Indonesia free from pasung: a policy analysis.

BACKGROUND: Many people with mental illnesses remain isolated, chained, and inside cages, called Pasung in Indonesia. Despite numerous policies introduced to eradicate Pasung, Indonesia has made slow progress in decreasing this practice. This policy analysis examined existing policies, plans and initiatives in Indonesia targeted at eradicating Pasung. Policy gaps and contextual constraints are identified in order to propose stronger policy solutions. METHODS: Eighteen policy documents were examined, including government news releases and organisational archives. A content analysis was undertaken of national-level policies that address Pasung within the context of the health system, social system and human rights since the establishment of Indonesia. This was followed by a case study analysis of policy and program responses particularly in West Java Province. FINDINGS: While policy to address Pasung exists at a national level, implementation at national and local levels is complicated. Pasung policy has generated a sense of awareness but the different directions and ambiguous messaging across all stakeholders, including policy actors, has created a lack of clarity about institutions' roles and responsibilities in the implementation process, as well as accountability for outcomes. This situation is exacerbated by an incomplete decentralisation of healthcare policymaking and service delivery, particularly at the primary level. It is possible that policymakers have overlooked international obligations and lessons learned from successful policymaking in comparable regional countries, resulting in disparities in target-setting, implementation mechanisms, and evaluation. CONCLUSION: While the public has become more informed of the need to eradicate Pasung, ongoing communication with the various clusters of policy actors on the aforementioned issues will be critical. Addressing the various segments of the policy actors and their challenges in response to policy will be critical as part of building the evidence base to establish a feasible and effective policy to combat Pasung in Indonesia.

Efficacy of mindfulness and goal setting interventions for increasing resilience and reducing smoking in lower socio-economic groups: randomised controlled trial protocol.

BACKGROUND: Smoking and resulting health problems disproportionately impact low socioeconomic status (SES) individuals. Building resilience presents an approach to 'closing the gap'. Mindfulness-based interventions and setting realistic goals are preferred in low socioeconomic communities. We aim to test if these interventions, delivered online and consolidated with peer support offered via ex-smokers, are successful in promoting smoking cessation and resilience. Our conceptualisation of resilience encompasses the inner capacity/skills and external resources (e.g., social support) which smokers utilise to bounce back from adversity. We include a process evaluation of barriers/facilitators to interventions and cost-effectiveness analysis (from health system perspective). METHODS: We plan a four-arm parallel 12-month RCT with a 6-month follow-up to test the efficacy of three group-based interventions each followed by peer support. Arm 1: mindfulness-integrated cognitive behavioural therapy; Arm 2: mindfulness training; Arm 3: setting realistic goals; Arm 4: active control group directed to quit services. All interventions will be administered online. Participants are adult smokers in Australia (N = 812) who have an average weekly household income less than $457AUD or receive welfare benefits. Group-based interventions will occur over 6 months, followed by 6 months of forum-based peer support. PRIMARY OUTCOME: self-reported 14-day period prevalence of smoking abstinence at 6 months, with remote biochemical verification of saliva cotinine (< 30 ng/mL). Secondary outcomes include: internal resilience (Connor-Davidson Resilience Scale-25); external resilience (ENRICHD social support tool); quality adjusted life years (EQ-5D-5L); self-efficacy for smoking abstinence (Smoking-Abstinence Self-Efficacy Questionnaire); motivation to quit smoking (Biener and Abrams Contemplation Ladder); nicotine dependence (Fagerstrom Test for Nicotine Dependency); equanimity (Equanimity Scale-16); stress (Perceived Stress Scale-10); goal assessment/attainment (Problems and Goals Assessment Scale). DISCUSSION: This study is the first to compare resilience interventions for low SES smokers which have been identified by them as acceptable. Our various repeated measures and process evaluation will facilitate exploration of mechanisms of impact. We intervene within the novel framework of the Psychosocial Model of Resilience, applying a promising paradigm to address a critical and inequitable public health problem. Trial registration Australian New Zealand Clinical Trials Registry ID: ACTRN12621000445875, registered 19 April 2021 ( https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381007&isReview=true ). The Universal Trial Number is U1111-1261-8951.

NDIS Participants with Psychosocial Disabilities and Life-Limiting Diagnoses: A Scoping Review.

