Suicide and community psychiatric care

A preliminary survey of 34 suicides among patients attending community services for the chronically mentally ill revealed a rate of 520 per 100,000 admitted. In contrast to earlier hospital surveys, no risk variables were identified for patients dying by suicide. Thirty-four percent of suicides occurred within one week of the last treatment and 59% within 3 months of service entry. It appears that early and intensive follow-up may be necessary to prevent suicide among patients receiving community psychiatric care.

The relationship between clinical outcomes and quality of life for residents of aged care facilities

Objectives It is widely assumed improving care in residential facilities will improve quality of life (QoL), but little research has explored this relationship. The Clinical Care Indicators (CCI) Tool was developed to fill an existing gap in quality assessment within Australian residential aged care facilities and it was used to explore potential links between clinical outcomes and QoL. Design and Setting Clinical outcome and QoL data were collected within four residential facilities from the same aged care provider. Subjects Subjects were 82 residents of four facilities. Outcome Measures Clinical outcomes were measured using the CCI Tool and QoL data was obtained using the Australian WHOQOL‑100. Results Independent t‑test analyses were calculated to compare individual CCIs with each domain of the WHOQOL‑100, while Pearson’s product moment coefficients (r) were calculated between the total number of problem indicators and QoL scores. Significant results suggested poorer clinical outcomes adversely affected QoL. Social and spiritual QoL were particularly affected by clinical outcomes and poorer status in hydration, falls and depression were most strongly associated with lower QoL scores. Poorer clinical status as a whole was also significantly correlated with poorer QoL. Conclusions Hydration, falls and depression were most often associated with poorer resident QoL and as such appear to be key areas for clinical management in residential aged care. However, poor clinical outcomes overall also adversely affected QoL, which suggests maintaining optimum clinical status through high quality nursing care, would not only be important for resident health but also for enhancing general life quality.

Using a longitudinal model to estimate the effect of methicillin-resistant staphylococcus aureus infection on length of stay in an intensive care unit

Healthcare-associated methicillin-resistant Staphylococcus aureus(MRSA) infection may cause increased hospital stay or, sometimes, death. Quantifying this effect is complicated because it is a time-dependent exposure: infection may prolong hospital stay, while longer stays increase the risk of infection. We overcome these problems by using a multinomial longitudinal model for estimating the daily probability of death and discharge. We then extend the basic model to estimate how the effect of MRSA infection varies over time, and to quantify the number of excess ICU days due to infection. We find that infection decreases the relative risk of discharge (relative risk ratio = 0.68, 95% credible interval: 0.54, 0.82), but is only indirectly associated with increased mortality. An infection on the first day of admission resulted in a mean extra stay of 0.3 days (95% CI: 0.1, 0.5) for a patient with an APACHE II score of 10, and 1.2 days (95% CI: 0.5, 2.0) for a patient with an APACHE II score of 30. The decrease in the relative risk of discharge remained fairly constant with day of MRSA infection, but was slightly stronger closer to the start of infection. These results confirm the importance of MRSA infection in increasing ICU stay, but suggest that previous work may have systematically overestimated the effect size.

Getting creative in health care

Health care accounts for a substantial and growing share of national expenditures, and Australia’s health-care system faces some unprecedented pressures. This paper examines the contribution of creative expertise and services to Australian health care. They are found to be making a range of contributions to the development and delivery of health-care goods and services, the initial training and ongoing professionalism of doctors and nurses, and the effective functioning of health-care buildings. Creative activities within health-care services are also undertaken by medical professionals and patients. Key functions that creative activities address are innovation and service delivery in information management and analysis, and making complex information comprehensible or more useful, assisting communication and reducing psycho-social and distance-mediated barriers, and improving the efficiency and effectiveness of services.

