Toby Freeman

Brief interventions: good in theory but weak in practice

A substantial body of research evidence has accumulated in support of the efficacy of brief interventions for a number of alcohol and drug-related problem areas, most notably alcohol and tobacco. This evidence has been used to exhort a range of professional groups such as general practitioners (GPs), and more recently emergency department hospital staff to engage in brief interventions. Internationally, however, these secondary prevention efforts have largely failed. Why have these proven interventions not been embraced by frontline workers? This is a little-asked question as efforts to press-gang unwilling professionals to take up the cudgel continue. This paper examines the characteristics of brief interventions and their principal delivery agents and explores reasons for the failure to move from efficacy to effectiveness. Given the prevention potential that rests with brief intervention, these are crucial questions to address. A key feature of brief intervention delivery also examined is the role of GPs versus the less well-explored option of the practice nurse. It will be proposed that perhaps we have the right vehicle but the wrong driver and that until closer scrutiny is made of this issue efforts in this key prevention area will continue to fail to achieve optimum results.

Health professionals’ attitudes towards AOD-related work: Moving the traditional focus from education and training to organizational culture

Aim: This article presents a critical review of research on health professionals’ attitudes towards alcohol and other drug (AOD)-related work relevant to both researchers and practitioners. It moves beyond education and training programs to examine the relevance of organizational culture in influencing attitudes. Method: A review of research conducted on health professionals’ attitudes towards AOD-related work, and strategies to develop positive attitudes was undertaken. Findings: 12 evidence-based tenets were identified in regard to attitudes towards AOD-related work. Key findings include the importance of professional attitudes related to confidence and perceived legitimacy of responding, and personal attitudes related to social justice concerns. Education/training and role support were identified as important evidence-based strategies to develop and support positive attitudes. Conclusion: To foster development of positive attitudes and effective responses in regard to AOD-related work a focus that extends beyond the individual worker is required. Education and training are a necessary, but not sufficient, condition to ensure health professionals’ capacity and willingness to respond to AOD issues. Research on organizational culture provides valuable insight into the types of organizational and systems factors likely to influence AOD-related attitudes and work practice. Key strategies to develop an organizational culture supportive of AOD-related work and future research areas are highlighted.

The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints

BackgroundThe Commission on the Social Determinants of Health and the World Health Organization have called for action to address the social determinants of health. This paper considers the extent to which primary health care services in Australia are able to respond to this call. We report on interview data from an empirical study of primary health care centres in Adelaide and Alice Springs, Australia.MethodsSixty-eight interviews were held with staff and managers at six case study primary health care services, regional health executives, and departmental funders to explore how their work responded to the social determinants of health and the dilemmas in doing so. The six case study sites included an Aboriginal Community Controlled Organisation, a sexual health non-government organisation, and four services funded and managed by the South Australian government.ResultsWhile respondents varied in the extent to which they exhibited an understanding of social determinants most were reflexive about the constraints on their ability to take action. Services’ responses to social determinants included delivering services in a way that takes account of the limitations individuals face from their life circumstances, and physical spaces in the primary health care services being designed to do more than simply deliver services to individuals. The services also undertake advocacy for policies that create healthier communities but note barriers to them doing this work. Our findings suggest that primary health care workers are required to transverse “dilemmatic space” in their work.ConclusionsThe absence of systematic supportive policy, frameworks and structure means that it is hard for PHC services to act on the Commission on the Social Determinants of Health’s recommendations. Our study does, however, provide evidence of the potential for PHC services to be more responsive to social determinants given more support and by building alliances with communities and social movements. Further research on the value of community control of PHC services and the types of policy, resource and managerial environments that support action on social determinants is warranted by this study’s findings.

