Challenges in health services and health systems research

The relationship between emerging trends in healthcare systems and the consequent research priorities will be explored.

Governments and policy makers in developed countries are increasingly focused on the management of chronic disease, reflecting demographic changes and shifts in the burden of disease. Systems of quality improvement and reward are increasingly based on performance in chronic disease management. There is some evidence that countries with well-developed systems of primary care, such as Australia, achieve better health outcomes at less cost. In the past 15 years, almost all developed countries have undergone some type of health care reform. There has been a major focus on reducing costs; often involving shifting services from secondary to primary care. While there are few international comparisons, most suggest a complex relationship between the strength of primary care within the overall health services system and good performance, particularly with regard to lower costs of care and particularly relevant measures of health.

Aims for 21st century health systems
What, then, are the issues which are shaping contemporary general practice in developed countries? There are several imperatives: Safety, effectiveness, patient-centredness, timeliness, efficiency and equity. A study by the Nuffield Trust (Dargie, 1999) projected the shape of healthcare for the first fifteen years of this century. The study identified six issues that need to be addressed in the process of formulating health systems policies:

• Peoples’ expectations and financial sustainability
• Demography and ageing
• Information and knowledge management
• Scientific advance and new technology
• Workforce education and training
• Systems performance and quality (efficiency, effectiveness, economy
and equity)

Each of these six issues requires innovative thinking and priority setting on the part of the health sector, such as the delivery of health services in new and creative ways. Furthermore, there is a clear need for a finely tuned research, development and evaluation strategies to match these goals.

Intervening to improve health indicators among Australian farm families

The Sustainable Farm Families project (http://www.sustainablefarmfamilies.org.au/) was a 3-year demonstration and education project designed to influence farmer behavior with respect to family health and well-being among cropping and grazing farmers in Victoria, New South Wales, and South Australia, Australia. The project was conducted by the Western District Health Service, Hamilton, Australia, in partnership with farmers; Farm Management 500 (peer discussion group); the Victorian Farmers Federation; Royal Melbourne Institute of Technology; and Land Connect. During the 3 years of the project, 128 farmers—men (70) and women (58)—were enrolled. The project utilized a combination of small group workshops, individualized health action plans, and health education opportunities to encourage farm safety and health behavior changes and to elicit sustained improvements in the following health indicators: body mass index (BMI), total cholesterol, fasting blood glucose, and blood pressure. Mean changes in these health indicators were analyzed using repeated measures analysis of variance (ANOVA) and McNemar's test compared the proportion of individuals with elevated indicators. Among participants with elevated values at baseline, the following average reductions were observed: BMI 0.44 kg/m2 (p = .0034), total cholesterol 48.7 mg/dl (p < .0001), blood glucose 10.1 mg/dl (p = .0016), systolic blood pressure 12.5 mm Hg (p < .0001), and diastolic blood pressure 5.0 mm Hg (p = .0007). The proportion of participants with elevated total cholesterol at baseline decreased after 24 months (p < .001). Such findings suggest that proactive intervention by farmer associations, rural health services, and government agencies may be an effective vehicle for promoting voluntary farm safety and health behavior change while empowering farm families to achieve measurable reductions in important health risk factors.

The competing discourses of workplace health

This article presents an analysis of workplace health programme discourses within an international information technology company. Discourse refers to a system of statements that share a common force and coherence and which are socially constitutive. The representation of entities such as workplace health can be subject to competition between discourses. A critical discourse analysis was undertaken on semi-structured interviews, participant observation and workplace health programme documents. Two competing discourses were identified: health as safety and health as lifestyle. Each discourse is described and shown to both implicitly and explicitly define health within this particular workplace. Lifestyle discourse encouraged moves towards linking of the employees' working and private lives while safety discourse defined health in the relationship between workers and their physical environment. Competition between discourses both constricts and opens spaces for alternative understandings of health in the workplace. The implications of this competition for workplace health policy and practice are discussed.

Application of the psychological contract to occupational safety

Psychological contracts were applied to occupational safety. A psychological contract of safety measure was developed and validated, and a model of safety developed to investigate breach and fulfilment of the psychological contract of safety. Findings suggest that the psychological contract of safety impacts safety attitudes and safety behaviour.

Associations between neighbourhood safety and physical activity among youth

This thesis examined how perceptions of neighbourhood safety and objective measures of the local road environment were related to physical activity among youth. Results demonstrated that neighbourhoods with walking tracks and traffic-calming measures promote active transport (walking/cycling) and may help stem age-related declines in physical activity among children and adolescents.

Nature and health

This chapter aims to demonstrate that the natural environment is a key determinant of human health. Natural environments are defined as organic environments where the majority of ecosystem processes are present (e.g. the cycle of life and death, reproduction, relationships between species). Including a spectrum of different environments ranging from wilderness areas in National Parks to farms, and human constructed gardens, 'natural' does not necessarily mean unaffected by human intervention. 'Nature' can also refer to any single element of the natural environment (such as plants, animals, soil and water), including domestic and companion animals as well as cultivated plants. The term 'natural environment' differs from the more usual use of the term 'environment' in that it can be a setting in itself, or it can be an element of other settings, including our homes, workplaces and schools.

