Privatisation of government services in Australia: what is known about health and equity impacts

BACKGROUND

Historically in Australia, all levels of government created collective wealth by owning and operating infrastructure, and managing natural assets, key public goods and essential services while being answerable to the public. This strong state tradition was challenged in the 1980s when privatisation became a widespread government approach globally. Privatisation involves displacing the public sector through modes of financing, ownership, management and product or service delivery. The Australian literature shows that negative effects from privatisation are not spread equitably, and the health and equity impacts appear to be under-researched. This narrative overview aims to address a gap in the literature by answering research questions on what evidence exists for positive and negative outcomes of privatisation; how well societal impacts are evaluated, and the implications for health and equity.

METHODS

Database and grey literature were searched by keywords, with inclusion criteria of items limited to Australia, published between 1990 and 2022, relating to any industry or government sector, including an evaluative aspect, or identifying positive or negative aspects from privatisation, contracting out, or outsourcing. Thematic analysis was aided by NVivo qualitative data software and guided by an a-priori coding frame.

RESULTS

No items explicitly reflected on the relationship between privatisation and health. Main themes identified were the public cost of privatisation, loss of government control and expertise, lack of accountability and transparency, constraints to accessing social determinants of health, and benefits accruing to the private sector.

DISCUSSION

Our results supported the view that privatisation is more than asset-stripping the public sector. It is a comprehensive strategy for restructuring public services in the interests of capital, with privatisation therefore both a political and commercial determinant of health. There is growing discussion on the need for re-nationalisation of certain public assets, including by the Victorian government.

CONCLUSION

Privatisation of public services is likely to have had an adverse impact on population health and contributed to the increase in inequities. This review suggests that there is little evidence for the benefits of privatisation, with a need for greater attention to political and commercial determinants of health in policy formation and in research.

The Benefits of Cooperative Inquiry in Health Services Research: Lessons from an Australian Aboriginal and Torres Strait Islander Health Study

Health services research is underpinned by partnerships between researchers and health services. Partnership-based research is increasingly needed to deal with the uncertainty of global pandemics, climate change induced severe weather events, and other disruptions. To date there is very little data on what has happened to health services research during the COVID-19 pandemic. This paper describes the establishment of an Australian multistate Decolonising Practice research project and charts its adaptation in the face of disruptions. The project used cooperative inquiry method, where partner health services contribute as coresearchers. When the COVID-19 pandemic hit, data collection needed to be immediately paused, and when restrictions started to lift, all research plans had to be renegotiated with services. Adapting the research surfaced health service, university, and staffing considerations. Our experience suggests that cooperative inquiry was invaluable in successfully navigating this uncertainty and negotiating the continuance of the research. Flexible, participatory methods such as cooperative inquiry will continue to be vital for successful health services research predicated on partnerships between researchers and health services into the future. They are also crucial for understanding local context and health services priorities and ways of working, and for decolonising Indigenous health research.

Evaluating local primary health care actions to address health inequities: analysis of Australia's Primary Health Networks

BACKGROUND

Meso-level, regional primary health care organisations such as Australia's Primary Health Networks (PHNs) are well placed to address health inequities through comprehensive primary health care approaches. This study aimed to examine the equity actions of PHNs and identify factors that hinder or enable the equity-orientation of PHNs' activities.

METHODS

Analysis of all 31 PHNs' public planning documents. Case studies with a sample of five PHNs, drawing on 29 original interviews with key stakeholders, secondary analysis of 38 prior interviews, and analysis of 30 internal planning guidance documents. This study employed an existing framework to examine equity actions.

RESULTS

PHNs displayed clear intentions and goals for health equity and collected considerable evidence of health inequities. However, their planned activities were largely restricted to individualistic clinical and behavioural approaches, with little to facilitate access to other health and social services, or act on the broader social determinants of health. PHNs' equity-oriented planning was enabled by organisational values for equity, evidence of local health inequities, and engagement with local stakeholders. Equity-oriented planning was hindered by federal government constraints and lack of equity-oriented prompts in the planning process.

CONCLUSIONS

PHNs' equity actions were limited. To optimise regional planning for health equity, primary health care organisations need autonomy and scope to act on the 'upstream' factors that contribute to local health issues. They also need sufficient time and resources for robust, systematic planning processes that incorporate mechanisms such as procedure guides and tools/templates, to capitalise on their local evidence to address health inequities. Organisations should engage meaningfully with local communities and service providers, to ensure approaches are equity sensitive and appropriately targeted.

Factors that influence evidence-informed meso-level regional primary health care planning: a qualitative examination and conceptual framework

BACKGROUND

Evidence-informed primary health care (PHC) planning in decentralised, meso-level regional organisations has received little research attention. In this paper we examine the factors that influence planning within this environment, and present a conceptual framework.

METHODS

We employed mixed methods: case studies of five Australian Primary Health Networks (PHNs), involving 29 primary interviews and secondary analysis of 38 prior interviews; and analysis of planning documents from all 31 PHNs. The analysis was informed by a WHO framework of evidence-informed policy-making, and institutional theory.

RESULTS

Influential actors included federal and state/territory governments, Local Health Networks, Aboriginal Community Controlled Health Organisations, local councils, public hospitals, community health services, and providers of allied health, mental health and aged care services. The federal government was most influential, constraining PHNs' planning scope, time and funding. Other external factors included: the health service landscape; local socio-demographic and geographic characteristics; (neoliberal) ideology; interests and politics; national policy settings and reforms; and system reorganisation. Internal factors included: organisational structure; culture, values and ideology; various capacity factors; planning processes; transition history; and experience. The additional regional layer of context adds to the complexity of planning.

CONCLUSIONS

Like national health policy-making, meso-level PHC planning occurs in a complex environment, but with additional regional factors and influences. We have developed a conceptual framework of the meso-level PHC planning environment, which can be employed by similar regional organisations to elucidate influential factors, and develop strategies and tools to promote transparent, evidence-informed PHC planning for better health outcomes.

Logic modelling as hermeneutic praxis: Bringing knowledge systems into view during comprehensive primary health care planning for homelessness in Australia

Logic modelling is used widely in health promotion planning for complex health and social problems. It is often undertaken collaboratively with stakeholders across sectors that hold and enact different institutional approaches. We use hermeneutic philosophy to explore how knowledge is 'lived' by - and unfolds differently for - cross-sectoral stakeholders during comprehensive primary healthcare service planning. An Organisational Action Research partnership was established with a non-government organisation designing comprehensive primary health care for individuals experiencing homelessness in Adelaide, Australia. Grey literature, stakeholder input, academic feedback, a targeted literature review and evidence synthesis were integrated in iterative cycles to inform and refine the logic model. Diverse knowledge systems are active when cross-sectoral stakeholders collaborate on logic models for comprehensive primary health care planning. Considering logic modelling as a hermeneutic praxis helps to foreground and explore these differences. In our case, divergent ideas emerged in how health/wellbeing and trust were conceptualised; language had different meanings across sectors; and the outcomes and data sought were nuanced for various collaborators. We explicate these methodological insights and also contribute our evidence-informed, collaboratively-derived model for design of a comprehensive primary health care service with populations experiencing homelessness. We outline the value of considering cross-sectoral logic modelling as hermeneutic praxis. Engaging with points of difference in cross-sectoral knowledge systems can strengthen logic modelling processes, partnerships and potential outcomes for complex and comprehensive primary health care services.