This research aimed to map evidence about system supports and gaps for Australians with psychosocial disabilities and life-limiting diagnoses. A scoping review of available policy documents, academic, and grey literature was completed to discover key characteristics of this concept and provide context around the phenomenon. Our focus was on Australia's National Disability Insurance Scheme (NDIS), a key reform providing support to the disability population nationally. No peer-reviewed or grey literature was retrieved on the phenomena. Therefore, three lines of enquiry were developed: experiences of NDIS participants living with psychosocial disabilities; the death, dying, and palliative care supports and experiences of NDIS participants of any disability type; and the experiences for people living with severe and persistent mental illness (SPMI) and life-limiting diagnoses. Five themes were identified: (1) the person; (2) advocacy; (3) informal supports; (4) formal supports; and (5) existing research. NDIS participants living with SPMI and their informal and formal support systems are still struggling to navigate the NDIS. While there are no specific publications about their end-of-life experiences, people with SPMI often experience poor end-of-life outcomes. Rigorous research into their death, dying, and palliative care experiences is needed to inform improved support to them, including their end-of-life care.

The Effectiveness and Cost of an Intervention to Increase the Provision of Preventive Care in Community Mental Health Services: Protocol for a Cluster-Randomized Controlled Trial.

Preventive care to address chronic disease risk behaviours is infrequently provided by community mental health services. In this cluster-randomised controlled trial, 12 community mental health services in 3 Local Health Districts in New South Wales, Australia, will be randomised to either an intervention group (implementing a new model of providing preventive care) or a control group (usual care). The model of care comprises three components: (1) a dedicated 'healthy choices' consultation offered by a 'healthy choices' clinician; (2) embedding information regarding risk factors into clients' care plans; and (3) the continuation of preventive care by mental health clinicians in ongoing consultations. Evidence-based implementation strategies will support the model implementation, which will be tailored by being co-developed with service managers and clinicians. The primary outcomes are client-reported receipt of: (1) an assessment of chronic disease risks (tobacco smoking, inadequate fruit and vegetable consumption, harmful alcohol use and physical inactivity); (2) brief advice regarding relevant risk behaviours; and (3) referral to at least one behaviour change support. Resources to develop and implement the intervention will be captured to enable an assessment of cost effectiveness and affordability. The findings will inform the development of future service delivery initiatives to achieve guideline- and policy-concordant preventive care delivery.

Self-reported suboptimal sleep and receipt of sleep assessment and treatment among persons with and without a mental health condition in Australia: a cross sectional study.

BACKGROUND: Poor sleep and poor mental health go hand in hand and, together, can have an adverse impact on physical health. Given the already disproportionate physical health inequities experienced by people with a mental health condition worldwide, the need to consider and optimise sleep has been highlighted as a means of improving both physical and mental health status. Sleep recommendations recently developed by the United States' National Sleep Foundation incorporate a range of sleep parameters and enable the identification of 'suboptimal' sleep. Among community-dwelling persons with and without a 12-month mental health condition in Australia, this study reports: [1] the prevalence of 'suboptimal' sleep and [2] rates of sleep assessment by a health care clinician/service and receipt of and desire for sleep treatment. METHODS: A descriptive study (N = 1265) was undertaken using self-report data derived from a cross-sectional telephone survey of Australian adults, undertaken in 2017. RESULTS: Fifteen per cent (n = 184) of participants identified as having a mental health condition in the past 12 months. Across most (7 of 8) sleep parameters, the prevalence of suboptimal sleep was higher among people with a mental health condition, compared to those without (all p < 0.05). The highest prevalence of suboptimal sleep for both groups was seen on measures of sleep duration (36-39% and 17-20% for people with and without a mental health condition, respectively). In terms of sleep assessment and treatment, people with a mental health condition were significantly more likely to: desire treatment (37% versus 16%), have been assessed (38% versus 12%) and have received treatment (30% versus 7%). CONCLUSIONS: The prevalence of suboptimal sleep among persons with a mental health condition in Australia is significantly higher than those without such a condition, and rates of assessment and treatment are low for both groups, but higher for people with a mental health condition. Population health interventions, including those delivered as part of routine health care, addressing suboptimal sleep are needed.

Implementing national mental health carer partnership standards in South Australia.

