The health outcomes and costs of people attending an interdisciplinary chronic disease service in regional Australia : protocol for a longitudinal cohort investigation

Background Rates of chronic disease are escalating around the world. To date health service evaluations have focused on interventions for single chronic diseases. However, evaluations of the effectiveness of new intervention strategies that target single chronic diseases as well as multimorbidity are required, particularly in areas outside major metropolitan centres where access to services, such as specialist care, is difficult and where the retention and recruitment of health professionals affects service provision. Methods This study is a longitudinal investigation with a baseline and three follow-up assessments comparing the health and health costs of people with chronic disease before and after intervention at a chronic disease clinic, in regional Australia. The clinic is led by students under the supervision of health professionals. The study will provide preliminary evidence regarding the effectiveness of the intervention, and evaluate the influence of a range of factors on the health outcomes and costs of the patients attending the clinic. Patients will be evaluated at baseline (intake to the service), and at 3-, 6-, and 12-months after intake to the service. Health will be measured using the SF-36 and health costs will be measured using government and medical record sources. The intervention involves students and health professionals from multiple professions working together to treat patients with programs that include education and exercise therapy programs for back pain, and Healthy Lifestyle programs; as well as individual consultations involving single professions. Discussion Understanding the effect of a range of factors on the health state and health costs of people attending an interdisciplinary clinic will inform health service provision for this clinical group and will determine which factors need to be controlled for in future observational studies. Preliminary evidence regarding changes in health and health costs associated with the intervention will be a platform for future clinical trials of intervention effectiveness. The results will be of interest to teams investigating new chronic disease programs particularly for people with multimorbidity, and in areas outside major metropolitan centres.

Do palliative care health professionals settle for low level evidence?

The findings of the recent independent review of the UK Liverpool Care Pathway (LCP)1, following substantial concerns raised by members of the public and health professionals found that the implementation of the LCP is often associated with poor care1. The Neuberger Report highlighted the complexity of various ethical, safety, clinical practice and negligence issues associated with pathway usage and how, despite technological advances, diagnosing dying continues to be challenging. The UK Government’s decision to phase out the LCP as policy following these findings, has generated considerable debate both within and beyond the UK. However, another key issue raised by the Neuberger’s report is the issue of the palliative care community’s perceived willingness to readily adopt new clinical practices in the absence of evidence. It is this translational issue that this editorial explores.

Project governance : ethical decision making in project procurement in the Malaysian public sectors

Managing public sector projects in Malaysia is a unique challenge. This is because of the ethical issues involved during the project procurement process. These ethical issues need attention because they will have an impact on the quality, cost and time of the project itself. The ethical issues here include conflict of interest, bid shopping, collusive tendering, bid cutting, corruption and the payment game. In 2006, 17.3% of 417 Malaysian government contract projects were considered sick due to contractors' performances that failed to conduct the project according to the project plan. Some of the sick projects from these statistics are due to the ethical issues involved. These construction projects have low quality due to the selection of the contractors, done unethically due to personal relationships instead of professional qualifications. That is why it is important to govern the project procurement processes to ensure the accountability and transparency of the decision making process to ensure that these ethical issues can be avoided. Extensive research has been conducted on the ethical issues in the tendering process or the award phase of project management. There is a lack of studies looking at the role of clients, including the government client, in relation to unethical practice in project procurement in the public sector. It is important to understand that ethical issues not only involve the contractors and suppliers but also the clients. Even though there are codes of ethics in the public sectors, ethical issues still arise. Therefore, this research develops a project governance framework (PGEDM) for ethical decision making in the Malaysian public sectors. This framework combines the ethical decision making process together with the project governance principals in guiding the public sectors with ethical decision making in project procurement. A triangulation of questionnaire survey and Delphi study was employed in this research to collect required qualitative and quantitative data. A questionnaire survey was conducted among the public officials (the practitioners) who are currently working in the procurement area in the Malaysian public sectors, in identifying the ethical behaviours and factors influencing further ethical behaviour to occur. A Delphi study was also conducted with the assistance of a panel of experts consisting of practitioners that have expertise in the area of project governance and project procurement as well as academician, which further considered the relationship and the influence of the criteria and indicators of ethical decision making (EDM) and project governance (project criteria, organisational culture, contract award criteria, individual criteria, client's requirements, government procedures and professional ethics). Through the identification and integration of the factors and EDM criteria as well as the project governance criteria and EDM steps for ethical issues, a PGEDM framework was developed to promote, and drive consistent decision outcome in project procurement in the public sector. The framework contributes significantly to ethical decision making in the project procurement process. These findings not only give benefit to the people involved in project procurement but also to the public officials in guiding them to be more accountable in handling ethical issues in the future and to have a more transparent decision making process.