Practical Transformations and Transformational Practices : Globalization, Postmodernism, and Early Childhood Education : Advances in Early Education and Day Care

Both traditional and progressive curricula are inadequate for the task of responding to the economic, political, social, and cultural changes that have occurred as a result of globalization. This book documents some of the ongoing work occurring in early childhood settings that is aimed at improving, and ultimately transforming, early childhood practice in these changed and changing times. The authors do not simply critique developmental approaches or the increasing standardization of the field. Instead, they describe how they are playing around with postmodern ideas in practice and developing unique approaches to the diverse educational circumstances that confront early childhood educators. Whether it is preparing teachers, using materials, or developing policies, each chapter provides readers with possibilities for enacting pedagogies that are responsive to the contemporary circumstances shaping the lives of young children.

Listening, sharing understanding and facilitating consumer, family and community empowerment through a priority driven partnership in Far North Queensland

Objectives: This paper provides an example of a mental health research partnership underpinned by empowerment principles that seeks to foster strength among community organizations to support better outcomes for consumers, families and communities. It aims to raise awareness among researchers and service providers that empowerment approaches to assist communities to address mental health problems are not too difficult to be practical but require long-term commitment and appropriate support. Methods: A collaborative research strategy that has become known as the Priority Driven Research (PDR) Partnership emerged through literature review,consultations, Family Wellbeing Program delivery with community groups and activities in two discrete Indigenous communities. Progress to date on three of the four components of the strategy is described. Results: The following key needs were identified in a pilot study and are now being addressed in a research-based implementation phase: (i) gaining two-way understanding of perspectives on mental health and promoting universal awareness; (ii) supporting the empowerment of carers, families, consumers and at-risk groups through existing community organizations to gain greater understanding and control of their situation; (iii) developing pathways of care at the primary health centre level to enable support of social and emotional wellbeing as well as more integrated mental health care; (iv) accessing data to enable an ongoing process of analysis/sharing/planning and monitoring to inform future activity. Conclusion: One of the key learnings to emerge in this project so far is that empowerment through partnership becomes possible when there is a concerted effort to strengthen grassroots community organizations. These include social health teams and men’s and women’s groups that can engage local people in an action orientation. Key words: Aboriginal, empowerment, Indigenous, mental health.

Spaces of care in the third sector : Understanding the effects of professionalization

Increasingly the health and welfare needs of individuals and communities are being met by third sector, or not-for-profit, organizations. Since the 1980s third sector organizations have been subject to significant, sector-wide changes, such as the development of contractual funding and an increasing need to collaborate with governments and other sectors. In particular, the processes of ‘professionalization’ and ‘bureaucratization’ have received significant attention and are now well documented in third sector literature. These processes are often understood to create barriers between organizations and their community groups and neutralize alternative forms of service provision. In this article we provide a case study of an Australian third sector organization undergoing professionalization. The case study draws on ethnographic and qualitative interviews with staff and volunteers at a health-based third sector organization involved in service provision to marginalized community groups. We examine how professionalization alters organizational spaces and dynamics and conclude that professionalized third sector spaces may still be ‘community’ spaces where individuals may give and receive care and services. Moreover, we suggest that these community spaces hold potential for resisting the neutralizing effects of contracting.

Mailed treatment to augment primary care for alcohol disorders : a randomised controlled trial

Introduction and Aims: Remote delivery of interventions is needed to address large numbers of people with alcohol use disorders who are spread over large areas. Previous correspondence trials typically examined its effects as stand-alone treatment. This study aimed to test whether adding postal treatment to general practitioner (GP) support would lower alcohol use more than GP intervention alone. Design and Methods: A single-blind, randomised controlled trial with a crossover design was conducted over 12 months on 204 people with alcohol use disorders. Participants in an immediate correspondence condition received treatment over the first 3 months; those receiving delayed treatment received it in months 3–6. Results: Few participants were referred from GPs, and little intervention was offered by them. At 3 months, 78% of participants remained in the study. Those in immediate treatment showed greater reductions in alcohol per week, drinking days, anxiety, depression and distress than those in the delayed condition. However, post-treatment and follow-up outcomes still showed elevated alcohol use, depression, anxiety and distress. Greater baseline anxiety predicted better alcohol outcomes, although more mental distress at baseline predicted dropout. Discussion and Conclusions: The study gave consistent results with those from previous research on correspondence treatments, and showed that high levels of participant engagement over 3 months can be obtained. Substantial reductions in alcohol use are seen, with indications that they are well maintained. However, many participants continue to show high-risk alcohol use and psychological distress.