Objective The aim of this study was to describe the current state of carer engagement and partnership in two mental health (MH) services in South Australia and the implementation of the six partnership standards in A Practical Guide to Working with Carers of People with a Mental Illness. Methods Anonymous surveys of carer experiences and clinician self-ratings of their own practice against the six partnership standards were completed by 94 staff and 58 carers within public and private MH in-patient units before and after exposure of clinicians to education about the partnership standards. Descriptive statistical analysis was performed and, where applicable, a comparative analysis used the two-sample Z-test of proportions. Qualitative data was analysed thematically. Results Considerable gaps were evident between carer experiences and clinician self-ratings of their own practice. Overall, the surveys point to the lack of a consistent approach by both public and private services, and suggest potential barriers to fostering carer participation and engagement. Confidentiality was a particularly noted barrier to partnership with carers. Conclusion Significant improvement is needed to meet the partnership standards. Brief exposure to the Guide is not, in itself, sufficient to effect change in the overall attitudes, skills and knowledge of clinical staff about engaging carers. Significantly more focus on staff education, clinical discussions and supervision is needed to meet the MH carer partnership standards. What is known about the topic? Partnership with MH consumers and carers is an established key principle within national MH policies and accreditation standards. Family carers play an important role in supporting consumers' recovery, yet many carers continue to report being excluded, particularly by in-patient clinical staff. What does this paper add? This is the first study to investigate the partnership standards in practice by comparing the perspectives of carers and in-patient MH clinical staff. What are the implications for practitioners? Improving partnership with carers of people with mental illness will require significant MH service leadership support shifts in current practice and culture. In addition, a more nuanced understanding of confidentiality is required to overcome the barriers to involving family carers more meaningfully in care.

The Frantic Seeking of Credit during Poker Machine Problem Gambling: A Public Health Perspective.

(1) Background: Financial harms associated with problem gambling are substantial and result in suicidal ideation, depression, anxiety and relationship damage, causing distress for problem gamblers and their families. This paper examines Electronic Gaming Machine gamblers' frantic use of credit during episodes of gambling as a substantial public health burden. (2) Methods: This qualitative study comprised 29 participants purposefully selected who participated in either focus groups or in-depth interviews, which were analysed using thematic, textual analysis. (3) Results: Ready access to credit in the gambling venues enabled problem gamblers to engage in desperate credit transactions to continue to gamble. Many showed frantic, repeated patterns of e-credit withdrawal, which may be typical of gambling while "in the zone", when it is highly likely that the gamblers are not able to make informed decisions about the use of credit. This pattern of the electronic withdrawal of cash may well be recognisable electronically by financial institutions in real-time, as part of a duty of care potentially owed by banks to their customers. It would provide an opportunity for the identification of people at financial risk due to gambling and systemic intervention to limit the financial harm at a time when financial decision-making is impaired. (4) Conclusions: Although this finding needs further confirmation, there are significant implications for harm minimisation and early intervention for affected PGs. It also raises the issue of the 'duty of care' owed to PG customers by financial institutions.

Supporting workforce practice change: protocol for a pilot study of a motivational interviewing virtual client software tool for health professionals.

INTRODUCTION: Motivating behavioural change during client consultations is of crucial importance across all health professions to address the growing burden of chronic conditions. Yet health professionals often lack the skills and confidence to use evidence-based counselling interventions to support clients' behavioural change and mobilise clients' resources and self-efficacy for change to address their long-term needs. AIMS: This pre-post pilot study will develop a motivational interviewing (MI) virtual client training tool for health professionals and test the effectiveness of the educational content and usability of the virtual client interaction. METHODS AND ANALYSIS: Postgraduate students across a range of health disciplines will be recruited. Data assessing attitudes towards preventive healthcare will be collected using a modified version of the Preventive Medicine Attitudes and Activities Questionnaire. Conversations with the virtual client will be analysed using the Motivational Interviewing Treatment Integrity code to assess changes in MI skills. The System Usability Scale will be used to assess the usability of the virtual client training tool. ETHICS AND DISSEMINATION: This protocol was approved by the Flinders University Social and Behavioural Research Ethics Committee in May 2019. The results of the pilot study will inform the development of an avatar-based mobile application consisting of MI teaching and interactions with a generic virtual client that can be easily adapted to multiple scenarios.