The health effects of temperature : current estimates, future projections, and adaptation strategies

Climate change is expected to be one of the biggest global health threats in the 21st century. In response to changes in climate and associated extreme events, public health adaptation has become imperative. This thesis examined several key issues in this emerging research field. The thesis aimed to identify the climate-health (particularly temperature-health) relationships, then develop quantitative models that can be used to project future health impacts of climate change, and therefore help formulate adaptation strategies for dealing with climate-related health risks and reducing vulnerability. The research questions addressed by this thesis were: (1) What are the barriers to public health adaptation to climate change? What are the research priorities in this emerging field? (2) What models and frameworks can be used to project future temperature-related mortality under different climate change scenarios? (3) What is the actual burden of temperature-related mortality? What are the impacts of climate change on future burden of disease? and (4) Can we develop public health adaptation strategies to manage the health effects of temperature in response to climate change? Using a literature review, I discussed how public health organisations should implement and manage the process of planned adaptation. This review showed that public health adaptation can operate at two levels: building adaptive capacity and implementing adaptation actions. However, there are constraints and barriers to adaptation arising from uncertainty, cost, technologic limits, institutional arrangements, deficits of social capital, and individual perception of risks. The opportunities for planning and implementing public health adaptation are reliant on effective strategies to overcome likely barriers. I proposed that high priorities should be given to multidisciplinary research on the assessment of potential health effects of climate change, projections of future health impacts under different climate and socio-economic scenarios, identification of health cobenefits of climate change policies, and evaluation of cost-effective public health adaptation options. Heat-related mortality is the most direct and highly-significant potential climate change impact on human health. I thus conducted a systematic review of research and methods for projecting future heat-related mortality under different climate change scenarios. The review showed that climate change is likely to result in a substantial increase in heatrelated mortality. Projecting heat-related mortality requires understanding of historical temperature-mortality relationships, and consideration of future changes in climate, population and acclimatisation. Further research is needed to provide a stronger theoretical framework for mortality projections, including a better understanding of socioeconomic development, adaptation strategies, land-use patterns, air pollution and mortality displacement. Most previous studies were designed to examine temperature-related excess deaths or mortality risks. However, if most temperature-related deaths occur in the very elderly who had only a short life expectancy, then the burden of temperature on mortality would have less public health importance. To guide policy decisions and resource allocation, it is desirable to know the actual burden of temperature-related mortality. To achieve this, I used years of life lost to provide a new measure of health effects of temperature. I conducted a time-series analysis to estimate years of life lost associated with changes in season and temperature in Brisbane, Australia. I also projected the future temperaturerelated years of life lost attributable to climate change. This study showed that the association between temperature and years of life lost was U-shaped, with increased years of life lost on cold and hot days. The temperature-related years of life lost will worsen greatly if future climate change goes beyond a 2 °C increase and without any adaptation to higher temperatures. The excess mortality during prolonged extreme temperatures is often greater than the predicted using smoothed temperature-mortality association. This is because sustained period of extreme temperatures produce an extra effect beyond that predicted by daily temperatures. To better estimate the burden of extreme temperatures, I estimated their effects on years of life lost due to cardiovascular disease using data from Brisbane, Australia. The results showed that the association between daily mean temperature and years of life lost due to cardiovascular disease was U-shaped, with the lowest years of life lost at 24 °C (the 75th percentile of daily mean temperature in Brisbane), rising progressively as temperatures become hotter or colder. There were significant added effects of heat waves, but no added effects of cold spells. Finally, public health adaptation to hot weather is necessary and pressing. I discussed how to manage the health effects of temperature, especially with the context of climate change. Strategies to minimise the health effects of high temperatures and climate change can fall into two categories: reducing the heat exposure and managing the health effects of high temperatures. However, policy decisions need information on specific adaptations, together with their expected costs and benefits. Therefore, more research is needed to evaluate cost-effective adaptation options. In summary, this thesis adds to the large body of literature on the impacts of temperature and climate change on human health. It improves our understanding of the temperaturehealth relationship, and how this relationship will change as temperatures increase. Although the research is limited to one city, which restricts the generalisability of the findings, the methods and approaches developed in this thesis will be useful to other researchers studying temperature-health relationships and climate change impacts. The results may be helpful for decision-makers who develop public health adaptation strategies to minimise the health effects of extreme temperatures and climate change.

