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(2012)ReportAustralia accepts more than 13,000 refugee and humanitarian immigrants annually and young people account for a large overall percentage of the refugee population in New South Wales (NSW). There is evidence that refugee families are highly vulnerable to social isolation in their countries of resettlement. The difficulties of refugee settlement are well documented, including the need to learn new languages, negotiate differing cultural and societal values and address past emotional trauma. Development through sport refers to the use of sporting activities to provide opportunities for personal and community development with effects that go well beyond the sphere of physical activity and [elite] player and game development. In recent years there has been an increase in programs that use sport to foster social development and engagement, however little robust research has been performed to evaluate these efforts. Football United ® was developed from a vision that people’s love for Football (soccer) can be used to build opportunities for belonging, racial harmony and community cohesion. Football United ®’s six years of operations confirms the Crawford report findings, and highlights other effects of inequity in participation: • Gaps in equity of participation in both community and public education sector sport which can contribute to general disaffection within society, including leaving school, aggressive behaviour and unemployment as examples. • Lack of opportunity to interact across cultural groups which can translate to racism and the ensuing problems it provokes. Football United ® addresses these issues basing its foundations on the premise that structural variables and social processes act at multiple levels to impact on health and social behaviour. Results of the study underline Football United ®’s positive impact on participating young people’s sense of self, and appreciation for and engagement with peers from diverse backgrounds. Learning from interviews found unanticipated connections between participating in Football United ® and learning English, positive engagement with school, and building self confidence.
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(2017)ThesisObjective To conceptualise a practically adequate theory and methodology of Human Rights Health Impact Assessment (HRHIA) using critical realist (CR) ontological perspectives and research approaches. Research design A CR framework for theory development and verification was applied. It involved four interrelated and iterative steps: description and analytic resolution of events and their effects; explication of structure using abductive and retroductive reasoning; assessment of explanatory power and contextualisation; and verification and concretisation of emergent theory. Application of the framework involved analysis and theorising of data from 23 international human rights (HR) and health impact assessment (HIA) experts; existing case studies of HIAs (11 case studies, 33 interviews) and a HR-based initiative (1 case study, 12 interviews); my own recollections and introspections on HIA projects; and relevant literature. Findings A methodology is conceptualised as an entity with specific properties that give it the power to guide an overall process intended to achieve a defined outcome or purpose. Methodologies can exist in four states: conceptualised, intended, enacted, and experienced. The properties that empower the guidance mechanisms of a methodology include interrelated points of view concerning: the (health rights) environment that the methodology is intended to respond to and influence; relevant knowledge properties of people involved in use of the methodology; the intended purpose and goals of the methodology; the methodology rationale; conceptual frameworks about HRHIA and HR environments that inform decision-making; processes for enacting the methodology that subsume methods, tools and conditions associated with their use; and criteria and standards for evaluating the methodology, and the outcomes when the methodology is enacted. This definition and framework were used to develop an HRHIA-specific methodology framework (state 1) and some aspects of an intended methodology (state 2). The latter included development of a procedural model and identification of potential mechanisms associated with its implementation. Conclusion This research demonstrates that a theory and methodology for HRHIA can be conceptualised using a critical realist theorising framework. The research makes a significant contribution to scholarship associated with the application of a CR paradigm in the contexts of HRHIA and methodology development.
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(2014)Journal ArticlePurpose and setting: The last decade has seen increased use of health impact assessment (HIA) to influence public policies developed outside the Health sector. HIA has developed as a structured, linear and technical process to incorporate health, broadly defined, into policy. This is potentially incongruent with complex, non-linear and tactical policy making which does not necessarily consider health. HIA research has however not incorporated existing public policy theory to explain practitioners’ experiences with HIA and policy. This research, therefore, used public policy theory to explain HIA practitioners’ experiences and investigate ‘What is the fit between HIA and public policy?’ Methods: Empirical findings from nine in-depth interviews with international HIA practitioners were reanalysed against public policy theory. We reviewed the HIA literature for inclusion of public policy theories then compared these for compatibility with our critical realist methodology and the empirical data. The theory ‘Policy Cycles and Subsystems’ (Howlett et al., 2009) was used to re-analyse the empirical data. Findings: HIAs for policy are necessarily both tactical and technical. Within policy subsystems using HIA to influence public policy requires tactically positioning health as a relevant public policy issue and, to facilitate this, institutional support for collaboration between Public Health and other sectors. HIA fits best within the often non-linear public policy cycle as a policy formulation instrument. HIA provides, tactically and technically, a space for practical reasoning to navigate facts, values and processes underlying the substantive and procedural dimensions of policy. Conclusions: Re-analysing empirical experiential data using existing public policy theory provided valuable explanations for future research, policy and practice concerning why and how HIA fits tactically and technically with the world of public policy development. The use of theory and empiricism opens up important possibilities for future research in the search for better explanations of complex practical problems.
