Routinely asking women about domestic violence in health settings

The stigma surrounding domestic violence means that many of those affected are reluctant or do not know how to get help. A systematic review of screening for domestic violence in healthcare settings concluded that although there was insufficient evidence to recommend screening programmes, health services should aim to identify and support women experiencing domestic violence.1 The review highlighted the importance of education and training of clinicians in promoting disclosure of abuse and appropriate responses.1 We argue that a strong case exists for routinely inquiring about partner abuse in many healthcare settings.

Issues in developing e-health systems: an Australian case study

Over the last few years, perceptions of the importance of eHealth have increased rapidly, together with the use of IS&T in the delivery of health and social services. Although “e” approaches to health and social services have much potential, they are not panaceas, and the use of new technologies in improving the efficiency and effectiveness of such systems cannot be considered in isolation from their wider context. eHealth systems remain complex socio-organisational systems and, as we will argue and illustrate through this case study, require that a balanced approach to feasibility and desirability analysis be taken.

The case study in this paper describes a feasibility study into the potential effectiveness of a smartdevice-based electronic data collection and payment system which was proposed for the provision of disability services. A key finding of the study was that the most significant impediment to such a system was the highly diffused, fragmented, interlocking organisational structure of the social service administration itself. Rather than raise issues specific to the implementation or diffusion of new technologies in designing e-health services, it raised issues associated with decision making and control in such an environment, and with the design of the underlying organisational system: for service provision, the level of detail required in the service data, and the locus of decision-making power among the stakeholders.

In our account we illustrate the existence of multiple, incommensurate but valid perceptions of the human service provision problem, and discuss the implications for developers or managers of information systems in the arena of e-health or governance. We examine this environment from sociological and information systems perspectives, and confirm the usefulness of socio-organisational approaches in understanding such contexts.

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.

The status of health-promoting schools in Hong Kong and implications for further development

An evaluation framework, called the Hong Kong Healthy Schools Award, has been developed to enable comprehensive collection and analysis of data reflecting the status of health-promoting schools (HPS) in Hong Kong. The key findings revealed a high prevalence of emotional problems, unhealthy eating habits, physical inactivity and risk-taking behaviours, leading to both intentional and unintentional injuries among students with higher prevalence among secondary school students. The results indicated a substantial lack of health policies in schools; it also indicated health services in schools not readily accessible to students and staff, and insufficient staff training in health promotion and education. However, most schools have made initiatives in environmental protection, established safety guidelines and strategies for managing students with emotional problems. The success of HPS depends largely on teachers' understanding of its building blocks. Evidence from the comprehensive mapping of the status of HPS in Hong Kong and from student surveys does show encouraging outcomes as well as identifying priority issues to be addressed in the next 5 years.

Does interpersonal psychotherapy improve clinical care for adolescents with depression attending a rural child and adolescent mental health service? Study protocol for a cluster randomised feasibility trial

Background: Depression amongst adolescents is a costly societal problem. Little research documents the effectiveness of public mental health services in mapping this problem. Further, it is not clear whether usual care in such services can be improved via clinician training in a relevant evidence based intervention. One such intervention, found to be effective and easily learned amongst novice clinicians, is Interpersonal Psychotherapy (IPT). The study described in the current paper has two main objectives. First, it aims to investigate the impact on clinical care of implementing Interpersonal Psychotherapy for Adolescents for the treatment of adolescent depression within a rural mental health service compared with Treatment as Usual (TAU). The second objective is to record the process and challenges (i.e. feasibility, acceptability, sustainability) associated with implementing and evaluating an evidence-based intervention within a community service. This paper outlines the study rationale and design for this community based research trial.

Methods/design: The study involves a cluster randomisation trial to be conducted within a Child and Adolescent Mental Health Service in rural Australia. All clinicians in the service will be invited to participate.  Participating clinicians will be randomised via block design at each of four sites to (a) training and delivery of IPT, or (b) TAU. The primary measure of impact on care will be a clinically significant change in depressive  symptomatology, with secondary outcomes involving treatment satisfaction and changes in other symptomatology. Participating adolescents with significant depressive symptomatology, aged 12 to 18 years, will complete assessment measures at Weeks 0, 12 and 24 of treatment. They will also complete a depression inventory once a month during that period. This study aims to recruit 60 adolescent participants and their parent/guardian/s. A power analysis is not indicated as an intra-class correlation coefficient will be calculated and used to inform sample size calculations for subsequent large-scale trials. Qualitative data regarding process implementation will be collected quarterly from focus groups with participating clinicians over 18 months, plus phone interviews with participating adolescents and parent/guardians at 12 weeks and 24 weeks of treatment. The focus group qualitative data will be analysed using a Fourth Generation Evaluation methodology that includes a constant comparative cyclic analysis method.