Recognising and respecting Torres Strait Islander mathematics knowledges and home languages through mainstream mathematics education [Abstract]

This abstract provides a preliminary discussion of the importance of recognising Torres Strait Islander knowledges and home languages of mathematics education. It stems from a project involving Torres Strait Islander Teachers and Teacher Aides and university based researchers who are working together to enhance the mathematics learning of students from Years 4-9. A key focus of the project is that mathematics is relevant and provides students with opportunities for further education, training and employment. Veronica Arbon (2008) questions the assumptions underpinning Western mainstream education as beneficial for Aboriginal and Torres Strait Islander people which assumes that it enables them to better participate in Australian society. She asks “how de we best achieve outcomes for and with Indigenous people conducive to our cultural, physical and economic sustainability as defined by us from Indigenous knowledge positions?” (p. 118). How does a mainstream education written to English conventions provide students with the knowledge and skills to participate in daily life, if it does not recognise the cultural identity of Indigenous students as it should (Priest, 2005; cf. Schnukal, 2003)? Arbon (2008) states that this view is now brought into question with calls for both ways education where mainstream knowledge and practices is blended with Indigenous cultural knowledges of learning. This project considers as crucial that cultural knowledges and experiences of Indigenous people to be valued and respected and given the currency in the same way that non Indigenous knowledge is (Taylor, 2003) for both ways education to work.

End-of-life care pathways for improving outcomes in caring for the dying (Protocol)

We aim to assess the effects of end-of-life care pathways, compared with usual care or with care guided by another end-of-life care pathway across all healthcare settings (hospitals, residential aged care facilities, community). In particular, we aim to assess the effects on symptom severity and quality of life of people who are dying and/or those related to the care such as families, caregivers and health professionals.

Should mental health issues be addressed in primary care, and can it be done? Views of rural general practitioners in Queensland

Objective: The aim of this paper was to examine self-efficacy and perceived appropriateness among rural general practitioners (GPs) in regards to screening and intervention for physical, lifestyle and mental health issues. ----- Method: Fifty GPs from 25 practices in eight rural Queensland towns completed a written survey designed for the study. ----- Results: General practitioners rated opportunistic screening or assessment for smoking and for detection of relapse of mental disorders as the most appropriate, with even cardiovascular and diabetes risk falling behind these. Self-efficacy was highest for medical disorders for smoking assessment. It was significantly lower for alcohol, mental health issues, and addressing risks of physical disorder in people with mental disorders. ----- Conclusions: High appropriateness ratings suggest that current strategies to boost self-efficacy of GPs in addressing mental health issues are timely.

Integrated versus non-integrated management and care for clients with co-occurring mental health and substance use disorders : a qualitative systematic review of randomised controlled trials

The purpose of this paper is to conduct a qualitative review of randomised controlled trials in relation to the treatment of adults with co-occurring mental health and substance use disorder (MH/SUD). In particular, integrated approaches are compared with non-integrated approaches to treatment. Ten articles were identified for inclusion in the review. The findings are equivocal with regard to the superior efficacy of integrated approaches to treatment, although the many limitations of the studies need to be considered in our understanding of this finding. Clearly, this is an extremely challenging client group to engage and maintain in intervention research, and the complexity and variability of the problems render control particularly difficult. The lack of available evidence to support the superiority of integration is discussed in relation to these challenges. Much remains to be investigated with regard to integrated management and care for people with co-occurring and MH/SUD, particularly for specific combinations of dual diagnosis and giving consideration to the level of inter-relatedness between the disorders.

