Royal Flying Doctor Service 'field days': a move towards more comprehensive primary health care

Objective: To examine the Royal Flying Doctor Service (RFDS) field day program as a means of strengthening community capacity within a primary health care context in remote communities of north Queensland. Design: Qualitative explanatory study using in‐depth face‐to‐face and phone interviews with field day participants, field day coordinators and RFDS staff and a focus group with RFDS staff. Setting: Rural and remote communities of north Queensland that participate in RFDS field days. Results: Field days were found to be contributing to building capacity for health in the remote communities that have been involved in field days. Participants reported increased linkages and partnerships; increased participation; improved problem‐solving capacity and increased knowledge transfer associated with the conduct of RFDS field days. Conclusion: RFDS field days represent a viable framework for building community capacity for health in remote communities within a primary health care context.     

Community Health Monitoring: Taking the Pulse of America's Children

Objective: To describe the development, content, enablers/barriers, and impact of child health reports in nine communities participating in the Robert Wood Johnson Foundation funded Child Health Initiative (1991–1996). Methods: A qualitative, prospective, multiyear, longitudinal evaluation using a multiple case-study methodology. Three waves of structured in-per-son and telephone interviews of the project staff, community leaders, and key participants tracked the development of child health reports in all nine communities. A mailed survey of project directors was administered to assess accomplishments at the completion of the project. Content analysis of each community health report was conducted using different conceptual frameworks for health measurement and reporting. Results: All communities succeeded in creating a report that contained a broad set of outcome indicators reflecting children's health and well-being. The process of creating these reports, their content, level of analysis, presentation formats, and dissemination varied across sites based on available resources, data and analysis capacity, and other political considerations. While commonly accepted outcome measures were used in most reports (e.g., infant mortality, teen births, immunization rates), process indicators, important for quality monitoring and community health improvement, were notably lacking. In each community the reports were credited with providing a more comprehensive and integrated view of the health needs of children. Conclusions: Additional conceptual and technical work is needed to improve the ability of community health reports to capture key indicators of interest. Community reports can serve an important role in building the consensus needed to create program and policy changes. Community reports may have additional utility in monitoring the impact of health systems change on population health. Community reports can also facilitate a shared learning process for the participants and the community, and can be a useful tool to advance a children's health policy agenda.     

Evaluating community participation: A comparison of participatory approaches in the planning and implementation of new primary health‐care services in northern Australia

Community participation is increasingly seen as a prerequisite for more acceptable and sustainable health services. It is difficult to evaluate the extent of participation in health planning and implementation of services, and there are limited tools available to assist in evaluating such processes. Our paper reports on community participation as part of the implementation of 2 primary health programs in regional north Queensland, Australia. We define community participation as collective involvement of people, including consultation, from a community of place or interest in aspects of health service development. We pragmatically evaluate and compare the extent of participation by using a framework developed by Rifkin and colleagues in 1988 and subsequently refined. Data collected from the implementation of each program were analyzed and ranked on a spidergram against 5 process indicators: needs assessment, leadership, resource mobilization, management, and organization. Community participation was found to vary across the programs but was most extensive in both programs in identifying need and potential solutions. Both programs demonstrated high levels of integration of the implementation of health programs with preexisting community structures. Involving local communities in genuine opportunities in managing the programs and mobilizing resources was more challenging. Key differences emerged in the people involved in the programs, the settings and frameworks used to facilitate implementation. We conclude that Rifkin's process indicators are a useful starting point for assessing community participation, particularly for health planners who are required to include participatory approaches when planning and implementing services. We suggest areas that require further consideration.     

Physical activity of young people in the Torres Strait and Northern Peninsula Region: an exploratory study

Objective: The present study explored the practices of, and perceived barriers to, physical activity of young people living in remote communities in the Torres Strait and Northern Peninsula Area of Far North Queensland. Design and setting: A cross‐sectional survey exploring physical activity practices of children attending primary and secondary schools in two communities in the Torres Strait, Far North Queensland. Participants: A total of 367 primary and secondary school‐aged children (aged 9–16 years). Main outcome measures: Only 50% of the children reported being active for more than 30 min a day and approximately 25% of both primary and high school children surveyed were ‘pretty much active only at week‐ends’. The major barriers cited to being active were related to the climate, lack of equipment and child‐specific activities and low self‐perception of ability. Conclusions: A large proportion of school students in the Torres Strait and Northern Peninsula Area reported low levels of physical activity. The main barriers cited to being active suggest that structural and family‐based strategies are required to help young people, especially girls, to engage in more physical activity. There is also a need for skills and confidence‐building activities delivered in a non‐competitive environment for those who feel that they lack the necessary skills to participate fully.     