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(2010)ReportRecent qualitative research conducted in Sydney suggests that there is considerable stigma attached to mental illness among low-acculturated Chinese-Australians. Under-utilisation of mental health services within Australia’s ethnic communities is well established. It is proposed that culturally-appropriate programs in “Assertive Communication Training” could help reducing acculturation stress (i.e. illness prevention) which, in turn, may open the door to accessing relevant information regarding mental health services (i.e. health promotion). Low-acculturated Chinese (N = 26) were recruited from ethnic media to attend seven, weekly, 90-minute workshops on assertive communication. The interactive program (adapted for non-Westerners) was aimed at improving interpersonal communication skills, especially during cross-cultural encounters. Fact sheets on mental illness and bilingual mental health services were provided seamlessly during the program. Participants completed the Depression Anxiety Stress Scale (DASS) and the Suinn-Lew Self-Identification Acculturation Scale pre- and 6-months post-training. Qualitative data assessing the impact of the program and strategies used to manage daily stress were also collected. Overall, participants rated the program as highly satisfactory. There was a marked improvement across all DASS subscales, particularly the Stress subscale. Pre- to post-training scores indicated a decrease in stress levels from above the normative mean for Chinese Australians (M=7.51) to levels well below this mean (M_T1=7.72; M_T2=6.44), p=.148. The results also indicated a significant improvement on measures of acculturation, p=.001. Finally, the qualitative component of the study yielded a rich description of assertive communication strategies used by participants to resolve conflicts, maintain positive emotional states and boost self-confidence. The results of this small, pilot study yielded positive and encouraging findings. The program, perceived by participants as carrying no stigma, was effective in reducing stress levels and improving acculturation in a sample of low-acculturated Chinese-Australians. The program was well received suggesting that further culturallyappropriate programs are needed to improve the mental health and well-being of Culturally and Linguistically Diverse (CALD) or ethnic minority groups.
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(2013)ThesisBackground Health impact assessment (HIA) and Healthy public policy (HPP) have been used interchangeably in discussions about the increasing interest in influencing public policy to improve health and health equity. This has sometimes conflated expectations about what each approach can deliver, limited understanding of the relationship between them and failed to identify wider influences on the practice of each. Critical realist methodology was used to identify and explain the factors underpinning the relationship between HIA and HPP. Methodology and Method Nine interviews and a workshop were held with international practitioners working in HIA and HPP. First, the empirical data was analysed using established critical realist analytic questions. Second, the empirically generated results were re-described using institutional public policy theory, specifically Howlett et al s Policy cycles and subsystems theory which explains how actors (emphasising people and their relationships), ideas (emphasising content) and institutions (emphasising systems) all play roles in progressing HIA and HPP. Findings Empirically HIA and HPP were demonstrated to be separate yet overlapping entities, each of which has essential and contingent characteristics. Public policy presupposes both HIA and HPP, and five public policy characteristics were identified as influences. Seven other contingent factors influence HIA and HPP and the relationship between them. Against theory HPP is largely concerned, tactically, with agenda-setting and HIA, technically and tactically, with policy formulation. Focussing in on HIA, particular emphasis is placed on substantive and procedural dimensions of public policy making. The findings include the institutional structures and mechanisms acting as conditions surrounding HIA for HPP, how the essential features of HIA fit with public policy making, and how the essential features of HIA as a policy formulation instrument operate and can be strengthened. Three propositions are developed which provide summary explanations for these features. Conclusion Separating the essential elements of HIA and HPP from contingent influences helps practitioners and researchers identify what can be directly controlled or changed to improve practice, and what else needs to be planned for as contingencies largely outside the control of HIA or HPP practitioners. Further case specific research is recommended to test the findings.