Burden of care and general health in families of patients with schizophrenia

Background: De-institutionalization of psychiatric patients has led to a greater emphasis on family management in the community, and family members are often overwhelmed by the demands that caring for a patient with schizophrenia involves. Most studies of family burden in schizophrenia have taken place in developed countries. The current study examined family burden and its correlates in a regional area of a medium income country in South America. Method: Sixty-five relatives of patients with schizophrenia who were attending a public mental health out-patient service in the province of Arica, Chile, were assessed on Spanish versions of the Zarit Caregiver Burden Scale and SF-36 Health Survey (SF-36). Results: Average levels of burden were very high, particularly for mothers, carers with less education, carers of younger patients and carers of patients with more hospitalisations in the previous 3 years. Kinship and number of recent hospitalisations retained unique predictive variance in a multiple regression. Burden was the strongest predictor of SF-36 subscales, and the prediction from burden remained significant after entry of other potential predictors. Conclusions: In common with families in developed countries, family members of schizophrenia patients in regional Chile reported high levels of burden and related functional and health impact. The study highlighted the support needs of carers in contexts with high rates of poverty and limited health and community resources.

Preliminary Results from Exercise for Health : A Breast Cancer Recovery Project [Abstract]

The Exercise for Health program is a telephone-delivered exercise intervention for women with breast cancer (BC) living in regional Queensland. The effect of the program is being evaluated in the context of a randomised controlled trial. Consenting, newly diagnosed BC patients, treated in one of 8 regional Queensland hospitals, were randomly allocated to telephone-based exercise counselling (EC) or usual care (UC) at 6-weeks post-surgery. EC participants received an exercise workbook and 16 calls from an exercise physiologist over 8 months. Physical activity levels (PA) (Active Australia & CHAMPS), quality-of-life (FACTB+4), upper-body function (DASH) and fatigue (FACIT-Fatigue) were assessed at baseline (4-6 weeks post-surgery), 6- and 12-months post-surgery. Preliminary analyses of available 6-month data were conducted using t-tests and repeated measures ANCOVAs. Participating women (n=143; EC n=73, UC n=70) were aged 53±9 years and 30% met PA guidelines at baseline. Up to two thirds of the women received adjuvant therapy during the first 6 months following surgery. Greater improvements (mean change+SD) occurred for the EC vs UC group in weekly sessions of walking (1.83±4.3 vs -0.5±5.5, p=0.029) moderate-vigorous PA (5.0±6.5 vs -1.1±6.1, p=0.005) and strength training (1.9±2.9 vs -0.5±4.2 p<0.001), and in upper-body function, reflected by lower log-transformed disability scores (-0.34±0.44 vs -0.17±0.28, p=0.038). More EC than UC participants met PA guidelines at 6 months (46.3% vs 32.7%). Preliminary findings from this ongoing trial suggest that the telephone is a feasible and effective medium for delivering exercise counselling to newly diagnosed BC patients living in regional areas.

Risk-assessment practices in the private rental sector : implications for low-income renters (Final Report)