Evaluating the impact of sustainable comprehensive primary health care on rural health

Objective: To develop a conceptual framework for monitoring the relationship between health services and health outcomes in rural Australia. Design and setting: Development of an evaluation framework for a rural comprehensive primary health service in Victoria. Results: Evidence regarding essential components for successful primary health care, and objective health service and health status measures were combined to develop a conceptual health service evaluation framework. Application of the framework is illustrated using a case study of a rural primary health service in Victoria. Conclusions: Inadequate health services limit access to health care, delay use at times of need and result in poor health outcomes. Currently, there is a lack of evidence from rigorous health service evaluations to indicate which rural health services work well, where and why that could inform rural health policies and funding. Although the nature of health service models will vary across communities in order to meet their differing geographic circumstances, there is considerable scope for the translation and generalisation of evidence gained from health service models that are shown to be sustainable, responsive and able to deliver local quality health care. This framework can guide future health service evaluation research and thereby provide a better understanding of a health service's impact on the health of the community and its residents.     

'We don't have anyone with dementia here': a case for better intersectoral collaboration for remote Indigenous clients with dementia

Objective: This paper reports on findings related to intersectoral collaboration stemming from an evaluation of a dementia awareness resource for use in remote Aboriginal communities * . The resource includes a DVD in English and three (3) Aboriginal languages of the Northern Territory. Design: A qualitative evaluation was conducted in four Northern Territory Aboriginal communities/organisations where the resource had been implemented by external dementia educators. The method included five focus groups with Indigenous aged care workers, community members and aged care service users (n = 26), individual interviews with health care professionals and service coordinators (n = 5), and observation. Data were analysed thematically. Results: Specific findings relating to intersectoral collaboration as a key enabling factor of effective dementia awareness and care are discussed in this paper. In addition to context variables such as understaffing and under‐resourcing, there might be a lack of knowledge or interest on the part of some health practitioners concerning clients with dementia within remote communities. Conclusion: Dementia awareness in remote communities needs to be tackled from a ‘whole system’ perspective and not be the exclusive domain of the aged care services. Strategies that increase the critical mass of informed caregivers as well as health professionals will contribute to better services.     

Intersections and evolution of ‘Butch-trans’ categories in Puerto Rico: Needs and barriers of an invisible population

ABSTRACT

Public health research among transgender populations globally has primarily focused on HIV/AIDS. However, trans men remain outside of this conceptual framework, with distinct but overlapping social contexts and needs. In Puerto Rico (PR), the trans men population has remained largely hidden within the ‘butch’ lesbian community. The objective of this article is to document the identity construction of trans men and ‘buchas’ (local term to refer to butch lesbians) in PR and its relation to their bodily practices and overall health. We conducted an exploratory qualitative study with 29 trans men and buchas based on ethnographic observation, focus groups, audio-recorded in-depth interviews, and critical discourse analysis. Findings emphasise two domains to be addressed by health policies and initiatives: (1) bodily representations and gender performance, and (2) the meanings of female biological processes. This small-scale ethnographic study represents an initial step towards understanding the social context of this ‘invisible’ community and significant implications for their health and well-being. We provide several recommendations to address public health concerns of this understudied, marginalised community.     

Depression among Low-Income Women of Color: Qualitative Findings from Cross-Cultural Focus Groups

This article describes the experiences with depression of women with young children living in ethnically and culturally diverse, low-income communities. A qualitative ethnographic design using a focus group process was implemented in 15 communities. Despite great diversity in ethnic and cultural backgrounds, these women of color reported similar experiences with depression and described: a range of social risk factors, including domestic violence, isolation, language barriers, and difficulties with schools and other public systems; lack of access to high quality, culturally competent health and mental health services; reliance primarily on informal systems of care--relatives, friends, peers--in dealing with their depression, although many also reported good relationships with primary care practitioners. They identified: the specialty mental health sector as one to which they seldom turned for assistance, citing stigma, lack of insurance coverage, cultural beliefs, and attitudes of providers as barriers; a number of strategies for outreach and engagement with mental health providers; qualitative measures of maternal depression among women with young children; and, strategies for reaching and engaging culturally diverse mothers.     