Responding to alcohol and other drug issues: the effect of role adequacy and role legitimacy on motivation and satisfaction

Aims: This study examined the antecedents of health professionals’ motivation and satisfaction in responding to alcohol and other drug (AOD) issues. Building on Shaw and colleagues’ seminal work, the study examined the influence of education, support, AOD experience, and perceptions of role adequacy and role legitimacy. Method: This study involved a national survey of Australian health professionals (N = 351) from two occupations: nurses (N = 223) and mental health professionals (N = 128). Findings: The strongest predictors of role legitimacy and role adequacy were support and the perceived usefulness of education. Satisfaction was predicted by perceived role legitimacy in both samples, and by perceived role adequacy for mental health professionals. Motivation was predicted by perceived role adequacy and role legitimacy in both samples. Conclusion: Identification of support as a key predictor of role adequacy and legitimacy reinforces the importance of workforce development interventions at an organizational or systems level rather than focusing exclusively on the knowledge, skills and experience of an individual worker. Furthermore, the emergence of role legitimacy as the primary predictor of motivation highlights the need to move beyond just the provision of education and training. These findings have important implications for future AOD workforce development strategies.

Methamphetamine use among Australian workers and its implications for prevention

INTRODUCTION AND AIMS Little attention has been directed to the use of methamphetamine among Australian workers. To address this, a study was conducted that examined drug consumption patterns of the Australian work-force. DESIGN AND METHOD A secondary analysis of the 2004 National Drug Strategy Household Survey (NDSHS) data was undertaken that focused on methamphetamine use among those in paid employment. RESULTS Methamphetamine use in the past 12 months was reported by 4.0% of workers compared to 2.2% of respondents not in the paid work-force. A larger proportion of male (4.8%) than female workers (3.0%) used methamphetamine. The highest prevalence occurred among 18-29-year-old workers (11.2%; males: 12.6%; females: 9.4%), and among workers in hospitality (9.5%), construction (5.4%) and transport (5.4%) industries and among tradespeople (6.5%). Significantly more methamphetamine users reported absenteeism compared to users of other illicit drugs and non-drug users. Among respondents reporting methamphetamine use, 13.4% reported absenteeism due to illicit drug use, while 56.8% reported absenteeism due to any illness or injury. Significantly more methamphetamine users (32.9%) reported going to work under the influence than users of other illicit drugs. Compared to users of other illicit drugs, methamphetamine users were also significantly more likely to drive a car, operate heavy machinery or abuse someone while under the influence. DISCUSSION AND CONCLUSIONS The specific details of the profile of workers using methamphetamine and the impact it has on work performance allows for the development of targeted interventions and tailored prevention strategies previously not possible.

Developing a good practice model to evaluate the effectiveness of comprehensive primary health care in local communities

BackgroundThis paper describes the development of a model of Comprehensive Primary Health Care (CPHC) applicable to the Australian context. CPHC holds promise as an effective model of health system organization able to improve population health and increase health equity. However, there is little literature that describes and evaluates CPHC as a whole, with most evaluation focusing on specific programs. The lack of a consensus on what constitutes CPHC, and the complex and context-sensitive nature of CPHC are all barriers to evaluation.MethodsThe research was undertaken in partnership with six Australian primary health care services: four state government funded and managed services, one sexual health non-government organization, and one Aboriginal community controlled health service. A draft model was crafted combining program logic and theory-based approaches, drawing on relevant literature, 68 interviews with primary health care service staff, and researcher experience. The model was then refined through an iterative process involving two to three workshops at each of the six participating primary health care services, engaging health service staff, regional health executives and central health department staff.ResultsThe resultant Southgate Model of CPHC in Australia model articulates the theory of change of how and why CPHC service components and activities, based on the theory, evidence and values which underpin a CPHC approach, are likely to lead to individual and population health outcomes and increased health equity. The model captures the importance of context, the mechanisms of CPHC, and the space for action services have to work within. The process of development engendered and supported collaborative relationships between researchers and stakeholders and the product provided a description of CPHC as a whole and a framework for evaluation. The model was endorsed at a research symposium involving investigators, service staff, and key stakeholders.ConclusionsThe development of a theory-based program logic model provided a framework for evaluation that allows the tracking of progress towards desired outcomes and exploration of the particular aspects of context and mechanisms that produce outcomes. This is important because there are no existing models which enable the evaluation of CPHC services in their entirety.

Cultural respect strategies in Australian Aboriginal primary health care services: beyond education and training of practitioners.