Discussion: This study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting cluster randomised trials within community practice such as mental health services.

Institutional and structural forms of HIV-related discrimination in health care : a study set in Beijing

This paper presents key findings of a situational analysis of institutional and structural levels of HIV/AIDS-related discrimination in Beijing, China, with a focus on the area of health care. Initially slow to respond to the presence of HIV, China has altered its approach and enacted strict legislative protection for people living with HIV/AIDS (PLWHA). In order to determine whether this has altered discrimination against PLWHA, this study examined existing legislation and policy, and interviewed key informants working in health care and PLWHA. The overall findings revealed that discrimination in its many forms continued to occur in practice despite China's generally strong legislative protection, and it is the actual practice that is hindering PLWHAs' access to health services. A number of legislative and policy gaps that allow discrimination to occur in practice were also identified and discussed. The paper concludes with a call to rectify specific gaps between legislation, policy and practice. An understanding of the underlying factors that drive discrimination will also be necessary for effective strategic interventions to be developed and implemented.

Evidence-based public health: what does it offer developing countries?

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public health and health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted in developing countries. The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.

Cervical cancer services for Indigenous Women: Advocacy, Community-Based Research and Policy Change in Australia

Collaborative research undertaken in the state of Queensland, Australia, resulted in major changes in cervical cancer screening and treatment for Indigenous women. Guided by an Indigenous statewide reference group and with an Indigenous researcher playing a lead role, qualitative data were collected using interviews, focus groups, and larger community meetings; and case studies were conducted with health workers and community members from diverse rural, remote and urban communities, to explore the different cultural and structural factors affecting understanding and awareness of cervical cancer and Indigenous women's use of and access to health services for screening, diagnosis and treatment. These data were supplemented by an analysis of clinical data and health service checklists. We discuss the methodology and summarize the key social and structural factors that discourage women from presenting for screening or returning for follow-up. These include women's misunderstanding of cervical cancer screening, fear of cancer, distrust of health services, poor recall and follow-up systems, and the economic and social burden to women presenting for treatment. We describe how the research process and subsequent activities provided Indigenous women with a vehicle for their own advocacy, resulting in important policy and program changes.

Gender and health promotion: A multisectoral policy approach

Women and men are different as regards their biology, the roles and responsibilities that society assigns to them and their position in the family and community. These factors have a great influence on causes, consequences and management of diseases and ill-health and on the efficacy of health promotion policies and programmes. This is confirmed by evidence on male–female differences in cause-specific mortality and morbidity and exposure to risk factors. Health promoting interventions aimed at ensuring safe and supportive environments, healthy living conditions and lifestyles, community involvement and participation, access to essential facilities and to social and health services need to address these differences between women and men, boys and girls in an equitable manner in order to be effective. The aim of this paper is to (i) demonstrate that health promotion policies that take women's and men's differential biological and social vulnerability to health risks and the unequal power relationships between the sexes into account are more likely to be successful and effective compared to policies that are not concerned with such differences, and (ii) discuss what is required to build a multisectoral policy response to gender inequities in health through health promotion and disease prevention. The requirements discussed in the paper include i) the establishment of joint commitment for policy within society through setting objectives related to gender equality and equity in health as well as health promotion, ii) an assessment and analysis of gender inequalities affecting health and determinants of health, iii) the actions needed to tackle the main determinants of those inequalities and iv) documentation and dissemination of effective and gender sensitive policy interventions to promote health. In the discussion of these key policy elements, we use illustrative examples of good practices from different countries around the world.

Assessing cost-effectiveness in mental health : vocational rehabilitation for schizophrenia and related conditions

Objective: Existing evidence suggests that vocational rehabilitation services, in particular individual placement and support (IPS), are effective in assisting people with schizophrenia and related conditions gain open employment. Despite this, such services are not available to all unemployed people with schizophrenia who wish to work. Existing evidence suggests that while IPS confers no clinical advantages over routine care, it does improve the proportion of people returning to employment. The objective of the current study is to investigate the net benefit of introducing IPS services into current mental health services in Australia.

Method: The net benefit of IPS is assessed from a health sector perspective using cost–benefit analysis. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis of the net benefit, defined as the benefits of IPS (comprising transfer payments averted, income tax accrued and individual income earned) minus the costs. The second stage involves application of 'second-filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using the multivariate probabilistic sensitivity analysis.

Results: The costs of IPS are $A10.3M (95% uncertainty interval $A7.4M–$A13.6M), the benefits are $A4.7M ($A3.1M–$A6.5M), resulting in a negative net benefit of $A5.6M ($A8.4M–$A3.4M).

