Do community treatment orders for mental illness reduce readmission to hospital? - An epidemiological study

Background It has been suggested that community treatment orders (CTOs) will prevent readmission to hospital, but controlled studies have been inconclusive. We aimed to test the hypothesis that hospital discharges made subject to CTOs are associated with a reduced risk of readmission. The use of such a measure is likely to change after its introduction as clinicians acquire familiarity with it, and we also tested the hypothesis that the characteristics of patients subject to CTOs changed over time in the first decade of their use in Victoria, Australia. Method A database from Victoria, Australia (total population 4.8 million) was used. Cox proportional hazard models compared the hazard ratios of readmission to hospital before the end of the study period (1992-2000) for 16,216 discharges subject to a CTO and 112,211 not subject to a CTO. Results Community treatment orders used on discharge from a first admission to hospital were associated with a higher risk of readmission, but CTOs following subsequent admissions were associated with lower readmission risk. The risk also declined over the study period. Conclusions The effect of using a CTO depends on the patient's history. At a population level their introduction may not reduce readmission to hospital. Their impact may change over time.

Mental health literacy in rural Queensland: results of a community survey

Objectives: The aim of this study was to assess the awareness of, and attitudes to, mental health issues in rural dwelling Queensland residents. A secondary objective was to provide baseline data of mental health literacy prior to the implementation of Australian Integrated Mental Health Initiative - a health promotion strategy aimed at improving the health outcomes of people with chronic or recurring mental disorders. Method: In 2004 a random sample of 2% (2132) of the estimated adult population in each of eight towns in rural Queensland was sent a postal survey and invited to participate in the project. A series of questions were asked based on a vignette describing a person suffering major depression. In addition, questions assessed respondents' awareness and perceptions of community mental health agencies. Results: Approximately one-third (36%) of those surveyed completed and returned the questionnaire. While a higher proportion of respondents (81%) correctly identified and labelled the problem in the vignette as depression than previously reported in Australian community surveys, the majority of respondents (66%) underestimated the prevalence of mental health problems in the community. Furthermore, a substantial number of respondents (37%) were unaware of agencies in their community to assist people with mental health issues while a majority of respondents (57.6%) considered that the services offered by those agencies were poor. Conclusion: While mental health literacy in rural Queensland appears to be comparable to other Australian regions, several gaps in knowledge were identified. This is in spite of recent widespread coverage of depression in the media and thus, there is a continuing need for mental health education in rural Queensland.

Conceptual Frameworks for SIA Revisited: a cumulative effects study on lead contamination and economic change

This article trials three conceptual frameworks on an Australian case study of a small remote city suffering lead contamination, with cumulative effects from concurrent economic change due to downsizing in the mining industry. It interprets the usefulness of these frameworks, and explores two questions: can they apply to circumstances other than project assessment, and what are their relative merits as guides to SIA? All the frameworks reviewed can be used in non-project and cumulative SIA, although, if they had been used to predict the impacts in our case study, we may easily have been misled as to the resilience of the community. Choosing among these frameworks becomes a matter personal preference: each has different merits.

Enabling change for corporate sustainability: An integrated perspective

This article explores the processes of change that enable corporations to move towards sustainable practices, focusing on the human resource and business strategies that support rather than diminish global ecology and human/social capabilities. We argue that this unified approach is necessary to bring about a change in the interpretation of corporate sustainability and to support the activities of change agents (managers, consultants, and community activists) in managing the massive corporate change needed to move corporations toward sustainable practices in a systematic way. We propose a schema in the form of an integrated phase model for understanding how corporations move from compliance modes to the attainment of strategic sustainability and beyond to the ‘ideal’ or sustaining corporation. We discuss the leadership of change and the roles and strategies that corporate change agents can employ to bring about both incremental and transformational change for sustainability.

Can we get General Practitioners to Promote Physical Activity? Results of the 10,000 Steps Rockhampton Community-Based Physical Activity Promotion Project

Evidence supporting the efficacy of physical activity promotion in primary care settings has evaluated patient-level changes in physical activity, with little focus on the issue of general practitioner (GP) uptake. The 'GP Strategy' of 10,000 Steps Rockhampton provided an opportunity to explore this issue in the context of a multi-strategy, community-based physical activity intervention project. The 'GP Strategy' was developed in partnership with the Capricornia Division of General Practice. It aimed to: 1) increase GP awareness of the 10,000 Steps project, 2) upskill GPs in brief physical activity counselling techniques, and 3) provide GPs with evidencebased physical activity counselling materials and pedometers. The evaluation, which was guided by the RE-AIM evaluation framework, used a pre-post design, including a GP mailed survey, and collection of process data. Survey response rates were 67% (n=44/66; baseline) and 70% (n=37/53; 14-month follow-up). GP awareness of 10,000 Steps Rockhampton increased from 46% to 97%. 21/23 practices were visited by 10,000 Steps staff and accepted 10,000 Steps posters, brochures, and pedometers. At follow-up, 78% had displayed the poster, 81% were using the brochures, and 70% had loaned pedometers to patients. Despite the very high rate of uptake and use of 10,000 Steps materials, there was no change in the percentage of patients counselled, and relatively few pedometers had been loaned to patients. The results of this trial indicate that it will take more effort to change GP physical activity counselling behaviour, and provide only modest support for use of pedometers in the busy general practice setting. Acknowledgement:This project is supported by a grant from Health Promotion Queensland.