Primary Health Care: A Darling Downs Focus

ABSTRACT: Primary health care is a policy model Which integrates social principles into the functioning of the health system at the local level. There is increasing interest in primary health care policy development and in the implementation of primary health care due in part to: the challenge which primary health care raises to existing practice in health service planning and delivery; the changes in roles of health service professionals and consumers which primary health care demands, and the claims on resources which the implementation of primary health care may engender.
The conceptual basis of primary health care demands that decision-making be devolved to the local level. The organisational structure of the public health care system in Queensland, since regionalisation in July 1991, provides an environment which favours this localised decision-making. The Darling Downs Regional Health Authority, one of 13 regional health authorities in Queensland, released a 'Primary Health Care Discussion Paper' as an element in its strategy for primary health care implementation at the regional level. This paper was intended to demystify the concept, raise the level of debate and stimulate discussion about how primary health care might affect health professionals and the community.
This article analyses that discussion paper to illuminate the concept of primary health care emerging in the region and in Queensland Health. It also identifies potential barriers to the implementation of primary health care and outlines activities being undertaken in the region which illustrate ways in which primary health care can be manifested in local communities.     

Measuring key integration outcomes: a case study of a large urban health center

BACKGROUND: Health care reform, through innovative health delivery systems, has been a high priority to address staff shortages, increasingly complex care needs of the aging population, and fragmentation of care. Community health centers have been promoted as one service delivery model with large potential for integration and collaboration. The South Calgary Health Centre (SCHC) opened in June 2004 with the mandate to provide a new model for accessible, accountable, integrated, and community-based health services. PURPOSE: The primary objective was to determine the performance of the SCHC; and further, to establish the value of the evaluation framework used in measuring organizational performance of an integrated service delivery model. METHODOLOGY: Multiple stakeholders were involved in the evaluation in a utilization-focused, participatory way. A comprehensive evaluation framework was developed and implemented to assess the performance of the SCHC at system, provider, and patient levels. Functional, clinical, and community integration were key systems outcomes within this framework. Case-study methodology with mixed methods drawing on multiple data sources (both qualitative and quantitative) was used. FINDINGS: The evaluation findings suggest that the center is functioning well and that staff and client satisfaction are high. Although the model has not achieved all that was originally intended (i.e., fully realized clinical integration), participants felt that the model has been successful and has great potential for integration. The comprehensive evaluation framework developed for this project proved useful in assessing different aspects of integration as well as provider and client perceptions of the center's performance. PRACTICE IMPLICATIONS: Evaluation findings and recommendations have been used to inform operations at the SCHC and for the planning of future health centers. The evaluation framework may help to standardize evaluation approaches across projects and can be used for monitoring progress of the SCHC as well as future evaluations of integrated service delivery models.     

Understanding Breastfeeding Initiation and Continuation in Rural Communities: A Combined Qualitative/Quantitative Approach

Objective To determine factors associated with breastfeeding in rural communities. Methods We combined qualitative and quantitative data from the Family Life Project, consisting of: (1) a longitudinal cohort study (N = 1292) of infants born September 2003–2004 and (2) a parallel ethnographic study (N = 30 families). Demographic characteristics, maternal and infant health factors, and health services were used to predict breastfeeding initiation and discontinuation using logistic and Cox regression models, respectively. Ethnographic interviews identified additional reasons for not initiating or continuing breastfeeding. Results Fifty-five percent of women initiated breastfeeding and 18% continued for at least 6 months. Maternal employment at 2 months and receiving WIC were associated with decreased breastfeeding initiation and continuation. Ethnographic data suggested that many women had never even considered breastfeeding and often discontinued breastfeeding due to discomfort, embarrassment, and lack of assistance. Conclusions Breastfeeding rates in these rural communities lag behind national averages. Opportunities for increasing breastfeeding in rural communities include enhancing workplace support, maximizing the role of WIC, increasing hospital breastfeeding assistance, and creating a social environment in which breastfeeding is normative.     

Community perspectives on roles and responsibilities for strengthening primary health care in rural Ethiopia

Abstract

Government–community partnerships are central to developing effective, sustainable models of primary health care in low-income countries; however, evidence about the nature of partnerships lacks the perspective of community members. Our objective was to characterise community perspectives regarding the respective roles and responsibilities of government and the community in efforts to strengthen primary health care in low-income settings. We conducted a qualitative study using focus groups (n=14 groups in each of seven primary health care units in Amhara and Oromia, Ethiopia, with a total of 140 participants) in the context of the Ethiopian Millennium Rural Initiative. Results indicated that community members defined important roles and responsibilities for both communities and governments. Community roles included promoting recommended health behaviours; influencing social norms regarding health; and contributing resources as feasible. Government roles included implementing oversight of health centres; providing human resources, infrastructure, equipment, medication and supplies; and demonstrating support for community health workers, who are seen as central to the rural health system. Renewed efforts in health system strengthening highlight the importance of community participation in initiatives to improve primary health care in rural settings. Community perspectives provide critical insights to defining, implementing and sustaining partnerships in these settings.     