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(2014)ThesisGeneral practice has an important role in screening for cardiovascular risk factors and providing appropriate interventions, including education, counseling and referral to address behavioural risk factors. The emotional outcomes of such interventions have not previously been measured. There is also limited evidence about the psychological impact of screening for cardiovascular risk factors and conflicting evidence about the mechanisms of association between mental health and health risk behaviours. This nested exploratory mixed methods study used questionnaires, record audit and participant interviews to investigate the relationship between mental health (using psychological distress as a non-specific measure) and the behavioural risk factors for cardiovascular disease in general practice patients who participated in a cluster randomised controlled trial of a complex general practice based intervention aiming to reduce vascular risk factors (HIPS trial). Four research questions were addressed: is there an association between psychological distress and behavioural risk factors; how does psychological distress influence maintaining or changing behavioural risk factors; what effect does changing behavioural risk factors have on psychological distress; and does the HIPS intervention impact on the participants’ psychological distress? The HIPS intervention, which addressed behavioural risk factors through screening and risk assessment in combination with education and support, did not have negative psychological consequences; and contributed to a small improvement in the mental health of the participants. This improvement was not mediated by a change in lifestyle behaviour or body mass index. However interview findings suggest there is a complex bi-directional association between distress and behaviour. A conceptual model articulating a new theory of the processes involved in behaviour change has been developed. It outlines the relationship between external stressors (stressful events), unhealthy behaviour and mood. Moderators and mediators of the relationships include personality, coping style, social support and beliefs and habits. The model could be used in the design of structured general practice based interventions addressing behavioural risk factors for cardiovascular disease; in the clinical setting to determine effective interventions for individual patients; or in a policy setting as the basis for clinical practice guidelines and regulations.
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(2014)ThesisThis thesis by publication examines the use of equity focused health impact assessment (EFHIA) on health service plans. The research questions addressed are: • What are the direct and indirect impacts of EFHIAs conducted on health sector plans? • Does EFHIA improve the consideration of equity in the development and implementation of health sector plans? • How does EFHIA improve the consideration of equity in health planning? The thesis is made up of seven peer-reviewed publications - five journal articles and two book chapters. It describes the use and evolution of health impact assessment (HIA) and EFHIA internationally and in Australia, how it has been used in relation to health service plans, examines its effectiveness and impacts on decision-making and implementation and examines several EFHIAs using case study and interpretive description methodologies. The thesis makes two substantial theoretical contributions in the form of (i) a typology for HIAs and (ii) a conceptual framework for evaluating the impact and effectiveness of HIAs. This conceptual framework is tested for its applicability to EFHIA in health service planning contexts and refined in this thesis based on three case studies of EFHIAs conducted on health service plans in the state of New South Wales, Australia. This research shows that EFHIA has the potential to have both direct and indirect impacts on health service planning. These impacts are influenced by a broad range of factors however, which are linked to the context in which the EFHIA is undertaken and the inputs into the EFHIA process and the procedures followed. The EFHIAs included in this thesis show that engagement with the EFHIA process and the extent to which EFHIA is regarded as a broader learning process are important factors that mediating the extent to which EFHIAs influence subsequent activities. This research also suggests that it is not possible to adequately describe the full range of impacts of EFHIA on decision-making and implementation without looking at individual perceptions of effectiveness. These perceptions change over time, suggesting that future research on the effectiveness of HIA should look at the mechanisms by which this change occurs.
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(2015)ThesisBACKGROUND: Aboriginal and Torres Strait Islander (Aboriginal) peoples have greater health needs than other Australians and those in urban areas experience greater disease. Approximately 60% of Aboriginal peoples use non-Aboriginal Community Controlled (mainstream) general practice. General practice may not provide culturally appropriate care to Aboriginal peoples, and few practices have effective systems in place to identify Indigenous status, resulting in inadequately targeted care. AIM: To develop and evaluate a tailor-made practice facilitation model to improve the acceptability of health care provided to Aboriginal peoples who attend urban mainstream general practice. METHODS: Set in two Medicare Local Areas in Sydney, a mixed-methods multiple-site case study was used, which was informed by an interpretivist constructionist paradigm. Data collection included focus groups with the two local Aboriginal communities; interviews with Medicare local staff (n=3); interviews and surveys with GPs, nurses and practice staff (n=29); a patient medical record audit, practice systems audit and Aboriginal unannounced standardised patient (USP) assessments at two time-points at seven general practices. The triangulated data were used to tailor quality improvement activities within each practice to improve their Indigenous-status recording systems and the quality of care offered to Aboriginal patients. The implementation of the intervention was evaluated using the Normalisation Process Theory (NPT). FINDINGS: Feedback from the USPs, combined with education and clinical audits, enabled practices to implement an organisational response consistent with the processes described in the NPT. At follow-up most practices improved their Indigenous-status identification systems, with a doubling in Indigenous-identified patients in six practices; and there was an increase in the number of Aboriginal Health Assessments performed and enrolments into the Closing the Gap Health Initiative schemes. The method was acceptable to providers, staff and the local Aboriginal communities. A key factor in the uptake of the intervention and commitment to change by practitioners and staff was that the USPs were from the local Aboriginal communities, providing face validity to the methodology. CONCLUSION: The innovative intervention used was acceptable, feasible and demonstrated some effectiveness as a quality improvement tool in general practice. It warrants further investigation and evaluation.
