Jeffrey Fuller

Self-management support and training for patients with chronic and complex conditions improves health-related behaviour and health outcomes

The Sharing Health Care SA chronic disease self-management (CDSM) project in rural South Australia was designed to assist patients with chronic and complex conditions (diabetes, cardiovascular disease and arthritis) to learn how to participate more effectively in the management of their condition and to improve their self-management skills. Participants with chronic and complex conditions were recruited into the Sharing Health Care SA program and offered a range of education and support options (including a 6-week peer-led chronic disease self-management program) as part of the Enhanced Primary Care care planning process. Patient self-reported data were collected at baseline and subsequent 6-month intervals using the Partners in Health (PIH) scale to assess self-management skill and ability for 175 patients across four data collection points. Health providers also scored patient knowledge and self-management skills using the same scale over the same intervals. Patients also completed a modified Stanford 2000 Health Survey for the same time intervals to assess service utilisation and health-related lifestyle factors. Results show that both mean patient self-reported PIH scores and mean health provider PIH scores for patients improved significantly over time, indicating that patients demonstrated improved understanding of their condition and improved their ability to manage and deal with their symptoms. These results suggest that involvement in peer-led self-management education programs has a positive effect on patient self-management skill, confidence and health-related behaviour.

Mental health and well-being within rural communities: The Australian Rural Mental Health Study

OBJECTIVE This paper outlines the methods and baseline data from a multisite cohort study of the determinants and outcomes of mental health and well-being within rural and remote communities. METHODS A stratified random sample of adults was drawn in non-metropolitan New South Wales using the Australian Electoral Roll, with the aim of recruiting all adult members of each household. Surveys assessed psychological symptoms, physical health and mental disorders, along with individual-, family/household- and community-level characteristics. A stratified subsample completed a telephone-administered World Mental Health-Composite International Diagnostic Interview (World Mental Health-3.0). Proxy measures of child health and well-being were obtained. Follow up of this sample will be undertaken at one, three and five years. RESULTS A total of 2639 individuals were recruited (1879 households), with 28% from remote/very remote regions. A significant relationship was found between recent distress (Kessler-10 scores), age and remoteness, with a linear reduction of Kessler-10 scores with age and the lowest mean scores in remote regions. CONCLUSIONS Existing rurality categories cannot address the diverse socio-cultural, economic and environmental characteristics of non-metropolitan regions. While it has limitations, the dataset will enable a fine-grained examination of geographic, household and community factors and provide a unique longitudinal dataset over a five-year period.

The TrueBlue model of collaborative care using practice nurses as case managers for depression alongside diabetes or heart disease: a randomised trial

Objectives To determine the effectiveness of collaborative care in reducing depression in primary care patients with diabetes or heart disease using practice nurses as case managers. Design A two-arm open randomised cluster trial with wait-list control for 6 months. The intervention was followed over 12 months. Setting Eleven Australian general practices, five randomly allocated to the intervention and six to the control. Participants 400 primary care patients (206 intervention, 194 control) with depression and type 2 diabetes, coronary heart disease or both. Intervention The practice nurse acted as a case manager identifying depression, reviewing pathology results, lifestyle risk factors and patient goals and priorities. Usual care continued in the controls. Main outcome measure A five-point reduction in depression scores for patients with moderate-to-severe depression. Secondary outcome was improvements in physiological measures. Results Mean depression scores after 6 months of intervention for patients with moderate-to-severe depression decreased by 5.7±1.3 compared with 4.3±1.2 in control, a significant (p=0.012) difference. (The plus–minus is the 95% confidence range.) Intervention practices demonstrated adherence to treatment guidelines and intensification of treatment for depression, where exercise increased by 19%, referrals to exercise programmes by 16%, referrals to mental health workers (MHWs) by 7% and visits to MHWs by 17%. Control-practice exercise did not change, whereas referrals to exercise programmes dropped by 5% and visits to MHWs by 3%. Only referrals to MHW increased by 12%. Intervention improvements were sustained over 12 months, with a significant (p=0.015) decrease in 10-year cardiovascular disease risk from 27.4±3.4% to 24.8±3.8%. A review of patients indicated that the studys safety protocols were followed. Conclusions TrueBlue participants showed significantly improved depression and treatment intensification, sustained over 12 months of intervention and reduced 10-year cardiovascular disease risk. Collaborative care using practice nurses appears to be an effective primary care intervention. Trial registration ACTRN12609000333213 (Australia and New Zealand Clinical Trials Registry).