Illustrating the impact of commercial determinants of health on the global COVID-19 pandemic: Thematic analysis of 16 country case studies

Previous research on commercial determinants of health has primarily focused on their impact on non-communicable diseases. However, they also impact on infectious diseases and on the broader preconditions for health. We describe, through case studies in 16 countries, how commercial determinants of health were visible during the COVID-19 pandemic, and how they may have influenced national responses and health outcomes. We use a comparative qualitative case study design in selected low- middle- and high-income countries that performed differently in COVID-19 health outcomes, and for which we had country experts to lead local analysis. We created a data collection framework and developed detailed case studies, including extensive grey and peer-reviewed literature. Themes were identified and explored using iterative rapid literature reviews. We found evidence of the influence of commercial determinants of health in the spread of COVID-19. This occurred through working conditions that exacerbated spread, including precarious, low-paid employment, use of migrant workers, procurement practices that limited the availability of protective goods and services such as personal protective equipment, and commercial actors lobbying against public health measures. Commercial determinants also influenced health outcomes by influencing vaccine availability and the health system response to COVID-19. Our findings contribute to determining the appropriate role of governments in governing for health, wellbeing, and equity, and regulating and addressing negative commercial determinants of health.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Explaining health inequalities in Australia: the contribution of income, wealth and employment

BACKGROUND

Studies show widespread widening of socioeconomic and health inequalities. Comprehensive primary health care has a focus on equity and to enact this requires more data on drivers of the increase in inequities. Hence, we examined trends in the distribution of income, wealth, employment and health in Australia.

METHODS

We analysed data from the Public Health Information Development Unit and Australian Bureau of Statistics. Inequalities were assessed using rate ratios and the slope index of inequality.

RESULTS

We found that the social gradient in health, income, wealth and labour force participation has steepened in Australia, and inequalities widened between the quintile living in the most disadvantaged areas and the quintile living in the least disadvantaged areas.

CONCLUSION

Widening income, wealth and employment inequalities have been accompanied by increasing health inequalities, and have reinforced and amplified adverse health effects, leading to increased mortality inequality. Effective comprehensive primary health care needs to be informed by an understanding of structural factors driving economic and health inequities.

Implementing Universal and Targeted Policies for Health Equity: Lessons From Australia

BACKGROUND

Debate continues in public health on the roles of universal or targeted policies in providing equity of access to health-related goods or services, and thereby contributing to health equity. Research examining policy implementation can provide fresh insights on these issues.

METHODS

We synthesised findings across case studies of policy implementation in four policy areas of primary healthcare (PHC), telecommunications, Indigenous health and land use policy, which incorporated a variety of universal and targeted policy structures. We analysed findings according to three criteria of equity in access - availability, affordability and acceptability - and definitions of universal, proportionate-universal, targeted and residual policies, and devolved governance structures.

RESULTS

Our analysis showed that existing universal, proportionate-universal and targeted policies in an Australian context displayed strengths and weaknesses in addressing availability, affordability and acceptability dimensions of equity in access.

CONCLUSION

While residualist policies are unfavourable to equity of access, other forms of targeting as well as universal and proportionate-universal structure have the potential to be combined in context-specific ways favourable to equity of access to health-related goods and services. To optimise benefits, policies should address equity of access in the three dimensions of availability, affordability and acceptability. Devolved governance structures have the potential to augment equity benefits of either universal or targeted policies.

Creating Political Will for Action on Health Equity: Practical Lessons for Public Health Policy Actors

BACKGROUND

Despite growing evidence on the social determinants of health and health equity, political action has not been commensurate. Little is known about how political will operates to enact pro-equity policies or not. This paper examines how political will for pro-health equity policies is created through analysis of public policy in multiple sectors.

METHODS

Eight case studies were undertaken of Australian policies where action was either taken or proposed on health equity or where the policy seemed contrary to such action. Telephone or face-to-face interviews were conducted with 192 state and non-state participants. Analysis of the cases was done through thematic analysis and triangulated with document analysis.

RESULTS

Our case studies covered: trade agreements, primary healthcare (PHC), work conditions, digital access, urban planning, social welfare and Indigenous health. The extent of political will for pro-equity policies depended on the strength of path dependency, electoral concerns, political philosophy, the strength of economic and biomedical framings, whether elite interests were threatened and the success or otherwise of civil society lobbying.

CONCLUSION

Public health policy actors may create political will through: determining how path dependency that exacerbates health inequities can be broken, working with sympathetic political forces committed to fairness; framing policy options in a way that makes them more likely to be adopted, outlining factors to consider in challenging the interests of elites, and considering the extent to which civil society will work in favour of equitable policies. A shift in norms is required to stress equity and the right to health.

POS0691 EMULATING A TARGET TRIAL OF ADALIMUMAB VERSUS TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS: A COMPARATIVE EFFECTIVENESS ANALYSIS USING THE OPAL REAL-WORLD DATASET

Background

There is increasing recognition of the complementary role for real-world evidence (RWE) in health care and regulatory decision-making (1). However, careful analysis is required when drugs are compared using observational data to account for differences between treatment groups. Electronic medical records (EMR) are an important source of real-world data (RWD), but outcomes are often recorded incompletely.

We emulated a target trial of adalimumab (ADA) versus tofacitinib (TOF) in patients with rheumatoid arthritis (RA) using the OPAL dataset to illustrate the application of methodologies to address the challenges of non-random treatment assignment and incomplete data. The OPAL dataset is derived from EMR of 112 community-based rheumatologists around Australia, where practitioners have discretion to prescribe whichever b/tsDMARD they consider most clinically appropriate.

Objectives

To estimate the average treatment effect (ATE) of TOF compared to ADA at 3 and 9 months, defined as the difference in mean disease activity score (DAS28CRP), in patients with RA who are new users of a b/tsDMARD. This is equivalent to aiming to estimate the intention-to-treat effect in a randomised controlled trial.

Methods

OPAL patients diagnosed with RA were included if they initiated ADA or TOF between 1 October 2015 and 1 April 2021, were new b/tsDMARD users (no prior recorded b/tsDMARD, at least 6 months of prior csDMARD treatment), and had at least 1 component of DAS28CRP recorded at baseline or during follow-up. Data were also extracted on baseline characteristics. Baseline characteristics were DAS28CRP, patient demographics, regional location, disease duration, prescriber characteristics (including gender, experience), prior recorded comorbidities, and prior and concomitant treatment with csDMARDs and oral corticosteroids.

