The introduction of small PV systems is envisaged for many households in the most remote areas. Several agencies have piloted the introduction of small solar home systems (SHS) and solar lanterns. In the Railaco sub-district of East Timor, some 1000 households have experience of using either SHS and/or solar lanterns and are in a unique position to indicate a preference regarding these forms of PV lighting technology. This paper reports on a survey of 76 households in Railaco investigating experience with PV lighting systems. Results of the survey indicate a strong preference by users for SHS rather than lanterns. The preference for SHS arose from a range of factors including: a perception of better light quality; ability to illuminate the whole house; reduced risk of damage to the PV equipment; and longer duration of nightly operation. The research indicates that where a single PV lighting system is provided, users are likely to prefer SHS to solar lanterns.

The whats, whys and wherefores of home education and its regulation in Australia

This paper presents a unique summary of Australian research on home education, and an evaluation of current regulation in an Australian context. It begins with the recognition that home education is a legal alternative to school education in Australia. However it argues that legal definitions of home education do not properly reflect the practice of home education. This is illustrated by an examination of different educational approaches taken by home educators and research on the socialisation of home educated children in Australia. Research on who chooses home education, why people choose home education and the educational outcomes for home educated children is also discussed. Home educating families represent all family types, are found in rural, suburban and city locations, and choose home education for a variety ofreasons. Research indicates that Australian home educated children have positive educational and social experiences and outcomes. The question of whether and ifso the extent to which, home education should be regulated by the state is examined. The authors argue that whilst regulation is acceptable to protect a childr right to education, a more consistent regulatory framework is needed across Australia. It is argued that such aframework should facilitate and encourage children who are being home educated and should be flexible enough to accommodate the variety ofeducational approaches taken to home education.

Activity preferences and participation of school-age children living in urban and rural environments

It is important for therapists to be knowledgeable about the impact of the environment on children’s participation patterns and activity preferences. This study investigated the activity preference and participation among school-age children living in urban and rural locations. The participation patterns and preferences for activities of 58 typically developing children (32 males and 26 females; response rate of 38.7%) aged 8–12 years were assessed across both urban (n = 24) and rural (n = 34) regions of southwest Victoria, Australia. The participation patterns and preferences for activities were assessed using the Children’s Assessment of Participation and Enjoyment and Preferences for Activities of Children (CAPE/PAC).An independent samples t-test was used to determinewhether significant differences existed for theCAPE/PACscores for urban and rurally based children as well as boys and girls. Significant differences were found between the scores of children living in urban and rural areas on the following subscales: CAPE Diversity, CAPE Intensity, CAPE Whom, CAPE Where, PAC Physical Preference, and PACSocial Preference.Asignificant difference for rural and urban groups was found on the following CAPE activity types:Recreation Diversity,Recreation Intensity, Social Diversity, Social Intensity, Self-Improvement Diversity, and Self-Improvement Intensity. Rurally based children were engaged in a broader range of activities and did so more frequently than urban children. Differences in gender were identified with girls preferring to participate in social and skill-based activities and being more likely to participate with friends or people outside their home. However, there were no significant differences in the participation patterns of boys and girls. Physical, social, and structural aspects of the location where a child lives impact the frequency, type of activities, and whom a child participates with most frequently in out-of-school activities. The activity participation of boys and girls in Australia has become quite similar.