Vietnamese women and pap smears: issues in promotion

Objective: Australian data indicate that Vietnamese‐born women in Australia have a significantly higher incidence of cervical cancer than other Australian women. This study explored self‐reported factors associated with Vietnamese‐born womens participation in cervical screening.

Factors associated with reported service use for mental health problems by residents of rural and remote communities: cross-sectional findings from a baseline survey

BackgroundThe patterns of health service use by rural and remote residents are poorly understood and under-represented in national surveys. This paper examines professional and non-professional service use for mental health problems in rural and remote communities in Australia.MethodsA stratified random sample of adults was drawn from non-metropolitan regions of New South Wales, Australia as part of a longitudinal population-based cohort. One-quarter (27.7%) of the respondents were from remote or very remote regions. The socio-demographic, health status and service utilization (professional and non-professional) characteristics of 2150 community dwelling residents are described. Hierarchical logistic regressions were used to identify cross-sectional associations between socio-demographic, health status and professional and non-professional health service utilization variables.ResultsThe overall rate of professional contacts for mental health problems during the previous 12 months (17%) in this rural population exceeded the national rate (11.9%). Rates for psychologists and psychiatrists were similar but rates for GPs were higher (12% vs. 8.1%). Non-professional contact rates were 12%. Higher levels of help seeking were associated with the absence of a partner, poorer finances, severity of mental health problems, and higher levels of adversity. Remoteness was associated with lower utilization of non-professional support. A Provisional Service Need Index was devised, and it demonstrated a broad dose–response relationship between severity of mental health problems and the likelihood of seeking any professional or non-professional help. Nevertheless, 47% of those with estimated high service need had no contact with professional services.ConclusionsAn examination of self-reported patterns of professional and non-professional service use for mental health problems in a rural community cohort revealed relatively higher rates of general practitioner attendance for such problems compared with data from metropolitan centres. Using a measure of Provisional Service Need those with greater needs were more likely to access specialist services, even in remote regions, although a substantial proportion of those with the highest service need sought no professional help. Geographic and financial barriers to service use were identified and perception of service adequacy was relatively low, especially among those with the highest levels of distress and greatest adversity.

Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study

Background Patients can have an important role in reducing harm in primary-care settings. Learning from patient experience and feedback could improve patient safety. Evidence that captures patients’ views of the various contributory factors to creating safe primary care is largely absent. The aim of this study was to address this evidence gap. Methods Four focus groups and eight semistructured interviews were conducted with 34 patients and carers from south-east Australia. Participants were asked to describe their experiences of primary care. Audio recordings were transcribed verbatim and specific factors that contribute to safety incidents were identified in the analysis using the Yorkshire Contributory Factors Framework (YCFF). Other factors emerging from the data were also ascertained and added to the analytical framework. Results Thirteen factors that contribute to safety incidents in primary care were ascertained. Five unique factors for the primary-care setting were discovered in conjunction with eight factors present in the YCFF from hospital settings. The five unique primary care contributing factors to safety incidents represented a range of levels within the primary-care system from local working conditions to the upstream organisational level and the external policy context. The 13 factors included communication, access, patient factors, external policy context, dignity and respect, primary–secondary interface, continuity of care, task performance, task characteristics, time in the consultation, safety culture, team factors and the physical environment. Discussion Patient and carer feedback of this type could help primary-care professionals better understand and identify potential safety concerns and make appropriate service improvements. The comprehensive range of factors identified provides the groundwork for developing tools that systematically capture the multiple contributory factors to patient safety.

Acceptability of participatory social network analysis for problem-solving in Australian Aboriginal health service partnerships.