Improving community health and social care practitioners’ confidence,perceived competence and intention to use behaviour change techniques in health behaviour change conversations

Community health and social care practitioners play an increasingly important role in the health promotion agenda, but lack confidence in having effective health behaviour change (HBC) conversations with members of the public. This study reports the development and evaluation of a training intervention based on health psychology to improve health and social care practitioner self-rated confidence, competence and intention to use five behaviour change techniques (BCTs) in their HBC conversations. A 2-day behavioural science interprofessional skills training course plus online learning module was designed for health and social care staff across North East Scotland, teaching five evidence-based BCTs (e.g. Action Planning), plus person-centred communication skills. Participants rated confidence, competence and future intention to use the BCTs on likert scales (1–10) pre-course and post-course, and provided acceptability data. 177 participants aged 20–64 took part, qualitative and quantitative data suggested that the course had high acceptability. Paired samples t tests (n = 120 with complete data) showed significant improvements in confidence, competence and intention following the course, which remained significant with a conservative analysis (n = 174) assuming no change for missing data. Perceived competence in Action Planning increased most during the course (mean change 3.09). In conclusion, health psychology-based skills training can improve practitioner confidence, competence and intention to use evidence-based BCTs; further evaluation is needed to assess practice change.     

Successful chronic disease care for Aboriginal Australians requires cultural competence

Objective: To review the literature to determine the attributes of culturally appropriate healthcare to inform the design of chronic disease management (CDM) models for Aboriginal patients in urban general practice. Methods: A comprehensive conceptual framework, drawing on the Access to Care, Pathway to Care, Chronic Care, Level of Connectedness, and Cultural Security, Cultural Competency and Cultural Respect models, was developed to define the search strategy, inclusion criteria and appraisal methods for the literature review. Selected papers were reviewed in detail if they examined a chronic disease intervention for an Aboriginal population and reported on its evaluation, impacts or outcomes. Results: In the 173 papers examined, only 11 programs met the inclusion criteria. All were programs conducted in rural and remote Aboriginal community‐controlled health services. Successful chronic disease care and interventions require adequate Aboriginal community engagement, utilising local knowledge, strong leadership, shared responsibilities, sustainable resources and integrated data and systems. These success factors fitted within the conceptual framework developed. Conclusions: Research and development of culturally appropriate CDM models concurrently in both urban and rural settings will enable more rigorous evaluation, leading to stronger evidence for best practice. A partnership of mainstream and Aboriginal‐controlled health services is essential to successfully ‘close the gap’. Implications: Findings will inform and guide the development, implementation and evaluation of culturally appropriate CDM in mainstream general practice and primary care.     

Rural sports and recreational injuries in Australia: what do we know?

Objective: It is widely recognised that individuals residing in regional or rural areas have poorer health outcomes than those from metropolitan areas. Factors associated with these poorer health outcomes include geographical isolation, population declines, limited health care provision and higher levels of inactivity compared to urban areas. The mental, social and physical health of individuals and communities in rural areas can be improved through active participation in sport and recreation activities. Unfortunately, participation in such activities can potentially lead to injury. There is a suggestion that there is an increased risk of sports injuries in rural areas due to the lack of health professionals and coaching personnel, fewer available volunteers to organise and deliver sport, and the general attitude towards injuries in rural settings. Results: There is very limited information about the number and types of injuries sustained during participation in sports activities in rural and regional settings. This is largely related to a lack of formal sporting structures and support mechanisms including research funding and trained personnel. Conclusion: A range of factors need to be implemented to improve safety for sporting and recreational participants in these areas. These include improved monitoring of injury occurrence, stronger promotion of safety initiatives and wider implementation of education strategies. What is already known: It has been speculated that there is an increased risk of injury during sport in rural areas, compared to metropolitan centres. However, there is very little information about the actual levels of sports injury risk in rural communities. What this study adds: This review of formal and informal sources has identified significant gaps in our knowledge about sports injuries in rural Australia. It is likely that this lack of information, and the injury risk, is related to a lack of formal sporting structures and support mechanisms in these areas.