We used random forest multiple imputation to impute missing baseline and follow-up DAS28CRP components (2). Stable balancing weights (SBW) were then used to balance the treatment groups in terms of their baseline characteristics, including DAS28CRP (3). For each imputed dataset, the ATE at 3 months was estimated as the difference between the mean outcome in the two treatment groups after balancing (i.e. weighting) the sample, and then these estimates were averaged across the 10 imputed datasets. The ATE at 9 months was estimated similarly. The whole procedure was subsequently performed in 1000 bootstrap samples to estimate a 95% confidence interval (CI) for the ATEs using the percentile method (4).

Results

842 patients were identified including n=569 treated with ADA and n=273 treated with TOF. After applying the SBW, the maximum difference between the mean of each baseline characteristic in the ADA and TOF groups was less than 0.03% of the corresponding standard deviation in the whole sample, indicating reasonable balance was achieved in this complex dataset. After weighting, mean DAS28CRP reduced from 5.3 at baseline (both ADA and TOF groups) to 2.6 and 2.3 at 3 and 9 months for ADA, and 2.4 and 2.3 at 3 and 9 months for TOF.

The estimated ATE was -0.22 (95% CI -0.36, -0.03; p=0.02) at 3 months, indicating a modest but significant reduction in disease activity for patients on TOF. The estimated ATE was -0.03 (95% CI -0.19, 0.1; p=0.56) at 9 months, indicating no difference between groups.

Conclusion

DAS28CRP was significantly lower at 3 months for patients treated with TOF compared to ADA. However, 3 months of treatment with either drug led to substantive average reductions in mean DAS28CRP, consistent with remission. There was no difference between drugs at 9 months. Future work will estimate a per-protocol effect.

References

[1]Arlett et al. Clin Pharmacol Ther 2022;111(1):21–3.

[2]van Buuren and Groothuis-Oudshoorn J Stat Softw 201145(3):1–67

[3]Zubizarreta J Am Stat Assoc 2015;110(511):910–22

[4]Bartlett and Hughes Stat Methods Med Res 2020;29(12):3533–46

Acknowledgements

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests

Claire Deakin: None declared, Bianca De Stavola: None declared, Geoff Littlejohn Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Gilead, Eli Lilly, and MSD, Hedley Griffiths Consultant of: AbbVie and Eli Lilly, Sabina Ciciriello: None declared, Peter Youssef Speakers bureau: AbbVie, Novartis, Eli Lilly, David Mathers: None declared, Paul Bird Speakers bureau: Abbvie, Janssen, Bristol Myers Squibb, Pfizer, Novartis, Gilead, Eli Lilly, Consultant of: Abbvie, Janssen, Bristol Myers Squibb, Pfizer, Novartis, Gilead, Eli Lilly, Imaging consulting for Synarc and Boston Imaging Core Lab., Tegan Smith: None declared, Catherine OSullivan: None declared, Tim Freeman: None declared, Dana Segelov: None declared, David Hoffman: None declared, Shaun Seaman: None declared

Deindustrialising economies, plant closures and affected communities: Identifying potential pathways to health inequities

ISSUE ADDRESSED

Deindustrialisation and transitions from traditional manufacturing to new technologies and service industries in many high-income countries including Australia has resulted in rising employment insecurity, unemployment and increased income and health inequities. In this paper, we explore potential impacts of an automotive plant closure on health in a disadvantaged area of South Australia. Our aim was to examine how prevailing factors affecting social and health inequity might be further affected following the plant closure and to identify levers for potential policy responses.

METHODS

In workshop discussions with 28 policy and 14 community stakeholders through an iterative process participants discussed how existing factors contributing to community social and health inequity might be worsened (or remediated) by the looming economic shock from the plant closure.

RESULTS

We identified eight key themes highlighted in the workshops. In particular local economic investment, availability of job opportunities, and appropriate training were identified as key factors influencing individual financial security, which was in turn linked to social and health impacts.

CONCLUSIONS

The pathways mapped between the plant closure and social and health equity impacts highlighted differential potential impacts on individuals and the community, and identified policy levers to reduce adverse health outcomes resulting from economic shocks such as the closure of a major employer. SO WHAT?: The study highlighted a broad range of intersecting factors affecting the health of the local community that policy responses to the plant closure needed to address to promote health and health equity. This included novel factors identified by community members, reinforcing the importance of including community perspectives when constructing policy responses.

Exploring access to, use of and benefits from population-oriented digital health services in Australia

The provision of population-oriented, on-demand digital health services in many countries exemplifies the perceived utility of digital health services in supporting population health. Yet, limited knowledge exists regarding the equity of these services. Using mixed-method research, we recruited users of a health website and general practice patients to surveys (n = 441) and telephone interviews (n = 40). We contribute specific evidence investigating barriers to access, use and benefit from digital health services within an equity framework that incorporates social determinant factors, eHealth Literacy and trust. Our research highlights the foundational role of trust in predicting use, showcases which groups are unlikely to benefit from population-oriented digital health services, and proposes strategies to enhance the equity of these services. The theoretical framework we developed serves as a roadmap for future health promotion research and action by outlining the complex and interrelated pathways that can promote and threaten digital health equity.

Barriers to digital health services among people living in areas of socioeconomic disadvantage: Research from hospital diabetes and antenatal clinics

ISSUE ADDRESSED

We sought to examine barriers to access to, use of, and benefits from digital health services in an area of socioeconomic disadvantage of Adelaide, Australia.

METHODS

We conducted waiting room surveys in two hospital diabetes clinics and one hospital antenatal clinic in South Australia, and follow-up telephone interviews with 20 patients. We examined the extent of access to, use of and benefits from digital health services, and what barriers people encountered. We undertook mixed methods, with quantitative descriptive analysis and qualitative analysis.

RESULTS

Thirty-seven diabetes clinic patients (54% response rate) and 99 antenatal clinic patients (33% response rate) participated. Sixty-two percent of the patients with diabetes and 27% of antenatal clinic patients had never used digital health services. Seventeen percent of patients with diabetes and 30% of antenatal clinic patients were hesitant users, and 22% of patients with diabetes and 44% of antenatal clinic patients were confident users. Barriers included struggling to afford the technology or to stay connected and a lack of trust in online health information. Potential benefits included feeling more empowered and complementing face-to-face care.

CONCLUSIONS

There are socioeconomic barriers to access, use of, and ability to benefit from digital health strategies that mean not everyone will be able to benefit from digital health services. SO WHAT?: As COVID-19 accelerates the shift towards digital health services, people experiencing socioeconomic disadvantage may be excluded. If barriers to access and use are not addressed, they will exacerbate already increasing health inequities.

Conducting a rapid health promotion audit in suburban Adelaide, South Australia: Can it contribute to revitalising health promotion?

ISSUES ADDRESSED

How health promotion is implemented varies and it is often not clear what activities are in place in a region. Understanding the extent of health promotion activities helps planning activities.

METHODS

This research involved a rapid audit of the types of health promotion activities in a suburban region of South Australia. This analysis was guided by the WHO Ottawa Charter's principles. To better understand population needs and which health promoting activities may help, an epidemiological, demographic and social determinants of health profile of southern Adelaide described disease patterns and health inequities.