The role of comorbidity assessment in guiding treatment decision-making for women with early breast cancer: a systematic literature review.

PURPOSE: Comorbidity in breast cancer patients impacts treatment choice, toxicity, and outcomes. While comorbidity measurement tools are frequently used by researchers, little is known about their use in clinical practice. The aim of this review was to examine the use of comorbidity measurement tools in clinical practice and their role in treatment decision-making in breast cancer. METHODS: Six electronic databases were searched from inception to 21 March 2019. Quantitative or mixed methods studies addressing primary treatment of breast cancer and identifying a comorbidity measurement tool used in clinical practice treatment decision-making were included. Data was extracted on tool utilized, impact on treatment decisions or outcomes, pattern of use, and psychometric properties. RESULTS: A systematic search of literature yielded 752 studies. Of the four studies that met inclusion criteria, each utilized a comprehensive geriatric assessment tool, though only in a subset of patients. No studies found direct comorbidity measurement tools utilized independently of geriatric assessment. Assessment results had variable impact on treatment decisions. Impacts on patient mortality and treatment toxicity, cost-effectiveness, and psychometric characteristics of the tools were not identified. CONCLUSIONS: There is little evidence on use of specific comorbidity tools in clinical decision-making in breast cancer outside of comorbidity assessment as part of geriatric assessment tools. There was limited impact on decision-making or patient outcomes when these were utilized. Further research is needed to identify barriers to comorbidity assessment in clinical practice and identify comorbidity tools that have the potential to improve patient outcomes.

Family-directed approach to brain injury (FAB) model: a preliminary framework to guide family-directed intervention for individuals with brain injury.

PURPOSE: This article proposes a theoretical framework to help professionals include family as active members in brain injury rehabilitation. A trend towards greater family involvement has lead to the development of family-collaboration models. However, current models appear to focus on information sharing rather than increasing the capability of family members. This article introduces a family-directed approach to brain injury model, which provides a theoretical framework for supporting family as facilitators of change. METHODS: Family-collaboration models and literature regarding family experiences following brain injury and support needs are reviewed to identify the driving forces behind family engagement in rehabilitation, including effective professional-family relationships, and important factors in the delivery of education underpinned by evidence-based practices. RESULTS: The family-directed approach to brain injury model is based on principles of hope, family expertise, education/skill building, and family-directed intervention. CONCLUSIONS: The family-directed approach to brain injury model provides a theoretical framework for educating and training family members as facilitators in the management process: promoting competence rather than dependency on service systems. Guiding recommendations encourage professionals to reflect on the importance of their therapeutic relationships and their capacity to positively impact rehabilitation outcomes beyond the technical aspects of health care and treatment. Implications for Rehabilitation Training family members as facilitators in the rehabilitation process is suggested to reduce dependency on the service system, address families' unmet support needs, and to optimize rehabilitation outcomes for individuals with brain injury. The family-directed approach to brain injury model is proposed to guide the increased involvement of family as active members in the rehabilitation team and to define potential active ingredients in this process.

The health and wellbeing needs of veterans: a rapid review.

BACKGROUND: For the majority of serving members, life in the military has a positive effect on wellbeing. However, the type, intensity and duration of service, along with the transition from fulltime military to civilian life, may have a negative effect on veterans' wellbeing. Such negative consequences, alongside the growing veteran population, indicate the need for greater exploration of veterans' physical, mental and social wellbeing. METHODS: The current paper reports on the findings of a rapid review of the literature on the health and wellbeing needs of veterans, commissioned by the Australian Department of Veterans' Affairs to inform future programs and services. The databases Embase, Medline, Cinahl, PubMed, Web of Science and Cochrane Database were searched for systematic reviews reporting on veterans' physical, mental and social wellbeing published in English in peer-reviewed journals. RESULTS: A total of 21 systematic reviews were included. The reviews reported on a range of mental, physical and social health problems affecting veterans. While there was limited information on prevalence rates of physical, mental and social health problems in veterans compared to civilian populations, the reviews demonstrated the interconnection between these domains and the effect of demographic and military service factors. CONCLUSIONS: A key finding of the review is the interconnection of the mental, physical, and social health of veterans, highlighting the importance that an integrated approach to veterans' wellbeing is adopted. It is suggested that understanding key factors, such as demographic factors and factors relating to military service, can support improved service provision for veterans.