Conclusions: The current analysis suggests that IPS costs are greater than the monetary benefits. However, the evidence-base of the current analysis is weak. Structural conditions surrounding welfare payments in Australia create disincentives to full-time employment for people with disabilities.

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.

People, places and public health : evaluating the benefits of civic environmentalism in an urban local government context

Recent political, economic and social trends pose threats to the sustainability both of ecosystems and of human health. Australia’s environmental management record is poor, and while by international standards Australians enjoy good health, this is variable (AIHW, 2000). Within developed nations, heart disease, depression, alcohol dependence and stroke are major health issues (Mathers et al. 2002). In Australia, mental disorder is the number one contributor to the disease burden (Vos & Mathers 2000). Recent research has highlighted the role of social capital as a key determinant of health (Kawachi et al., 1997). Despite this, Putnam (1995) observes that social connectedness and civic engagement are in decline. People have less time for leisure and for volunteering, as many juggle paid work and caring for children. Anecdotal evidence suggests that engagement in civic environmentalism has human health benefits, relating to a combination of exposure to natural environments and increased social capital (Maller, Brown, Townsend & St. Leger, 2002). This link is supported by Furnass (1996) who defines well-being as including: satisfactory human relationships, meaningful occupation, opportunities for contact with nature, creative expression, and making a positive contribution to human society. Research conducted by Deakin University confirms the efficacy of linking people and places through civic environmentalism for addressing both ecosystem sustainability and human health and wellbeing. The research has included a pilot study to explore the human health benefits of membership of a local parkland ‘Friends’ group, and a more detailed follow-up study. The aims of the pilot study included:- To identify the range of motivations for joining the Friends group;- To document members’ perceptions of the benefits gained from membership of the group;- To assess the potential for Friends groups to be used as an ‘upstream’ health promotion measure.Face-to-face interviews were conducted with eleven members of a ‘Friends’ group in the eastern suburbs of Melbourne. Data was analysed thematically and key findings included:- Motivations: environmental; social; and pragmatic.- General benefits: community belonging; personal satisfaction; learning opportunities; physical activity; and better environment.- Health benefits: physical health; mental health; and social support. There was unanimous support for the use of ‘Friends’ groups as a tool for health promotion.The follow-up study, in the western suburbs of Melbourne, expanded on the pilot study by measuring the group’s social capital and by collecting self-report data on levels of health service usage. Data was collected through face-to-face interviews and a questionnaire. The findings were similar to the pilot study in relation to the motivations, benefits and the health promotion potential of such groups. However, health service usage data highlighted an apparent anomaly: while respondents perceived significant health benefits, some were nevertheless utilising health services at a relatively high level. This poses some questions requiring further exploration: Is this due to the poorer baseline health of the high health service usage members compared with their fellow members? Does involvement in the group offer health benefits that enable people who would otherwise be too unhealthy to participate in community groups to continue such involvement?If this is the case, then we may do well to look to locally-based mechanisms for promoting ecological sustainability as a tool also for promoting human health. Instead of prescribing a pill, connecting people and places through engagement with a local friends group may address our health problems at the same time as addressing local environmental problems.

Cultural diversity and mental health : the relationship between leisure experiences and wellbeing in an ageing Italian community in Australia

One of the population health implications for Australia’s ageing population is that a larger proportion of the Australian community will be retired and have more time for leisure pursuits. Meaningful leisure activities for this group are thought to be a factor in promoting positive mental health. However, a search of health literature revealed a paucity of research on how older adults make use of their leisure time, what meaning these pursuits have to them, and whether their chosen leisure activities are health enhancing and promote wellbeing. Australia’s population is diverse with many cultures represented. As the population ages, mental health workers will be called upon to provide culturally-appropriate mental health services to clients from a range of ethnic groups. Literature on how people of culturally diverse backgrounds understand leisure activities is also limited. This paper reports on a study carried out in an Italian community in a large regional centre. The participants were selected based on the following criteria; aged 65 years and over, born in Italy, independently living in the community, ambulant, and retired from paid workforce. This study explored how a well-elderly group from an ethnic community derived meaning from their leisure activities and how this impacted on their mental health. Establishing the relationship between leisure and mental health in an ageing ethnic community is important because it sheds light on potential intervention strategies that can be used to maintain the mental health of people living independently in the community. Participants were interviewed using semi-structured questions about their perceptions of leisure, the meanings they derived from these activities, and their perceived impact of these activities on their health. Participant observation was also used to add trustworthiness to the data. Themes arising from the interviews and participant observation will be related to the participants’ sense of health. Results also revealed how older Italians engaged in leisure activities. Implications of the research findings will be directed towards mental health practice with older ethnic clients in community settings. The promotion of healthy lifestyles and positive mental health for Australia’s ageing population will also be discussed.