BackgroundWhile participatory social network analysis can help health service partnerships to solve problems, little is known about its acceptability in cross-cultural settings. We conducted two case studies of chronic illness service partnerships in 2007 and 2008 to determine whether participatory research incorporating social network analysis is acceptable for problem-solving in Australian Aboriginal health service delivery.MethodsLocal research groups comprising 13–19 partnership staff, policy officers and community members were established at each of two sites to guide the research and to reflect and act on the findings. Network and work practice surveys were conducted with 42 staff, and the results were fed back to the research groups. At the end of the project, 19 informants at the two sites were interviewed, and the researchers conducted critical reflection. The effectiveness and acceptability of the participatory social network method were determined quantitatively and qualitatively.ResultsParticipants in both local research groups considered that the network survey had accurately described the links between workers related to the exchange of clinical and cultural information, team care relationships, involvement in service management and planning and involvement in policy development. This revealed the function of the teams and the roles of workers in each partnership. Aboriginal workers had a high number of direct links in the exchange of cultural information, illustrating their role as the cultural resource, whereas they had fewer direct links with other network members on clinical information exchange and team care. The problem of their current and future roles was discussed inside and outside the local research groups. According to the interview informants the participatory network analysis had opened the way for problem-solving by “putting issues on the table”. While there were confronting and ethically challenging aspects, these informants considered that with flexibility of data collection to account for the preferences of Aboriginal members, then the method was appropriate in cross-cultural contexts for the difficult discussions that are needed to improve partnerships.ConclusionCritical reflection showed that the preconditions for difficult discussions are, first, that partners have the capacity to engage in such discussions, second, that partners assess whether the effort required for these discussions is balanced by the benefits they gain from the partnership, and, third, that “boundary spanning” staff can facilitate commitment to partnership goals.

Service provision for older people with mental health problems in a rural area of Australia

Objectives: Unmet mental health care needs of older people (aged 65 and over) have been identified as a serious problem internationally, particularly in rural areas. In this study we explored the views of health and social care providers of the barriers to effective mental health care for older people in a rural region in Australia.Method: Semi-structured interviews were conducted with 19 participants from 13 organisations providing care and support to older people in a rural region of Australia. A framework analysis approach was used to thematically analyse the data.Results: Two main themes were identified: ‘Recognising the Problem’ and ‘Service Availability and Access’. In particular the participants identified the impact of the attitudes of older people and health professionals, as well as service inadequacies and gaps in services, on the provision of mental health care to older people in a rural region.Conclusion: This study supports previous work on intrinsic and extrinsic barriers to older people with mental health problems accessing mental health services. The study also offers new insight into the difficulties that arise from the separation of physical and mental health systems for older people with multiple needs, and the impact of living in a rural region on unmet mental health care needs of older people.

Intercultural health care as reflective negotiated practice.

This interpretive study sought to understand how intercultural health care to immigrants can be practically conceptualized in multicultural populations. Interviews were conducted with 20 Canadian health service informants, and 12 interviews were staged during 31 months with a multicultural coordinator in an Australian teaching hospital. Transcripts of 11 previously con-ducted group discussions with 34 staff members from this same Australian hospital were also included. Interpretation was based on these data as well as on the literature and the authors own experience. It was concluded that intercultural health care can be practically conceptualized as reflective health worker practice. Through this practice, responsive care can be situationally negotiated between the health worker and the client in a framework of jointly considered needs. For implementation, the barriers to negotiation must be addressed.

Secondary prevention of osteoporosis post minimal trauma fracture in an Australian regional and rural population

OBJECTIVE Minimal trauma fracture (MTF) is an indication of osteoporosis and risk of future fracture. Our objective was to describe osteoporosis risk identification and secondary prevention in a regional and rural population hospitalised for an MTF. DESIGN A retrospective inpatient file audit and follow-up telephone interview. SETTING Patients aged 45 years and over admitted for MTF management to two regional hospitals in northern New South Wales between July 2006 and June 2007. MAIN OUTCOME MEASURES Proportion of patients who received bone mineral densitometry (BMD) assessment and proportion commenced on osteoporosis medication post fracture. RESULTS There were 459 patients included in our inpatient file audit. During admission only 16% had osteoporosis risk documented, uptake of vitamin D assay or BMD were minimal and only 22% were discharged on preventive medication. Of 219 patients contacted post discharge, 36% reported discussing osteoporosis risk with their GPs, 22% reported post-discharge BMD and 32% were taking a bisphosphonate. Men were less likely to have commenced preventive medication (OR 0.42, CI, 0.19-0.91) and patients informed of their osteoporosis risk during hospitalisation were more likely to have had BMD (OR 1.93, CI, 1.03-3.61). Neither age nor history of previous MTF was predictive of preventive treatment post discharge. CONCLUSION Overall, fracture risk identification and initiation of secondary prevention in this regional and rural population was low and this is consistent with findings in recent metropolitan studies. Effective regional and rural strategies are required that ensure identification and effective communication of risk to patients and their GPs.