RESULTS

While there was evidence of a range of health promoting activities, most concerned individual or behavioural services. A key finding was the small number of activities that the state health department and local health system were responsible for. Alongside local government, NGOs provided the bulk of health promotion activities. In addition, there were no overarching health promotion strategies or coordinating bodies to evaluate the activities. The epidemiological, demographic and social determinants of health profile found persistent health and social inequities.

CONCLUSION

This rapid audit of health promotion in a region enabled a quick assessment of the current health promotion situation and provided evidence of gaps and areas where policy change should be advocated. SO WHAT?: The key findings distilled from this research were designed to inform policy priorities to shift health promotion in southern Adelaide onto a trajectory consistent with the Ottawa Charter and prevent further focus on individualised behaviour change strategies known as 'lifestyle drift'.

Power and the people's health

Public policy plays a central role in creating and distributing resources and conditions of daily life that matter for health equity. Policy agendas have tended to focus on health care delivery and individualised interventions. Asking why there is a lack of policy action on structural drivers of health inequities raises questions about power inequities in policy systems that maintain the status quo. In this paper we investigate the power dynamics shaping public policy and implications for health equity. Using a Health Equity Power Framework (HEPF), we examined data from 158 qualitative interviews with government, industry and civil society actors across seven policy case studies covering areas of macroeconomics, employment, social protection, welfare reform, health care, infrastructure and land use planning. The influence of structures of capitalism, neoliberalism, sexism, colonisation, racism and biomedicalism were widely evident, manifested through the ideologies, behaviours and discourses of state, market, and civil actors and the institutional spaces they occupied. Structurally less powerful public interest actors made creative use of existing or new institutional spaces, and used network, discursive and moral power to influence policy, with some success in moderating inequities in structural and institutional forms of power. Our hope is that the methodological advancement and empirical data presented here helps to illuminate how public interest actors can navigate structural power inequities in the policy system in order to disrupt the status quo and advance a comprehensive policy agenda on the social determinants of health equity. However, this analysis highlights the unrealistic expectation of turning health inequities around in a short time given the long-term embedded power dynamics and inequities within policy systems under late capitalism. Achieving health equity is a power-saturated long game.

Capturing the social determinants of health at the individual level: a pilot study

Objective and importance of study: Considerable evidence suggests that adverse social determinants of health (SDH), such as poor education, unemployment, food and housing insecurity, interpersonal violence, inadequate social support and poverty, are key determinants of health and wellbeing. This prospective cohort study piloted a screening tool to collect individual SDH data in a South Australian hospital inpatient population. We explored participants' attitudes to SDH screening in brief follow-up interviews.

METHODS

This mixed-methods study used an SDH screening tool to collect individual-level SDH data from inpatients living in a highly disadvantaged socio-economic area. Participants had a primary diagnosis of chronic obstructive pulmonary disease (COPD), heart failure (HF) or diabetes mellitus. Follow-up interviews were completed post discharge via telephone. Descriptive statistics were employed to examine the prevalence and type of adverse SDH reported by the sample. Thematic analysis was applied to explore participants' attitudes to the screening.

RESULTS

The sample population (N = 37) reported a substantial burden of a range of adverse SDH (mean 4.7 adverse SDH experienced per participant, standard deviation 2.8). Participants involved in follow-up interviews (n = 8) believed screening might enhance communication between healthcare providers and patients and assist in identifying underlying social problems.

CONCLUSION

A screening tool for SDH was successfully used to collect individual-level data in a hospital setting. An array of adverse SDH was common in the sample population. Participants believed screening for SDH may potentially benefit doctors and patients. A larger study is required to more robustly characterise the adverse SDH affecting individuals in this population and to explore how the healthcare system might effectively intervene.

POS1461-HPR THE DEVELOPMENT OF A NOVEL EPRO DELIVERY SYSTEM TO MEASURE PATIENT QUALITY OF LIFE IN ROUTINE CLINICAL CARE: AN ANALYSIS OF 5 YEARS OF EXPERIENCE

Background:

Registry studies and clinical trials are increasingly incorporating patient reported outcomes (PROs) to measure the full burden of disease and better measure the efficacy and value of medicines; however, the burden of paper-based surveys, time constraints, and privacy concerns impede the widespread use of PROs in routine clinical care.

Objectives:

To develop a simple and secure technological solution to incorporate validated PROs into routine clinical care for patients with rheumatic diseases, and to assess the patient response to functional assessment of chronic illness therapy fatigue (FACIT-F), patient health questionnaire-2 (PHQ-2), and healthcare resource utilization (HCRU) questionnaires delivered using this ePRO method.

Methods:

A novel ePRO questionnaire delivery system was developed by Software4Specialists in partnership with OPAL Rheumatology. Validated PRO questionnaires were sent from the patient’s electronic medical record (Audit4, Software4Specialists) and delivered to the patient’s email address at time intervals specified by the rheumatologist (defaults to quarterly) or completed in the clinic waiting room prior to the consultation using a tablet or the patient’s smart phone (in-practice). Completed questionnaires were encrypted and returned directly to the patient’s Audit4 electronic medical record held on the clinician’s server for review at the next clinical consultation. The link to the PRO questionnaire expired within 28 days if the questionnaire was not completed, and the questionnaires were automatically cancelled if 2 consecutive links expired. This technology was made available to up to 111 rheumatologists located in 42 clinics in 6 states/territories in Australia, and the use of this technology to furnish the clinical consultation was voluntary for clinicians and patients. Deidentified clinical data was extracted from the servers of participating rheumatologists and aggregated across all sites.1 Data collected between April 2016-Dec 2020 was analysed descriptively.

Results:

Between April 2016-Dec 2020, 99,505 FACIT-F, PHQ-2 and HCRU questionnaires have been delivered to 5,784 patients from 39 of 42 contributing clinics (93%). 85% of questionnaires were delivered via email and 15% in-practice. Overall, 85% of patients completed at least one questionnaire, and of all questionnaires sent, 73% were completed. These rates have remained consistent over time. The completion rates were higher when questionnaires were delivered to patients in-practice compared to email (96% vs 69%). Females were more likely to engage with the questionnaires than males (87% vs 81%), and older patients were slightly more likely to complete all questionnaires delivered. 69% of questionnaires sent via email were completed on the day they were delivered and 94% were completed within 7 days. The median (IQR) number of questionnaires completed per patient was 3 (1,7) and the median (IQR) time since the first questionnaire was completed was 13 months (5,26).

Conclusion:

The novel Audit4 ePRO delivery system is an effective tool for incorporating PROs into routine clinical care to capture data directly from the patient on the impact of their condition on their quality of life. The data generated provides a unique opportunity to understand the full burden of disease for patients in the real-world setting and the impact of interventions.

References:

[1]Littlejohn GO, Tymms KE, Smith T, Griffiths HT. Using big data from real-world Australian rheumatology encounters to enhance clinical care and research. Clin Exp Rheum 2020:38(5): 874 -880.