Rural self-reliance: the impact on health experiences of people living with type II diabetes in rural Queensland, Australia

Objective: The objective of the study was to explore whether and how rural culture influences type II diabetes management and to better understand the social processes that rural people construct in coping with diabetes and its complications. In particular, the study aimed to analyse the interface and interactions between rural people with type II diabetes and the Australian health care system, and to develop a theoretical understanding that reflects constructs that may be more broadly applicable. Methods: The study applied constructivist grounded theory methods within an interpretive interactionist framework. Data from 39 semi-structured interviews with rural and urban type II diabetes patients and a mix of rural health care providers were analysed to develop a theoretical understanding of the social processes that define diabetes management in that context. Results: The analysis suggests that although type II diabetes imposes limitations that require adjustment and adaptation, these processes are actively negotiated by rural people within the environmental context to fit the salient social understandings of autonomy and self-reliance. Thus, people normalized self-reliant diabetes management behaviours because this was congruent with the rural culture. Factors that informed the actions of normalization were relationships between participants and health care professionals, support, and access to individual resources. Conclusions: The findings point to ways in which rural self-reliance is conceived as the primary strategy of diabetes management. People face the paradox of engaging with a health care system that at the same time maximizes individual responsibility for health and minimizes the social support by which individuals manage the condition. The emphasis on self-reliance gives some legitimacy to a lack of prevention and chronic care services. Success of diabetes management behaviours is, however, contingent on relative resources. Where there is good primary care, there develops a number of downstream effects including a sense of empowerment to manage difficult rural environmental circumstances. This has particular bearing on health outcomes for people with fewer resources.

Food and Brisbane households : dietary, social and health consequences of food insecurity