Objective: There is little literature on health‐service‐level strategies for culturally respectful care to Aboriginal and Torres Strait Islander Australians. We conducted two case studies, which involved one Aboriginal community controlled health care service and one state government‐managed primary health care service, to examine cultural respect strategies, client experiences and barriers to cultural respect.

Comprehensive primary health care under neo-liberalism in Australia

This paper applies a critical analysis of the impact of neo-liberal driven management reform to examine changes in Australian primary health care (PHC) services over five years. The implementation of comprehensive approaches to primary health care (PHC) in seven services: five state-managed and two non-government organisations (NGOs) was tracked from 2009 to 2014. Two questions are addressed: 1) How did the ability of Australian PHC services to implement comprehensive PHC change over the period 2009-2014? 2) To what extent is the ability of the PHC services to implement comprehensive PHC shaped by neo-liberal health sector reform processes? The study reports on detailed tracking and observations of the changes and in-depth interviews with 63 health service managers and practitioners, and regional and central health executives. The documented changes were: in the state-managed services (although not the NGOs) less comprehensive service coverage and more focus on clinical services and integration with hospitals and much less development activity including community development, advocacy, intersectoral collaboration and attention to the social determinants. These changes were found to be associated with practices typical of neo-liberal health sector reform: considerable uncertainty, more directive managerial control, budget reductions and competitive tendering and an emphasis on outputs rather than health outcomes. We conclude that a focus on clinical service provision, while highly compatible with neo-liberal reforms, will not on its own produce the shifts in population disease patterns that would be required to reduce demand for health services and promote health. Comprehensive PHC is much better suited to that task.

Service providers' views of community participation at six Australian primary healthcare services: scope for empowerment and challenges to implementation

Community participation is a key principle of comprehensive primary health care (PHC). There is little literature on how community participation is implemented at Australian PHC services. As part of a wider study conducted in partnership with five South Australian PHC services, and one Aboriginal community controlled health service in the Northern Territory, 68 staff, manager, regional health executives, and departmental funders were interviewed about community participation, perceived benefits, and factors that influenced implementation. Additional data were collected through analysis of policy documents, service reports on activity, and a web-based survey completed by 130 staff. A variety of community participation strategies was reported, ranging from consultation and participation as a means to improve service quality and acceptability, to substantive and structural participation strategies with an emphasis on empowerment. The Aboriginal community controlled health service in our study reported the most comprehensive community participation. Respondents from all services were positive about the benefits of participation but reported that efforts to involve service users had to compete with a centrally directed model of care emphasising individual treatment services, particularly at state-managed services. More empowering substantive and structural participation strategies were less common than consultation or participation used to achieve prescribed goals. The most commonly reported barriers to community participation were budget and lack of flexibility in service delivery. The current central control of the state-managed services needs to be replaced with more local management decision making if empowering community participation is to be strengthened and embedded more effectively in the culture of services.

Health promotion in Australian multi-disciplinary primary health care services: case studies from South Australia and the Northern Territory

This paper reports on the health promotion and disease prevention conducted at Australian multi-disciplinary primary health care (PHC) services and considers the ways in which the organizational environment affects the extent and type of health promotion and disease prevention activity. The study involves five PHC services in Adelaide and one in Alice Springs. Four are managed by a state health department and two by boards of governance. The study is based on an audit of activities and on 68 interviews conducted with staff. All the sites undertake health promotion and recognize its importance but all report that this activity is under constant pressure resulting from the need to provide services to people who have health problems. We also found an increased focus on chronic disease management and prevention which prioritized individuals and behavioural change strategies rather than addressing social determinants affecting whole communities. There was little health promotion work that reflected a salutogenic approach to the creation of health. Most activity falls under three types: parenting and child development, chronic disease prevention and mental health. Only the non-government organizations reported advocacy on broader policy issues. Health reform and consequent reorganizations were seen to reduce the ability of some services to undertake health promotion. The paper concludes that PHC in Australia plays an important role in disease prevention, but that there is considerable scope to increase the amount of community-based health promotion which focuses on a salutogenic view of health and which engages in community partnerships.