Learner initiative in the language classroom

This article looks at learner initiative in teacher-fronted activities and how this can influence classroom interaction. Extracts from lesson transcripts of adult evening classes in Italy are used to give a precise definition of what is meant by learner initiative and to illustrate how it can change interaction patterns. It is suggested that learner initiative could have an important role to play in promoting comprehensible input and output and therefore language learning. It will be seen how, by giving learners more space and time, initiative can be actively encouraged. However, there are direct implications for teacher training as it is necessary to change traditional interaction patterns and make learner initiative more effective.

The public health role of community pharmacies

This article describes the experience of developing an enhanced public health role for a community pharmacy in the Castle Vale estate in Birmingham. It shows that the neighbourhood-based regeneration context of Castle Vale has created a stimulating setting for an ambitious and innovative pharmacy company to demonstrate what might be possible on a much wider scale in the UK. A core ethos of the Castle Vale regeneration initiative has been public-private partnership and this project reveals some 'critical success factors' for on-the-ground achievement.

Reducing medicines waste in the community

There is increasing concern at the amount and cost of prescribed medicines that are unused or wasted and then have to be disposed of. Previous studies have used health promotion and Dispose Unwanted Medicines Properly campaigns targeted at the patient to describe and quantify the annual cost of waste. The reasons patients return unused drugs to pharmacies have also been explored. The paper focuses on patient explanations for not needing medication; categorized as: over-collection in the past, self-management strategies, changes in medical condition, other changes in patient circumstances, or the repeat medicines policy at the surgery. The aim of the original study was to make a measurable change in prescribed medicines with a reduction in medicines wastage, whilst at the same time achieving improved standards of pharmaceutical care. Information on patient needs and behaviour came from consultation in the pharmacy monitoring forms and interview. The study was based on two medical practices in the West Midlands, UK, comparing an outer city and an inner city population. The participants were general practitioners, pharmacists and 350 repeat prescription patients. Prescriptions were issued for two three-month periods. The outcome was that 23.8% of the prescribed items were not dispensed, at a value of £13.1K, 58% of the medications that would be expected to be regularly supplied were collected. The study suggests that closer professional management at the point of dispensing and an understanding of patient experiences can help reduce the amount of unwanted medication collected by patients.

Communities of implementation

The concept of communities of practice (CoPs) has rapidly gained ground in fields such as knowledge management and organisational learning since it was first identified by Lave and Wenger (1991) and Brown and Duguid (1991). In this article, we consider a related concept that we have entitled “communities of implementation.” Communities of implementation (CoIs) are similar to communities of practice in that they offer an opportunity for a collection of individuals to support each other and share knowledge in a dynamic environment and on a topic in which they share interest. In addition, and to differentiate them from CoPs, a community of implementation extends the responsibilities of a CoP by having as its focus the implementation of a programme of change. This may well extend to designing the change programme. Thus, whereas a main purpose of a CoP is to satisfy “a real need to know what each other knows” (Skyrme, 1999) in an informal way, we argue that a main purpose of a community of implementation is to “pool individual knowledge (including contacts and ways of getting things done) to stimulate collective enthusiasm in order to take more informed purposeful action for which the members are responsible.” Individual and collective responsibility and accountability for successfully implementing the actions/change programme is a key feature of a community of implementation. Without these pressures the members might lower the priority of implementation, allowing competing priorities to dominate their attention and resources. Without responsibility and accountability, the result is likely to be (at best) an organisation which has not begun a change programme, or (at worst) an organisation which is stuck halfway through another failing initiative. To achieve these additional objectives beyond those of a CoP, the CoI needs to provide heightened support to its members. In fact often the members will collectively strategise the development and implementation of the change programme they are leading in the organisation. Other concepts similar to CoPs have appeared in the literature, for example “communities of knowing” (Boland & Tenkasi, 1995), but none have a specific focus on implementation. Perhaps the closest example of a CoI, as suggested by our definition, is reported by Karsten, Lyytinen, Hurskainen, and Koskelainen (2001) who describe a CoP in a paper machinery manufacturer which seems to have the necessary focus on implementation. The theoretical aspects of this article will explore the relationship between CoPs and CoIs, and the needs for different arrangements for a CoI. The practical aspect of this article will consist of a report on a case study of a CoI that was successful in its implementation of a programme of change that aimed to improve its organisation’s knowledge management activities. Over two years the CoI implemented a suite of complementary actions across the organisation. These actions transformed the organisation and moved it towards achieving its ‘core values’ and overall objectives. The article will explore: the activities that formed and gelled the community, the role of the community in the implementation of actions, and experiences from key members of this community on its success and potential improvements.