Background & Aims: Access to sufficient amounts of safe and culturally-acceptable foods is a fundamental human right. Food security exists when all people, at all times, have physical, social, and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life. Food insecurity therefore occurs when the availability or access to sufficient amounts of nutritionally-adequate, culturally-appropriate and safe foods, or, the ability to acquire such foods in socially-acceptable ways, is limited. Food insecurity may result in significant adverse effects for the individual and these outcomes may vary between adults and children. Among adults, food insecurity may be associated with overweight or obesity, poorer self-rated general health, depression, increased health-care utilisation and dietary intakes less consistent with national recommendations. Among children, food insecurity may result in poorer self or parent-reported general health, behavioural problems, lower levels of academic achievement and poor social outcomes. The majority of research investigating the potential correlates of food insecurity has been undertaken in the United States (US), where regular national screening for food insecurity is undertaken using a comprehensive multi-item measurement. In Australia, screening for food insecurity takes place on a three yearly basis via the use of a crude, single-item included in the National Health Survey (NHS). This measure has been shown to underestimate the prevalence of food insecurity by 5%. From 1995 – 2004, the prevalence of food insecurity among the Australian population remained stable at 5%. Due to the perceived low prevalence of this issue, screening for food insecurity was not undertaken in the most recent NHS. Furthermore, there are few Australian studies investigating the potential determinants of food insecurity and none investigating potential outcomes among adults and children. This study aimed to examine these issues by a) investigating the prevalence of food insecurity among households residing in disadvantaged urban areas and comparing prevalence rates estimated by the more comprehensive 18-item and 6-item United States Department of Agriculture (USDA) Food Security Survey Module (FSSM) to those estimated by the current single-item measure used for surveillance in Australia and b) investigating the potential determinants and outcomes of food insecurity, Methods: A comprehensive literature review was undertaken to investigate the potential determinants and consequences of food insecurity among developed countries. This was followed by a cross-sectional study in which 1000 households from the most disadvantaged 5% of Brisbane areas were sampled and data collected via mail-based survey (final response rate = 53%, n = 505). Data were collected for food security status, sociodemographic characteristics (household income, education, age, gender, employment status, housing tenure and living arrangements), fruit and vegetable intakes, meat and take-away consumption, presence of depressive symptoms, presence of chronic disease and body mass index (BMI) among adults. Among children, data pertaining to BMI, parent-reported general health, days away from school and activities and behavioural problems were collected. Rasch analysis was used to investigate the psychometric properties of the 18-, 10- and 6-item adaptations of the USDA-FSSM, and McNemar's test was used to investigate the difference in the prevalence of food insecurity as measured by these three adaptations compared to the current single-item measure used in Australia. Chi square and logistic regression were used to investigate the differences in dietary and health outcomes among adults and health and behavioural outcomes among children. Results were adjusted for equivalised household income and, where necessary, for indigenous status, education and family type. Results: Overall, 25% of households in these urbanised-disadvantaged areas reported experiencing food insecurity; this increased to 34% when only households with children were analysed. The current reliance on a single-item measure to screen for food insecurity may underestimate the true burden among the Australian population, as this measure was shown to significantly underestimate the prevalence of food insecurity by five percentage points. Internationally, major potential determinants of food insecurity included poverty and indicators of poverty, such as low-income, unemployment and lower levels of education. Ethnicity, age, transportation and cooking and financial skills were also found to be potential determinants of food insecurity. Among Australian adults in disadvantaged urban areas, food insecurity was associated with a three-fold increase in experiencing poorer self-rated general health and a two-to-five-fold increase in the risk of depression. Furthermore, adults from food insecure households were twoto- three times more likely to have seen a general practitioner and/or been admitted to hospital within the previous six months, compared to their food secure counterparts. Weight status and intakes of fruits, vegetables and meat were not associated with food insecurity. Among Australian households with children, those in the lowest tertile were over 16 times more likely to experience food insecurity compared to those in the highest tertile for income. After adjustment for equivalised household income, children from food insecure households were three times more likely to have missed days away from school or other activities. Furthermore, children from food insecure households displayed a two-fold increase in atypical emotions and behavioural difficulties. Conclusions: Food insecurity is an important public health issue and may contribute to the burden on the health care system through its associations with depression and increased health care utilisation among adults and behavioural and emotional problems among children. Current efforts to monitor food insecurity in Australia do not occur frequently and use a tool that may underestimate the prevalence of food insecurity. Efforts should be made to improve the regularity of screening for food insecurity via the use of a more accurate screening measure. Most of the current strategies that aim to alleviate food insecurity do not sufficiently address the issue of insufficient financial resources for acquiring food; a factor which is an important determinant of food insecurity. Programs to address this issue should be developed in collaboration with groups at higher risk of developing food insecurity and should incorporate strategies to address the issue of low income as a barrier to food acquisition.

Review: "Health service frameworks for small rural and remote communities: issues and options" by J. Humphreys, S. Mathews-Cowey, F. Rolley 1996

This monograph is a welcome investigation of current issues in rural health service delivery in smaller communities. The underlying assumption is that existing health service frameworks for rural and remote communities with populations of less than 230 are simply- not appropriate for their needs. With this in mind, the authors identify the strengths and weaknesses of frameworks presently utilised, and offer viable alternatives. They have made information accessible to those who wish to improve the delivery of rural health care, and have provided a catalyst for further research and dialogue on rural health issues...