This report focuses on risk-assessment practices in the private rental market, with particular consideration of their impact on low-income renters. It is based on the fieldwork undertaken in the second stage of the research process that followed completion of the Positioning Paper. The key research question this study addressed was: What are the various factors included in ‘risk-assessments’ by real estate agents in allocating ‘affordable’ tenancies? How are these risks quantified and managed? What are the key outcomes of their decision-making? The study builds on previous research demonstrating that a relatively large proportion of low-cost private rental accommodation is occupied by moderate- to high-income households (Wulff and Yates 2001; Seelig 2001; Yates et al. 2004). This is occurring in an environment where the private rental sector is now the de facto main provider of rental housing for lower-income households across Australia (Seelig et al. 2005) and where a number of factors are implicated in patterns of ‘income–rent mismatching’. These include ongoing shifts in public housing assistance; issues concerning eligibility for rent assistance; ‘supply’ factors, such as loss of low-cost rental stock through upgrading and/or transfer to owner-occupied housing; patterns of supply and demand driven largely by middle- to high-income owner-investors and renters; and patterns of housing need among low-income households for whom affordable housing is not appropriate. In formulating a way of approaching the analysis of ‘risk-assessment’ in rental housing management, this study has applied three sociological perspectives on risk: Beck’s (1992) formulation of risk society as entailing processes of ‘individualisation’; a socio-cultural perspective which emphasises the situated nature of perceptions of risk; and a perspective which has drawn attention to different modes of institutional governance of subjects, as ‘carriers of specific indicators of risk’. The private rental market was viewed as a social institution, and the research strategy was informed by ‘institutional ethnography’ as a method of enquiry. The study was based on interviews with property managers, real estate industry representatives, tenant advocates and community housing providers. The primary focus of inquiry was on ‘the moment of allocation’. Six local areas across metropolitan and regional Queensland, New South Wales, and South Australia were selected as case study localities. In terms of the main findings, it is evident that access to private rental housing is not just a matter of ‘supply and demand’. It is also about assessment of risk among applicants. Risk – perceived or actual – is thus a critical factor in deciding who gets housed, and how. Risk and its assessment matter in the context of housing provision and in the development of policy responses. The outcomes from this study also highlight a number of salient points: 1.There are two principal forms of risk associated with property management: financial risk and risk of litigation. 2. Certain tenant characteristics and/or circumstances – ability to pay and ability to care for the rented property – are the main factors focused on in assessing risk among applicants for rental housing. Signals of either ‘(in)ability to pay’ and/or ‘(in)ability to care for the property’ are almost always interpreted as markers of high levels of risk. 3. The processing of tenancy applications entails a complex and variable mix of formal and informal strategies of risk-assessment and allocation where sorting (out), ranking, discriminating and handing over characterise the process. 4. In the eyes of property managers, ‘suitable’ tenants can be conceptualised as those who are resourceful, reputable, competent, strategic and presentable. 5. Property managers clearly articulated concern about risks entailed in a number of characteristics or situations. Being on a low income was the principal and overarching factor which agents considered. Others included: - unemployment - ‘big’ families; sole parent families - domestic violence - marital breakdown - shift from home ownership to private rental - Aboriginality and specific ethnicities - physical incapacity - aspects of ‘presentation’. The financial vulnerability of applicants in these groups can be invoked, alongside expressed concerns about compromised capacities to manage income and/or ‘care for’ the property, as legitimate grounds for rejection or a lower ranking. 6. At the level of face-to-face interaction between the property manager and applicants, more intuitive assessments of risk based upon past experience or ‘gut feelings’ come into play. These judgements are interwoven with more systematic procedures of tenant selection. The findings suggest that considerable ‘risk’ is associated with low-income status, either directly or insofar as it is associated with other forms of perceived risk, and that such risks are likely to impede access to the professionally managed private rental market. Detailed analysis suggests that opportunities for access to housing by low-income householders also arise where, for example: - the ‘local experience’ of an agency and/or property manager works in favour of particular applicants - applicants can demonstrate available social support and financial guarantors - an applicant’s preference or need for longer-term rental is seen to provide a level of financial security for the landlord - applicants are prepared to agree to specific, more stringent conditions for inspection of properties and review of contracts - the particular circumstances and motivations of landlords lead them to consider a wider range of applicants - In particular circumstances, property managers are prepared to give special consideration to applicants who appear worthy, albeit ‘risky’. The strategic actions of demonstrating and documenting on the part of vulnerable (low-income) tenant applicants can improve their chances of being perceived as resourceful, capable and ‘savvy’. Such actions are significant because they help to persuade property managers not only that the applicant may have sufficient resources (personal and material) but that they accept that the onus is on themselves to show they are reputable, and that they have valued ‘competencies’ and understand ‘how the system works’. The parameters of the market do shape the processes of risk-assessment and, ultimately, the strategic relation of power between property manager and the tenant applicant. Low vacancy rates and limited supply of lower-cost rental stock, in all areas, mean that there are many more tenant applicants than available properties, creating a highly competitive environment for applicants. The fundamental problem of supply is an aspect of the market that severely limits the chances of access to appropriate and affordable housing for low-income rental housing applicants. There is recognition of the impact of this problem of supply. The study indicates three main directions for future focus in policy and program development: providing appropriate supports to tenants to access and sustain private rental housing, addressing issues of discrimination and privacy arising in the processes of selecting suitable tenants, and addressing problems of supply.