An integrative review of e-learning in the delivery of self-management support training for health professionals.

BACKGROUND: E-learning involves delivery of education through Information and Communication Technology (ITC) using a wide variety of instructional designs, including synchronous and asynchronous formats. It can be as effective as face-to-face training for many aspects of health professional training. There are, however, particular practices and skills needed in providing patient self-management support, such as partnering with patients in goal-setting, which may challenge conventional practice norms. E-learning for the delivery of self-management support (SMS) continuing education to existing health professionals is a relatively new and growing area with limited studies identifying features associated with best acquisition of skills in self-management support. METHODS: An integrative literature review examined what is known about e-learning for self-management support. This review included both qualitative and quantitative studies that focused on e-learning provided to existing health professionals for their continuing professional development. Papers were limited to those published in English between 2006 and 2016. Content analysis was used to organize and focus and describe the findings. RESULTS: The search returned 1505 articles, with most subsequently excluded based on their title or abstract. Fifty-two full text articles were obtained and checked, with 42 excluded because they did not meet the full criteria. Ten peer-reviewed articles were included in this review. Seven main themes emerged from the content analysis: participants and professions; time; package content; guiding theoretical framework; outcome measures; learning features or formats; and learning barriers. These themes revealed substantial heterogeneity in instructional design and other elements of e-learning applied to SMS, indicating that there is still much to understand about how best to deliver e-learning for SMS skills development. CONCLUSIONS: Few e-learning approaches meet the need for high levels of interactivity, reflection, practice and application to practice for health professionals learning to deliver effective SMS. Findings suggest that the context of SMS for patients with chronic condition matters to how health professional training is delivered, to ensure partnership and person-centred care. Further creative approaches and their rigorous evaluation are needed to deliver completely online learning in this space. Blended learning that combines e-learning and face-to-face methods is suggested to support SMS skills development for health professionals.

The barriers and facilitators that indigenous health workers experience in their workplace and communities in providing self-management support: a multiple case study.

BACKGROUND: The inequality in health outcomes between Indigenous (Throughout the paper, the term Indigenous will be used to represent both Aboriginal Australians and Torres Strait Islander Australians.) and non-Indigenous Australians continues to be a major public health issue. Chronic conditions are responsible for the majority of the gap in life expectancy for this population. Evidence suggests that chronic condition management models focusing on self-management have led to improved health outcomes in Indigenous populations. The Flinders Closing the Gap Program (FCTGP) is a chronic condition care planning tool which aims to engage Indigenous people in self-managing their chronic conditions. Indigenous health workers (IHWs) can provide culturally appropriate self-management support; however there is paucity in current literature describing specific barriers and facilitators that they may experience when attempting to deliver this support. This study aimed to explore IHWs' perceptions of the effectiveness and appropriateness of the FCTGP, as an evidence-based example of self-management support, and to explore the barriers and facilitators that IHWs experience in their workplace and communities in providing self-management support. METHODS: In-depth interviews were undertaken with five IHWs, drawn from five different states in Australia. Their selection was aided by key informants from the FCTGP training unit. Interviews were recorded and transcribed verbatim, and were analysed using thematic analysis. RESULTS: The following themes were identified. IHWs reported that the FCTGP was appropriate, flexible and acceptable in their communities. Facilitators included factors improving client and worker empowerment, and activities around sharing knowledge. Barriers included competing priorities that clients experience relating to social determinants of health, and negative experiences within mainstream health services. IHW burnout from time pressures, lack of support, and high staff turnover were also considered important barriers. CONCLUSIONS: This study contributes an insight into the experiences of IHWs who are considered important stakeholders in implementation and sustainability of chronic condition management programs, including the FCTGP. Recommendations focus on supporting and supplementing the role of IHWs and identify the FCTGP as a facilitator in providing self-management support to a population with complex needs.

Practice change in chronic conditions care: an appraisal of theories.