Characteristics of chemotherapy practice in rural and remote area health facilities in Queensland

Objective The overall objective of this study was to document the nature of the chemotherapy nursing practice of rural and remote area nurses in Queensland. Design A questionnaire survey that elicited descriptive quantitative and qualitative data. Setting Forty-seven rural and remote area health facilities in Queensland involved in the administration of chemotherapy. Subjects Sixty-seven Queensland rural and remote area nurses involved in the administration of cytotoxic drugs. Main outcome measures: Characteristics of chemotherapy practice including context of practice, amount and type of chemotherapy administered, logistical problems, level of support from referral centres, policies and procedures, safety issues. Results The results indicate that the risks to nursing staff and the potential for poor patient outcomes are higher than in specialist chemotherapy facilities. This is largely due to the human and material resource constraints characteristic of rural practice. These include a lack of understanding on the part of metropolitan-based health departments and the specialist cancer centres that refer patients to rural areas of the constraints that may adversely influence patient outcomes. Conclusions It is essential that steps are taken to ensure that rural and remote area cancer patients have equitable access to safe and competent chemotherapy care delivered in their choice of context, and the results of this study provide guidance on ways that this can be achieved.

Why nurses are resigning from rural and remote Queensland health facilities

This paper presents a selection of the results reported in the study “Factors Influencing the Recruitment and Retention of Rural and Remote Area Nurses in Queensland” (Hegney et al 2001). The main aim of this study was to determine why nurses in those rural and remote areas of Queensland that reported higher than State average turnover rates between February 1999 and May 2000, chose to leave their employment. The study therefore investigated the factors that influenced nurses' decisions to leave rural and remote area practice, the factors that influenced them to remain in practice and those factors nurses considered irrelevant to leaving or staying in rural/remote area nursing. This paper reports those factors the participants believed influenced them to leave rural and remote area nursing in Queensland. While the findings cannot be generalised to the Australian nursing workforce or to nurses not employed by Queensland Health, the study does confirm the findings of previous Australian research and formulates recommendations to assist future nursing workforce planning and policy.

Effects of size of health service on scope of rural nursing practice

This paper presents the findings of an analysis of the activities of rural nurses from a national audit of the role and function of the rural nurse (Hegney, Pearson and McCarthy 1997). The results suggest that the size of the health service (defined by the number of acute beds) influences the activities of rural nurses. Further, the study reports on the differences of the context of practice between different size rural health services and the impact this has on the scope of rural nursing practice. The paper will conclude that the size of the health service is an outcome of rurality (small population densities, distance from larger health facilities, lack of on-site medical and allied health staff). It also notes that the size of the health service is a major contextual determinant of patient acuity and staff skill-mix in small rural hospitals, and therefore the scope of rural nursing practice.

Experiencing information across the phenomenon of health information literacy

Interest in the concept of information literacy in different contexts is a topic that has steadily gained increased attention in information literacy discourse and research efforts over recent years. In particular the emergence of the term ‘health information literacy’ attests to this interest and has elevated awareness about the importance and relevance of information literacy in a health context. This paper reports on research that has taken a relational perspective to explore how people experience health information literacy. Initially established by Bruce (1997) the relational perspective draws from an experiential framework that emphasizes the relationship between users and information when learning in different contexts. This approach seeks outcomes that are deeply embedded in users’ informational life worlds and complements experiential phenomenological perspectives that have been used in health research. In keeping with the relational approach this research interprets health information literacy as being the different ways in which people experience using information to learn about health. Using interpretive phenomenography, this research explored variation in the lived experience of how people use information to learn about their health, and variation in what is constituted as information when learning about their health. Participants included 23 males and females aged between 45 and 64 years. All participants were residents from the Greater Brisbane area of Queensland, Australia. The research used semi-structured interviews for data collection. The types of questions posed during interviews included ‘Can you describe a time when you used information to learn about your health?’ and ‘What kinds of information have you used to learn about your health?’. This paper will focus on presenting one element of research findings that concerns the differences in ‘what’ participants experienced as information. Analysis of interview data identified significant variation in the experienced nature of information, specifically the different qualities or elements that comprised the ‘object’ of information, or in other words, what was perceived as ‘informing’. Illustrations of this variation include information experienced as traditional information sources, facts and experiences, something exhibiting particular qualities, physical or psychological changes, other people and role models. These findings provide new insights into what people may experience as information, and build upon existing literature regarding information as a theoretical construct. In addition the potential implications of these findings with respect to the design and delivery of health information literacy education will also be discussed. These research findings contribute to the emergence of information literacy investigations in everyday life and community. Although such settings have long been identified as a significant gap for exploration, research to date in this field has predominantly focused on educational and workplace environments. In this way the knowledge gained from this research has further revealed the contextual nature of information literacy, as well as its complexity as a phenomenon and focus of study.