Acknowledgements:

The authors acknowledge the members of OPAL Rheumatology Ltd and their patients for providing clinical data for this study, and Software4Specialists Pty Ltd for providing the Audit4 platform.

Disclosure of Interests:

Kathleen Tymms: None declared, Tegan Smith: None declared, Claire Deakin: None declared, Tim Freeman: None declared, David Hoffman: None declared, Dana Segelov: None declared, Hedley Griffiths Consultant of: AbbVie, Gilead, Novartis and Lilly., Sabina Ciciriello: None declared, Peter Youssef: None declared, David Mathers: None declared, Catherine OSullivan: None declared, Geoff Littlejohn Consultant of: Over the last 5 years Geoffrey Littlejohn has received educational grants and consulting fees from AbbVie, Bristol Myers Squibb, Eli Lilly, Gilead, Novartis, Pfizer, Janssen, Sandoz, Sanofi and Seqirus

Why Community Health Systems Have Not Flourished in High Income Countries: What the Australian Experience Tells Us

Background: Despite the value of community health systems, they have not flourished in high income countries and there are no system-wide examples in high income countries where community health is regarded as the mainstream model. Those that do exist in Australia, Canada, the United States and the United Kingdom provide examples of comprehensive primary healthcare (PHC) but are marginal to bio-medical primary medical care. The aim of this paper is to examine the factors that account for the absence of strong community health systems in high income countries, using Australia as an example.

Methods: Data are drawn from two Australian PHC studies led by the authors. One examined seven case studies of community health services over a five-year period which saw considerable health system change. The second examined regional PHC organisations. We conducted new analysis using the ‘three I’s’ framework (interests, institutions, ideas) to examine why community health systems have not flourished in high-income countries.

Results: The elements of the community health services that provide insights on how they could become the basis of an effective community health system are: a focus on equity and accessibility, effective community participation/control; multidisciplinary teamwork; and strategies from care to health promotion. Key barriers identified were: when general practitioners (GPs) were seen to lead rather than be part of a team; funding models that encourage curative services rather than disease prevention and health promotion; and professional and medical dominance so that community voices are drowned out.

Conclusion: Our study of the community health system in Australia indicates that instituting such a system in high income countries will require systematic ideological, political and institutional change to shift the overarching government policy environment, and health sector policies and practices towards a social model of health which allows community control, and multidisciplinary service provision.

Assessing organisational capacity for evidence-informed health policy and planning: an adaptation of the ORACLe tool for Australian primary health care organizations

Background

Many nations have established primary health care (PHC) organizations that conduct PHC planning for defined geographical areas. The Australian Government established Primary Health Networks (PHNs) in 2015 to develop and commission PHC strategies to address local needs. There has been little written about the capacity of such organizations for evidence-informed planning, and no tools have been developed to assess this capacity, despite their potential to contribute to a comprehensive effective and efficient PHC sector.

Methods

We adapted the ORACLe tool, originally designed to examine evidence-informed policy-making capacity, to examine organizational capacity for evidence-informed planning in meso-level PHC organizations, using PHNs as an example. Semi-structured interviews were conducted with 14 participants from five PHNs, using the ORACLe tool, and scores assigned to responses, in seven domains of capacity.

Results

There was considerable variation between PHNs and capacity domains. Generally, higher capacity was demonstrated in regard to mechanisms which could inform planning through research, and support relationships with researchers. PHNs showed lower capacity for evaluating initiatives, tools and support for staff, and staff training.

Discussion and conclusions

We critique the importance of weightings and scope of some capacity domains in the ORACLe tool. Despite this, with some minor modifications, we conclude the ORACLe tool can identify capacity strengths and limitations in meso-level PHC organizations. Well-targeted capacity development enables PHC organizations’ strategies to be better informed by evidence, for optimal impact on PHC and population health outcomes.

Challenges facing primary health care in federated government systems: Implementation of Primary Health Networks in Australian states and territories

In many federated countries, there is divided health system responsibility that can affect primary health care (PHC) policy and implementation, and complicate collaboration between PHC actors. We examined an Australian policy initiative, Primary Health Networks (PHNs), which are regional PHC organisations, to examine how they collaborated with state and territory PHC actors, and what factors enhanced or constrained collaboration. For PHNs we surveyed 66 staff, interviewed 82 staff, examined board membership, and analysed documents from all 31 PHNs. We also interviewed 11 state and 5 federal health bureaucrats. We mapped the PHC system in each state, and conducted team thematic analysis of the qualitative data collected. We found variation in how well PHNs collaborated with state and territory actors, ranging from poor relationships through to strong cooperation and co-commissioning. This was affected by factors to do with the state health department, geography, PHN funding and regulations, ambiguities in the federal/state divided responsibilities for PHC, and the extent of use of collaboration mechanisms and strategies. Resourcing and supporting such collaboration mechanisms, and increasing regional funding flexibility of funding would increase the potential for regional organisations to successfully navigate ambiguities in responsibility and foster a more integrated, cohesive PHC system.

Explaining covid-19 performance: what factors might predict national responses?

Correspondence to: F Baum fran.baum@flinders.edu.au Fran Baum and colleagues discuss the factors that affected prediction of the success of national responses to covid-19 and will influence future pandemic preparedness

Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare

Background: Universal health coverage (UHC) is central to current international debate on health policy. The primary healthcare (PHC) system is crucial to achieving UHC, in order to address the rising incidence of non-communicable diseases (NCDs) more effectively and equitably. In this paper, we examine the Australian case as a mature system of UHC and identify lessons for UHC policy to support equity of access to PHC and reduce NCDs.

Methods: Our qualitative research used policy mapping and monitoring and 30 key informant interviews, and applied policy theory, to investigate the implementation of Australian PHC policy between 2008 and 2018.

Results: Although the Australian PHC system does support equity of access to primary medical care, other ideational, actor-centred and structural features of policy detract from the capacities of the system to prevent and manage NCDs effectively, deliver equity of access according to need, and support equity in health outcomes. These features include a dominant focus on episodic primary medical care, which is a poor model of care for NCDs, and an inequitable distribution of these services. Also, a mixed system of public and private insurance coverage in PHC contributes to inequities in access and health outcomes, driving additional NCD demand into the health system.

Conclusion: Countries aiming to achieve UHC to support health equity and reduce NCDs can learn from strengths and weaknesses in the Australian system. We recommend a range of ideational, actor-centred and structural features of UHC systems in PHC that will support effective action on NCDs, equity of access to care according to need, and equity in health outcomes across geographically and ethnically diverse populations.

Why do some countries do better or worse in life expectancy relative to income? An analysis of Brazil, Ethiopia, and the United States of America

BACKGROUND

While in general a country's life expectancy increases with national income, some countries "punch above their weight", while some "punch below their weight" - achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally.

METHODS

We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014-2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country.

RESULTS

Possible drivers identified for Ethiopia's extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States' neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight.

CONCLUSIONS

The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities.