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(2014)ThesisIn addition to its role in improving patient autonomy, Advance Care Planning (ACP) is increasingly being recognised as an important component of quality end-of-life care. However, the literature suggests a number of problems with ACP, including the low uptake and lack of impact that Advance Care Plans currently have on future patient care. Moreover, ACP has not been incorporated into primary care in Australia despite its recognition as an ideal setting for ACP. This thesis therefore aimed to explore: the current state of ACP and how it is conceptualised in Australia; the perspectives of Australian general practitioners (GPs) on how end-of-life care decisions are made; and Australian GPs’ perspectives on the influence that various contextual factors have on the facilitation and implementation of ACP. The study was guided by Qualitative Description and Grounded Theory methodologies. Study data was collected from interviews with the representatives of key stakeholder organisations, policymakers, expert clinicians and GPs. The findings showed that ACP is conceptualised as having both autonomy-centric and non-autonomy-centric functions and aims. The low uptake and the lack of impact of Advance Care Plans on patient care were identified as major problems affecting ACP in Australia. Recommended strategies to address this involved increasing the general awareness of ACP and implementing a system-wide program of ACP that: (i) shifts the focus away from documentation to a process of communication about patient’s wishes; (ii) improves the response of health professionals to Advance Care Plans; and (iii) improves the facilitation, documentation and accessibility of Advance Care Plans. The findings also highlighted the importance of individualising the process of ACP – particularly the role of formal documentation, and the flexibility in the implementation of the Advance Care Plan – to suit the unique needs and context of each patient. A range of contextual factors that should be taken into account when individualising ACP were identified. In summary, this thesis provides important evidence to inform the development of an individualised, patient-centred approach to ACP that is suitable for a successful implementation in the Australian primary care setting.
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(2012)ThesisRepeat hospitalisations by frequently readmitted patients (FRPs) are costly and might be avoidable. Many frequent readmissions are due to acute exacerbations of chronic disease treatable outside hospital. FRPs were defined as patients who were admitted three or more times in a year. The aim of this research was to explore the reasons behind frequent readmissions in patients with chronic disease. The study at a regional hospital in NSW, involved analysis of emergency department data to distinguish patient factors associated with three types of frequent hospital users: FRPs, frequent attenders (FAs) with four or more presentations in a year and patients who have an unplanned return visit to hospital within 28 days for the same condition (URVPs). Differences in attitudes to and beliefs about chronic disease self-management were explored by analysing interview data from FRPs compared with data from self-managing patients (SMPs), who had all been FRPs but had adopted self-management. A sample of clinicians treating patients with chronic disease in hospital, general practice and self-management services was interviewed to determine differences in attitudes to and beliefs about self-management. FRPs, FAs and URVPs shared some characteristics, but were discrete groups. The findings confirmed that patients with chronic disease contributed to the FRPs group and provided a basis of developing solutions to frequent use. The qualitative findings indicated that patients adopted self-management in response to encouragement by a proactive clinician. Activation involved acceptance; responding emotionally and changing identity, which was not described by FRPs. Hospital clinicians and general practitioners thought that some patients were resistant to self-management, were less familiar with self-management services and saw their role as being restricted to referral to services. Clinicians involved in self-management had the skills to be proactive and believed that all patients could be activated to self-manage. The findings provide insights into interactions between patients and clinicians leading to patient activation. The implications are that self-management activation in patients presenting to hospital can be increased by improving clinician skills in and understanding of the process of patient activation in self-management. This may help to reduce further reliance on presentation to hospital.