Hepatitis C, mental health and equity of access to antiviral therapy : a systematic narrative review

Introduction Access to hepatitis C (hereafter HCV) antiviral therapy has commonly excluded populations with mental health and substance use disorders because they were considered as having contraindications to treatment, particularly due to the neuropsychiatric effects of interferon that can occur in some patients. In this review we examined access to HCV interferon antiviral therapy by populations with mental health and substance use problems to identify the evidence and reasons for exclusion. Methods We searched the following major electronic databases for relevant articles: PsycINFO, Medline, CINAHL, Scopus, Google Scholar. The inclusion criteria comprised studies of adults aged 18 years and older, peer-reviewed articles, date range of (2002--2012) to include articles since the introduction of pegylated interferon with ribarvirin, and English language. The exclusion criteria included articles about HCV populations with medical co-morbidities, such as hepatitis B (hereafter HBV) and human immunodeficiency virus (hereafter HIV), because the clinical treatment, pathways and psychosocial morbidity differ from populations with only HCV. We identified 182 articles, and of these 13 met the eligibility criteria. Using an approach of systematic narrative review we identified major themes in the literature. Results Three main themes were identified including: (1) pre-treatment and preparation for antiviral therapy, (2) adherence and treatment completion, and (3) clinical outcomes. Each of these themes was critically discussed in terms of access by patients with mental health and substance use co-morbidities demonstrating that current research evidence clearly demonstrates that people with HCV, mental health and substance use co-morbidities have similar clinical outcomes to those without these co-morbidities. Conclusions While research evidence is largely supportive of increased access to interferon by people with HCV, mental health and substance use co-morbidities, there is substantial further work required to translate evidence into clinical practice. Further to this, we conclude that a reconsideration of the appropriateness of the tertiary health service model of care for interferon management is required and exploration of the potential for increased HCV care in primary health care settings.

Acute poststreptococcal glomerulonephritis : public health implications of recent clusters in New South Wales and epidemiology of hospital admissions

Acute poststreptococcal glomerulonephritis (APSGN) is an inflammatory kidney condition that can complicate Group A streptococcal infections. Two clusters of APSGN occurred recently in New South Wales (NSW), Australia; one in a rural town in December 1999 and the other in a Sydney suburb in January 2000. We interviewed carers of the affected children but found no common exposures except three of the Sydney cases were cousins in frequent contact. To assess the probability of these clusters occurring, we analysed hospital admissions for acute glomerulonephritis, as a proxy for APSGN in younger patients. The incidence of acute glomerulonephritis in NSW during 1989/90-1997/8 in residents aged under 20 years was 2(.)2/100000/year (95% CI 2(.)0-2(.)5). Incidence was highest in children aged 5-9 years, boys and Aboriginal children. We found no evidence for other clusters during that period. The recent clusters highlight the continued potential for unexpected future outbreaks of APSGN.

Privacy : bad for your health?

TO THE EDITOR: In Australia, personal and health information that identifies an individual cannot be used or disclosed for research without specific requirements being met.1 Even if these requirements are met, data custodians may still refuse access if their views are discordant with those of the relevant human research ethics committee (HREC). It is now evident that there are adverse consequences of this well-meaning legislation...