Advancing a health equity agenda across multiple policy domains: a qualitative policy analysis of social, trade and welfare policy

OBJECTIVE

While there is urgent need for policymaking that prioritises health equity, successful strategies for advancing such an agenda across multiple policy sectors are not well known. This study aims to address this gap by identifying successful strategies to advance a health equity agenda across multiple policy domains.

DESIGN

We conducted in-depth qualitative case studies in three important social determinants of health equity in Australia: employment and social policy (Paid Parental Leave); macroeconomics and trade policy (the Trans Pacific Partnership agreement); and welfare reform (the Northern Territory Emergency Response). The analysis triangulated multiple data sources included 71 semistructured interviews, document analysis and drew on political science theories related to interests, ideas and institutions.

RESULTS

Within and across case studies we observed three key strategies used by policy actors to advance a health equity agenda, with differing levels of success. The first was the use of multiple policy frames to appeal to a wide range of actors beyond health. The second was the formation of broad coalitions beyond the health sector, in particular networking with non-traditional policy allies. The third was the use of strategic forum shopping by policy actors to move the debate into more popular policy forums that were not health focused.

CONCLUSIONS

This analysis provides nuanced strategies for agenda-setting for health equity and points to the need for multiple persuasive issue frames, coalitions with unusual bedfellows, and shopping around for supportive institutions outside the traditional health domain. Use of these nuanced strategies could generate greater ideational, actor and institutional support for prioritising health equity and thus could lead to improved health outcomes.

A Framework to Determine the Extent to Which Regional Primary Healthcare Organisations Are Comprehensive or Selective in Their Approach

BACKGROUND

There is an increasing emphasis on the importance of comprehensive primary healthcare (CPHC) in improving population health and health equity. There is, therefore, a need for a practical means to determine how comprehensive regional primary healthcare organisations (RPHCOs) are in their approach. This paper proposes a framework to provide such a means. The framework is then applied to assess the comprehensiveness of Australian RPHCOs.

METHODS

Drawing on a narrative review of the broader literature on CPHC versus selective primary healthcare (SPHC) and examples of international models of RPHCOs, we developed a framework consisting of the key criteria and a continuum from comprehensive to selective interventions. We applied this framework to Australian RPHCOs using data from the review of their planning documents, and survey and interviews with executive staff, managers, and board members. We used a spidergram as a means to visualise how comprehensive they are against each of these criteria, to provide a practical way of presenting the assessment and an easy way to compare progress over time.

RESULTS

Key criteria for comprehensiveness included (1) focus on population health; (2) focus on equity of access and outcomes; (3) community participation and control; (4) integration within the broader health system; (5) inter-sectoral collaboration; and (6) local responsiveness. An examination of Australian RPHCOs using the framework suggests their approach is far from comprehensive and has become more selective over time.

CONCLUSION

The framework and spidergram offer a practical means of gauging and presenting the comprehensiveness of RPHCOs, and to identify gaps in comprehensiveness, and changes over time.

A comparison of the characteristics, motivations, preferences and expectations of men donating sperm online or through a sperm bank

STUDY QUESTION

How do the demographic characteristics, motivations, experiences and expectations of unregulated sperm donors (men donating sperm online through a connection website) compare to sperm donors in the regulated sector (men donating through a registered UK sperm bank)?

SUMMARY ANSWER

Online donors were more likely to be older, married and have children of their own than sperm bank donors, were more varied in their preferences and expectations of sperm donation, and had more concerns about being a sperm donor.

WHAT IS KNOWN ALREADY

While studies have examined motivations and experiences of both regulated sperm bank, and unregulated online sperm donors, no study has directly compared these two groups of donors.

STUDY DESIGN, SIZE, DURATION

An email was sent to the 576 men who were registered sperm donors at the London Sperm Bank, the UK’s largest sperm bank regulated by the Human Fertilisation and Embryology Authority (HFEA), who had commenced donation between January 2010 and December 2016, and had consented to be contacted for research. The online survey, which contained multiple choice and open-ended questions, was completed by 168 men over a 7-week period. The responses were compared to those of sperm donors registered on Pride Angel, a large UK-based connection website for donors and recipients of sperm: our research team had already collected these data. In total, 5299 sperm donors were on Pride Angel at time of data capture and 400 men had completed a similar survey. The responses of 70 actual online sperm donors (i.e. those whose sperm had been used to conceive at least one child) were used for comparison with the sperm bank donors.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The survey obtained data on the sperm donors’ demographic characteristics, motivations, experiences and expectations of sperm donation. Data from sperm bank donors were compared to online donors to examine differences between the two groups. The study compared online and clinic donors who had all been accepted as sperm donors: online donors who had been ‘vetted’ by recipients and sperm bank donors who had passed the rigorous screening criteria set by the clinic.

MAIN RESULTS AND THE ROLE OF CHANCE

A response rate of 29% was obtained from the sperm bank donors. Online donors were significantly older than sperm bank donors (mean ± SD: 38.7 ± 8.4 versus 32.9 ± 6.8 years, respectively) and were more likely to have their own children (p < 0.001 for both characteristics). Both groups rated the motivation ‘I want to help others’ as very important. Online donors rated ‘I don’t want to have children myself’, ‘to have children/procreate’ and ‘to enable others to enjoy parenting as I have myself’ as more important than sperm bank donors, whereas sperm bank donors rated financial payment as more important than online donors, as well as confirmation of own fertility. Most (93.9%) online donors had donated their sperm elsewhere, through other connection sites, fertility clinics, sperm banks or friends and family, compared to only 2.4% of sperm bank donors (p < 0.001). There was a significant difference in how donors viewed their relationship to the child, with online donors much less likely than sperm bank donors to see their relationship as a ‘genetic relationship only’. Online donors had more concerns about being a donor (p < 0.001), for example, being concerned about ‘legal uncertainty and child financial support’ and ‘future contact and uncertainty about relationship with donor-conceived child’.

LIMITATIONS, REASONS FOR CAUTION

Findings may not be representative of all sperm donors as only one online connection site and one HFEA registered sperm bank were used for recruitment.

WIDER IMPLICATIONS OF THE FINDINGS

Despite concern regarding shortages of sperm donors in licensed clinics and unease regarding the growing popularity of unregulated connection websites, this is the first study to directly compare online and sperm bank donors. It highlights the importance of considering ways to incorporate unregulated online sperm donors into the regulated sector. With many online donors well aware of the legal risks they undertake when donating in the unregulated online market, this would both increase the number of sperm donors available at clinics but also provide legal protection and support for donors.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Wellcome Trust Grants 104 385/Z/14/Z and 097857/Z/11/Z. The authors have no conflicts of interest.

Gaining political will for actions to achieve health equity: lessons from Australia for advocates

Background

There has been an accumulation of evidence on the importance of action on the social determinants of health to reduce global and national health equity. Yet there has been little effective systematic action by governments. This is commonly attributed to the absence of political will. Despite its importance, however, little research has examined how political will might be created or prevented.