Medical tourism : a comparison of Australian, French and South Korean medical and health tourists to Thailand.

The high cost of surgery in Western countries has led to an increase in the demand for surgery in developing countries (York, 2008). The objective of this article is to examine the utilization and satisfaction with medical and health services purchased by Australian, French and South Korean visitors to Thailand. In late 2006 a face-to-face survey was conducted with 1,200 randomly selected tourists who had visited Thailand. Results show substantial usage of medical and health services. Satisfaction levels vary across type of service provided and by country of origin of tourist. Recommendations are provided to the national tourism authority. Future research directions are discussed.

Knowledge of human papillomavirus (HPV) and the HPV vaccine in a national sample of Australian men and women

Background: Human papillomavirus (HPV) knowledge has rarely been investigated in the context of a national vaccination program. The present study investigated HPV knowledge after the introduction of a national HPV vaccination program in Australia using a national sample of men and women. Methods: Questions assessing HPV knowledge were part of a broader national study of health and relationships administered via a computer-assisted telephone interview. These findings are from wave four of the study, conducted between 2007 and 2008. Knowledge questions about HPV included its association with cervical cancer, genital warts and abnormal Pap tests. Results: A total of 2634 women and 2556 men between the ages of 18 and 70 were interviewed. Overall, 62.8% (95% confidence interval (CI): 60.8–64.7%) of women and 38.3% (95% CI: 36.3–40.4%) of men had heard of HPV. Of these, 66.0% (95% CI: 64.1–67.9%) correctly answered that HPV is associated with cervical cancer, 50.2% (95% CI: 48.2–52.1%) answered that HPV is associated with abnormal Pap tests and 44.5% (95% CI:42.5–46.5%) answered that HPV causes warts. Predictors of good knowledge included being female, aged between 26 and 45, holding higher education levels and older age at first sex. Ever having a Pap test was also associated with awareness about HPV. Conclusion: One of the highest levels of knowledge about HPV in Australia to date is reported in the present study. Knowledge about the association between HPV and cervical cancer was particularly high, especially when compared with knowledge of the association with genital warts. This appears to be a consequence of the marketing of the HPV vaccine as a vaccination against cervical cancer.

Consumer concerns about food and health : examination of general and specific relationships with personal values and demographics

Purpose – Aims to investigate the relationships between consumers' food concerns and their personal values and demographic characteristics.

Design/methodology/approach – A questionnaire was administered in a cross sectional random population survey conducted among a sample of 1,000 adults in South Australia. The questionnaire elicited information about respondents' concerns about 20 food and health issues, the perceived importance of 23 values items derived from the Schwartz values inventory, and their demographic characteristics.

Findings – Principal components analyses derived four food concerns factors and six personal values factors. Respondents' safety concerns scores were positively associated with devout-tradition, order-discipline, and moderate-independent values. Their disease concerns score was positively linked to beauty-nature, devout-tradition, and order-discipline. Multiple regression and chi-square automatic interaction detection (CHAID) analyses showed that individual values items were strong predictors of consumers; specific concerns such as food and heart disease, and, genetic modification of foods.

Research limitations/implications – The research was based on a cross sectional study. More refined indices of food concerns and personal values should be used in replications of this preliminary study.

Practical implications – The findings support the use of psychographic market segmentation approaches in communication programs about food and health issues.

Originality/value – The findings suggest that personal values, may be stronger predictors of consumers' concerns about food and health issues than demographics. They also show that measurement level of values and concerns influence the observed strength of their relationships.

A bi-directional relationship between obesity and health-related quality of life : evidence from the longitudinal AusDiab study

Objective: To assess the prospective relationship between obesity and health-related quality of life, including a novel assessment of the impact of health-related quality of life on weight gain.

Design and setting: Longitudinal, national, population-based Australian Diabetes, Obesity and Lifestyle (AusDiab) study, with surveys conducted in 1999/2000 and 2004/2005.

Participants: A total of 5985 men and women aged 25 years at study entry.

Main outcome measure(s): At both time points, height, weight and waist circumference were measured and self-report data on health-related quality of life from the SF-36 questionnaire were obtained. Cross-sectional and bi-directional, prospective associations between obesity categories and health-related quality of life were assessed.

Results: Higher body mass index (BMI) at baseline was associated with deterioration in health-related quality of life over 5 years for seven of the eight health-related quality of life domains in women (all P0.01, with the exception of mental health, P>0.05), and six out of eight in men (all P<0.05, with the exception of role-emotional, P=0.055, and mental health, P>0.05). Each of the quality-of-life domains related to mental health as well as the mental component summary were inversely associated with BMI change (all P<0.0001 for women and P0.01 for men), with the exception of vitality, which was significant in women only (P=0.008). For the physical domains, change in BMI was inversely associated with baseline general health in women only (P=0.023).

Conclusions: Obesity was associated with a deterioration in health-related quality of life (including both physical and mental health domains) in this cohort of Australian adults followed over 5 years. Health-related quality of life was also a predictor of weight gain over 5 years, indicating a bi-directional association between obesity and health-related quality of life. The identification of those with poor health-related quality of life may be important in assessing the risk of future weight gain, and a focus on health-related quality of life may be beneficial in weight management strategies.