BACKGROUND: Management of chronic conditions can be complex and burdensome for patients and complex and costly for health systems. Outcomes could be improved and costs reduced if proven clinical interventions were better implemented, but the complexity of chronic care services appears to make clinical change particularly challenging. Explicit use of theories may improve the success of clinical change in this area of care provision. Whilst theories to support implementation of practice change are apparent in the broad healthcare arena, the most applicable theories for the complexities of practice change in chronic care have not yet been identified. METHODS: We developed criteria to review the usefulness of change implementation theories for informing chronic care management and applied them to an existing list of theories used more widely in healthcare. RESULTS: Criteria related to the following characteristics of chronic care: breadth of the field; multi-disciplinarity; micro, meso and macro program levels; need for field-specific research on implementation requirements; and need for measurement. Six theories met the criteria to the greatest extent: the Consolidate Framework for Implementation Research; Normalization Process Theory and its extension General Theory of Implementation; two versions of the Promoting Action on Research Implementation in Health Services framework and Sticky Knowledge. None fully met all criteria. Involvement of several care provision organizations and groups, involvement of patients and carers, and policy level change are not well covered by most theories. However, adaptation may be possible to include multiple groups including patients and carers, and separate theories may be needed on policy change. Ways of qualitatively assessing theory constructs are available but quantitative measures are currently partial and under development for all theories. CONCLUSIONS: Theoretical bases are available to structure clinical change research in chronic condition care. Theories will however need to be adapted and supplemented to account for the particular features of care in this field, particularly in relation to involvement of multiple organizations and groups, including patients, and in relation to policy influence. Quantitative measurement of theory constructs may present difficulties.

Carers' experiences of accessing and navigating mental health care for older people in a rural area in Australia.

OBJECTIVES: Mental health care for older people is primarily delivered in the community and is largely dependent on informal carers. Mental health policy encourages partnerships between carers and service providers to facilitate service access, coordination and positive experience of care. However, carers often lack information and support from services, with the potential for carer burden, and negative impacts on their own health and capacity to fulfil caring tasks. This paper explores rural carers' experiences of accessing care from a range of services for older people with mental health problems. METHOD: The Pathways Interview Schedule was used to facilitate 9 in-depth care journey interviews with 11 carers of older people with a mental health problem. Interviews explored their journeys to and through mental health, aged care, primary care and social care services. Framework analysis was used to explore carers' experiences and perceptions of care with a focus on access enablers and barriers. RESULTS: Carers had a significant role in navigating services and operationalising care for their relative. Enablers to accessing care included carer knowledge and workers actively involving carers in planning. Barriers included carer mental health literacy, consumer and carer readiness for services, and worker misinterpretation of confidentiality and privacy laws. CONCLUSION: Carers should be considered key partners in mental health care planning that crosses service sectors. For this to occur, changes are required at the worker level, including increased communication between mental health workers and carers, and the service level, involving training for staff in interpreting confidentiality and privacy policy.

Support workers can develop the skills to work with complexity in community aged care: An Australian study of training provided across aged care community services.

Enhancing support workers' (SW) role is timely given increasing demands on human and financial health care resources. This article presents outcomes of a program, delivered to 140 participants from five community aged care providers in Australia, designed to enhance knowledge, skills, and confidence of community aged care SWs, building their practical skills in understanding, recognizing, and responding to complexity. Evaluation training modules on communication, complexity, behavior change, and chronic condition self-management support involved pre/post surveys with SWs and their supervisors. SWs reported greater awareness, skills, and confidence in working with complexity, reinforcing the value of their existing practices and skills. Coordinators reported greater appreciation of SWs' skills, and greater awareness of gaps in SWs' support and supervision needs. Educators, policy makers, and services should account for these contributions, given growing fiscal restraint and focus on reablement and consumer-directed care.

Support workers as agents for health behavior change: An Australian study of the perceptions of clients with complex needs, support workers, and care coordinators.

An expanding aging population has placed increased demands on health care resources in many countries. Enhancing community aged care support workers' role to support greater client self-management and reablement is therefore timely. This article presents perceptions of the impact of an Australian practice change initiative designed to enhance knowledge, skills, and confidence of support workers to support behavior change in clients with complex health care needs. A comprehensive training program was delivered in 2013. Methods included thematic analysis of interviews with clients, focus groups with support workers and coordinators, and collection of case studies of client/support worker behavior change interactions. Client, support worker, and coordinator responses were highly positive, reporting improvement in the quality of interactions with clients, client health outcomes, care coordination, communication, and teamwork. Mental health literacy remained the biggest knowledge gap. This research showed that support workers are ideally placed to be more actively involved in motivating clients to achieve behavior change goals.