Methods

This paper reports on the results of eight case studies of the extent to which Australian public policy is likely to contribute to reducing health inequities. 192 participants were interviewed including public servants, politicians and their staff, non-government organisation workers and community members. The transcripts were interrogated with the assistance of NVivo software to determine lessons about the creation or destruction of political will. The case studies were of: national primary health care policy, crucial determinants of health (work conditions, internet access, urban planning, social welfare, trade) and an automotive plant closure.

Results

We found the following factors to be important in determining the extent of political will for health equity, whether: path dependency was present; the issue would impact on staying in or winning government; political philosophies stressed collectivism or individualism; there were negative or positive social constructions of groups affected by the policies; economic and/or biomedical framings were dominant; elites (especially business interests) lobbied against the policies; and there was effective civil society and policy advocacy in favour of the policies.

Conclusions

Building on our insights from our case studies of action for political will, we conclude with a series of questions to guide the work of public health activists and policy advocates working to support existing and to create new political will in multiple contexts.

Key messages

The creation of political will is vital to the adoption of policies supportive of health equity. Analysis of 8 policy case studies points to how advocacy can most effectively create political will.

Global health activists' lessons on building social movements for Health for All

BACKGROUND

The People's Health Movement (PHM) was formed in 2000 and drew inspiration from the Alma Ata Declaration on Primary Health Care's 'Health for All' (1978). Since then PHM has been an active part of a global counter-hegemonic social movement. This study aimed to gain insights on social movement building, drawing on the successes and failures reported by activists over their experiences of working in the Health for All social movement to improve health, justice and equity.

METHODS

Qualitative research methods were employed in this study to capture complex and historical narratives of individual activists, through semi-structured interviews and subsequent thematic analysis of transcripts. The research design and analysis were informed by social movement theory and literature on health activism as a pathway for social change. In this study we examine the semi-structured interviews of 15 health activists who are part of the PHM, with the aim of deriving lessons for strengthening movements for Health for All.

RESULTS

This study locates the activists' narratives within a socio-political analysis of the global trends of late modern individualism and capitalist neoliberalism. This highlights the challenges faced by civil society groups mobilising collective action and building social movements for Health for All. The study found that within the constraints of the neoliberal socio-political and economic conditions which have caused the rise in social and health inequities, this group of long-term health activists have been nurturing alternative approaches to structuring society and building collective agency to improve health.

CONCLUSION

The practical long-term experiences of the PHM activists examined in this study contribute to a better understanding of the processes and motivations that lead to and sustain health activism, and the dilemmas, strategies, impacts and achievements of such activism.

The contribution of group work to the goals of comprehensive primary health care

ISSUE ADDRESSED

Group work, such as peer support and health promotion is an important strategy available to comprehensive primary health care. However, group work and how it contributes to the goals of comprehensive primary health care has been under-researched and under-theorised.

METHODS

In this 5-year study, we partnered with seven Australian primary health care services, and drew on service reports, two rounds of staff interviews (2009-2010 and 2013, N = 68 and 55), 10 community assessment workshops (N = 65), a client survey (N = 315) and case tracking of clients with diabetes (N = 184, plus interviews with 35 clients, and five practitioners) and clients with depression (N = 95, plus interviews with 21 clients, and 11 practitioners). We conducted a rapid literature review of existing research on group work, and developed a model showing a group work reinforcing cycle. We examined the nature of the groups run, and the benefits staff and clients perceived.

RESULTS

Benefits were grouped into four main themes: (a) social support, including for clients of the Aboriginal services, opportunities to celebrate their cultural identity, (b) improving skills and knowledge, (c) increasing access to services and (d) empowerment and solidarity.

CONCLUSIONS

The perceived collective and individual benefits aligned with a comprehensive primary health care vision. However, the individualism stressed by neoliberal-driven health policy threatened the provision of group work and its potential collectivist benefits.

SO WHAT

There are multiple benefits of group work in primary health care that cannot be achieved through individual work, highlighting the importance of policy and organisational support for group work.

Strife of Interests: Constraints on integrated and co-ordinated comprehensive PHC in Australia

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Developing a screening tool to recognise social determinants of health in Australian clinical settings

Objective and importance of study: The importance of social determinants for individual health recovery outcomes is well recognised in public health. However, no succinct social health screening (SHS) tool exists that has been developed with information from clinicians and patients. This proof-of-concept study asked health consumer advocates, patients and clinicians about their attitudes towards social determinants of health (SDH) and the usefulness of an SHS tool for collecting these data for use in clinical settings. We then developed a streamlined SHS tool to bring this knowledge to clinicians, and conducted a proof-of-concept trial to check its acceptability with patients and clinicians.

METHODS

This qualitative study had two stages. Stage 1 involved focus groups with health consumer advocates and interviews with clinicians about the draft SHS tool. Stage 2 involved refining the SHS tool and piloting it with 50 new patients in anxiety disorder and sleep disorder clinics, which often treat patients living in disadvantaged socio-economic conditions. The tool was evaluated by patients and clinicians. The data were analysed using framework analysis.

RESULTS

All interviewees were positive about the benefits of addressing SDH in clinical practice to help reduce health inequities. We developed and refined an SHS tool that could be completed by patients ('self-complete').

CONCLUSION

The response to introducing an SHS tool in clinical settings was positive. Further piloting across diverse clinical settings is required to determine efficacy. This tool promotes public health equity outcomes by improving clinician understanding of individual social circumstances, and has the potential to provide useful epidemiological data on SDH.

Case study of a decolonising Aboriginal community controlled comprehensive primary health care response to alcohol-related harm

OBJECTIVE

This paper provides a case study of the responses to alcohol of an Aboriginal Community Controlled Health Service (The Service), and investigates the implementation of comprehensive primary health care and how it challenges the logic of colonial approaches.

METHODS

Data were drawn from a larger comprehensive primary health care study. Data on actions on alcohol were collected from: a) six-monthly service reports of activities; b) 29 interviews with staff and board members; c) six interviews with advocacy partners; and d) community assessment workshops with 13 service users.

RESULTS

The Service engaged in rehabilitative, curative, preventive and promotive work targeting alcohol, including advocacy and collaborative action on social determinants of health. It challenged other government approaches by increasing Aboriginal people's control, providing culturally safe services, addressing racism, and advocating to government and industry.

CONCLUSIONS

This case study provides an example of implementation of the full continuum of comprehensive primary health care activities. It shows how community control can challenge colonialism and ongoing power imbalances to promote evidence-based policy and practice that support self-determination as a positive determinant for health. Implications for public health: Aboriginal Community Controlled Health Services are a good model for comprehensive primary health care approaches to alcohol control.

The feasibility and potential use of case-tracked client journeys in primary healthcare: a pilot study

OBJECTIVES

To determine the feasibility of case-tracking methods in documenting client journeys at primary healthcare (PHC) services in order to investigate the comprehensiveness of service responses and the experiences of clients.

DESIGN

Prospective pilot study. Quantitative and qualitative case management data were collected from staff via questionnaire or interview.

SETTING

Five Australian multidisciplinary PHC services were involved including four South Australian state-managed and one Northern Territory Aboriginal community-controlled PHC service.

PARTICIPANTS

Clients using services for depression (95) or diabetes (185) at the PHC services were case tracked over a 12-month period to allow construction of client journeys for these two conditions. Clients being tracked were invited to participate in two semi-structured interviews (21) and complete a health log.

RESULTS

Though a number of challenges were encountered, the case-tracking methods were useful in documenting the complex nature of client journeys for those with depression or diabetes accessing PHC services and the need to respond to the social determinants of health. A flexible research design was crucial to respond to the needs of staff and changing organisational environments.

CONCLUSIONS

The client journeys provided important information about the services' responses to depression and diabetes, and about aspects unique to comprehensive PHC such as advocacy and work that takes into account the social determinants of health.

Interagency collaboration in primary mental health care: lessons from the Partners in Recovery program

Background

Collaborative care is a means of improving outcomes particularly for people with complex needs. The Partners in Recovery (PIR) program, established in Australia in 2012, provides care coordination to facilitate access to health and social support services for people with severe and persistent mental illness. Of the 48 PIR programs across Australia, 35 were led by Medicare Locals, the previous Australian regional primary health care organisation and nine involved Medicare Locals as partner organisations.

Aims

To identify features which enabled and hindered collaboration in PIR programs involving Medicare Locals and determine what can be learnt about delivering care to this population.

Methods

Data were collected from 50 interviews with senior staff at Medicare Locals and from eight focus groups with 51 mental health stakeholders in different Australian jurisdictions.

Results

Successful PIR programs were based upon effective collaboration. Collaboration was facilitated by dedicated funding, a shared understanding of PIR aims, joint planning, effective network management, mutual respect and effective communication. Collaboration was also enhanced by the local knowledge and population health planning functions of Medicare Locals. Jurisdictional boundaries and funding discontinuity were the primary barriers to collaboration.

The value of a causal loop diagram in exploring the complex interplay of factors that influence health promotion in a multisectoral health system in Australia

BACKGROUND

Despite calls for the application of complex systems science in empirical studies of health promotion, there are very few examples. The aim of this paper was to use a complex systems approach to examine the key factors that influenced health promotion (HP) policy and practice in a multisectoral health system in Australia.

METHODS

Within a qualitative case study, a schema was developed that incorporated HP goals, actions and strategies with WHO building blocks (leadership and governance, financing, workforce, services and information). The case was a multisectoral health system bounded in terms of geographical and governance structures and a history of support for HP. A detailed analysis of 20 state government strategic documents and interviews with 53 stakeholders from multiple sectors were completed. Based upon key findings and dominants themes, causal pathways and feedback loops were established. Finally, a causal loop diagram was created to visualise the complex array of feedback loops in the multisectoral health system that influenced HP policy and practice.

RESULTS

The complexity of the multisectoral health system was clearly illustrated by the numerous feedback mechanisms that influenced HP policy and practice. The majority of feedback mechanisms in the causal loop diagram were vicious cycles that inhibited HP policy and practice, which need to be disrupted or changed for HP to thrive. There were some virtuous cycles that facilitated HP, which could be amplified to strengthen HP policy and practice. Leadership and governance at federal-state-local government levels figured prominently and this building block was interdependently linked to all others.

CONCLUSION

Creating a causal loop diagram enabled visualisation of the emergent properties of the case health system. It also highlighted specific leverage points at which HP policy and practice can be improved. This paper demonstrates the critical importance of leveraging leadership and governance for HP and adds urgency to the need for increased and strong advocacy efforts targeting all levels of government in multisectoral health systems.

Collaborative population health planning between Australian primary health care organisations and local government: lost opportunity

OBJECTIVE

To examine the strength and extent of collaborations between primary health care organisations and local government in population health planning.

METHODS

Methods included: a) online surveys with Medicare Locals (n=210) and Primary Health Networks (n=66), comparing the two using two-level mixed models; b) interviews with Medicare Local (n=50) and Primary Health Network (n=55) executives; c) interviews with members of local government associations and Primary Health Network board members with local government experience (n=7); and d) review of 54 Medicare Local and 31 Primary Health Network publicly available annual reports.

RESULTS

Despite partnership being a policy objective for Medicare Locals/ Primary Health Networks, they reported limited time and financial support for collaboration with local government. Organisational capacity and resources, supportive governance and public health legislation mandating a role for local governments were critical to collaborative planning.

CONCLUSIONS

Local government has the potential to tackle social factors affecting health; therefore, their inclusion in population health planning is valuable. Legislative mandates would help to achieve this, and PHNs require a stronger Federal Government mandate backed by sufficient resources and a governance structure that supports collaboration. Implications for public health: Improving primary health care and local government collaboration has great potential to improve the quality of health planning and action on social determinants, thus advancing population health and health equity.

Community Health Worker Programs to Improve Healthcare Access and Equity: Are They Only Relevant to Low- and Middle-Income Countries?

Background: Community Health Workers (CHWs) are proven to be highly effective in low- and middle-income countries with many examples of successful large-scale programs. There is growing interest in deploying CHW programs in high-income countries to address inequity in healthcare access and outcomes amongst population groups facing disadvantage. This study is the first that examines the scope and potential value of CHW programs in Australia and the challenges involved in integrating CHWs into the health system. The potential for CHWs to improve health equity is explored.

Methods: Academic and grey literature was searched to examine existing CHW roles in the Australian primary healthcare system. Semi-structured telephone interviews were conducted with a purposive sample of 11 people including policymakers, program managers and practitioners, to develop an understanding of policy and practice.

Results: Literature on CHWs in Australia is sparse, yet combined with interview data indicates CHWs conduct a broad range of roles, including education, advocacy and basic clinical services, and work with a variety of communities experiencing disadvantage. Many, and to some extent inconsistent, terms are used for CHWs, reflecting the various strategies employed by CHWs, the characteristics of the communities they serve, and the health issues they address. The role of aboriginal health workers (AHWs) is comparatively well recognised, understood and documented in Australia with evidence on their contribution to overcoming cultural barriers and improving access to health services. Ethnic health workers assist with language barriers and increase the cultural appropriateness of services. CHWs are widely seen to be well accepted and valuable, facilitating access to health services as a trusted ‘bridge’ to communities. They work best where ‘health’ is conceived to include action on social determinants and service models are less hierarchical. Short term funding models and the lack of professional qualifications and recognition are challenges CHWs encounter.

Conclusion: CHWs serve a range of functions in various contexts in Australian primary healthcare (PHC) with a common, valued purpose of facilitating access to services and information for marginalised communities. CHWs offer a promising opportunity to enhance equity of access to PHC for communities facing disadvantage, especially in the face of rising chronic disease.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Punching above their weight: a network to understand broader determinants of increasing life expectancy

Background

Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected – they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available.

New research network

In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens.

Conclusion

Further research using this framework has considerable potential to advance effective policies to advance health and equity.