Establishing consensus for the assessment of chronic pain in children and young people with cerebral palsy: a Delphi study.

PURPOSE: Inconsistent and inadequate pain assessment practices in cerebral palsy (CP) have resulted from a lack of standardisation of pain assessment, limited use of appropriate tools and failure to integrate disability and biopsychosocial models. To assist with improving consistency, this study aimed to establish consensus from key stakeholders regarding domains considered essential for measuring chronic pain in children and young people with CP. METHOD: A modified electronic Delphi study was conducted on 83 stakeholders, including clinicians, researchers, people with CP and parents of children with CP. Participants rated 18 domains sourced from existing literature as either "core", "recommended", "exploratory" or "not required". RESULTS: After two rounds of surveys, 12 domains were considered core: pain location, pain frequency, pain intensity, changeable factors, impact on emotional wellbeing, impact on participation, pain communication, influence on quality of life, physical impacts, sleep, pain duration and pain expression. CONCLUSION: These domains reflect the complexity of pain in a heterogeneous population where medical comorbidities are common and communication and intellectual limitations impact significantly on the ability of many to self-report. The domains will be utilised to build a framework of pain assessment specific to children and young people with CP guided by the biopsychosocial model.Implications for rehabilitationChronic pain is under-identified and poorly assessed in the cerebral palsy (CP) population.The perspectives of clinicians, researchers and consumers are vital for developing a framework for chronic pain assessment in CP.Consensus of key stakeholders found 12 domains considered essential to incorporate into a chronic pain assessment model in CP.

Enlisting the support of trusted sources to tackle policy problems: The case of antimicrobial resistance.

Antimicrobial resistance represents one of the world's most pressing public health problems. Governments around the world have-and will continue to-develop policy proposals to deal with this problem. However, the capacity of government will be constrained by very low levels of trust in government. This stands in contrast to 'medical scientists' who are highly trusted by the public. This article tests to what extent trusted sources can alter attitudes towards a policy proposal to regulate the use of antibiotics. We find that respondents are much more likely to support a policy put forward by 'medical scientists.' This article provides some initial evidence that medical scientists could be used to gain support for policies to tackle pressing policy challenges such as AMR.

Exploring productivity and collaboration in Australian Indigenous health research, 1995-2008.

BACKGROUND: Building research capacity in Indigenous health has been recognised as integral in efforts to reduce the significant health disparities between Indigenous and other Australian populations. The past few decades have seen substantial changes in funding policy for Australian Indigenous health research, including increases in overall expenditure and a greater focus on collaborative and priority-driven research. However, whether these policy shifts have resulted in any change to the structure of the research workforce in this field is unclear. We examine research publications in Australian Indigenous health from 1995-2008 to explore trends in publication output, key themes investigated, and research collaborations. METHODS: A comprehensive literature search was undertaken to identify research publications about Australian Indigenous health from 1995-2008. Abstracts of all publications identified were reviewed by two investigators for relevance. Eligible publications were classified according to key themes. Social network analyses of co-authorship patterns were used to examine collaboration in the periods 1995-1999, 2000-2004 and 2005-2008. RESULTS: Nine hundred and fifty three publications were identified. Over time, the number of publications per year increased, particularly after 2005, and there was a substantial increase in assessment of health service-related issues. Network analyses revealed a highly collaborative core group of authors responsible for the majority of outputs, in addition to a series of smaller separate groups. In the first two periods there was a small increase in the overall network size (from n = 583 to n = 642 authors) due to growth in collaborations around the core. In the last period, the network size increased considerably (n = 1,083), largely due to an increase in the number and size of separate groups. The general size of collaborations also increased in this period. CONCLUSIONS: In the past few decades there has been substantial development of the research workforce in Indigenous health, characterised by an increase in authors and outputs, a greater focus on some identified priority areas and sustained growth in collaborations. This has occurred in conjunction with significant changes to funding policy for Indigenous health research, suggesting that both productivity and collaboration may be sensitive to reform, including the provision of dedicated funding.

Influencing public policy on oral health.

OBJECTIVES: In policy studies, an enduring research question is why some issues are taken seriously while others never become a central focus of policy making. This study aims to analyse the predecision stage of policy making and examines the position of oral health on the broader health policy agenda. METHODS: A study of networks of influence in health policy in the state of Victoria (Australia) is used to examine the health policy agenda, and the position of oral health within the broader health policy agenda. Social network concepts were used to structure the data collection. Nominations of influential people were collected using a snowball method, followed by interviews with a selection of those nominated. RESULTS: Combining an assessment of who is seen to be influential with an examination of the issues they are interested in provides insights into how influence helps shape the policy agenda and how this changes over time. CONCLUSIONS: The study describes how oral health might become more central to the health policy agenda through deliberate strategies to change the network structure.

Indigenous health organizations in Australia: connections and capacity.

The health of Aboriginal people is significantly worse than that of the rest of the Australian population. Aboriginal community-controlled health organizations live with uncertainty in terms of funding, and the amount of money spent on indigenous people through mainstream health services is less than that spent on the non-indigenous population, especially when the different needs of these two groups are taken into account. The Aboriginal population is small and widely dispersed, causing problems for policy and funding. This article provides an analysis of the network of health organizations in Victoria, with a specific focus on indigenous health, and analyzes the connections between mainstream and indigenous-specific health services. The research approach involved semi-structured interviews with informants from a range of health organizations within the state. This research illustrates the importance of Aboriginal community-controlled health organizations to the indigenous community. There is evidence that connections between the indigenous and mainstream health systems need to be further developed and strengthened to provide the indigenous population with a high-quality, culturally sensitive, and comprehensive health service.

Evaluation of the blood stabilizers TransFix and Cyto-Chex BCT for low-cost CD4 T-cell methodologies.

TransFix(TM) and Cyto-Chex((R)) BCT (blood collection tube) reagents have been shown to maintain whole blood integrity for delayed immunophenotyping by flow cytometry. We evaluated the ability of these blood-stabilizing reagents to preserve HIV-seropositive blood for delayed CD4(+) T-cell quantification utilizing the Dynal((R)) Biotech T4 Quant Kit. TransFix was added to EDTA-anticoagulated whole blood and tested at a 1:10 dilution over 7 d using the Dynal (n = 21) manual method. Compared to baseline analysis, a significant decrease in mean CD4(+) counts was observed over time. Cyto-Chex BCT-preserved samples (n = 20) were tested for CD4(+) counts by Dynal over 7 d, with storage at varying temperatures: room temperature (21 degrees C), 37 degrees C, and 37 degrees C with intermittent storage at 42 degrees C. A significant decline in mean CD4(+) counts was observed in samples at all temperatures compared to baseline (p < 0.05). Increases in temperature to and above 37 degrees C resulted in a greater decline in mean CD4(+) counts over time. Our findings indicated that neither TransFix or Cyto-Chex BCT was a suitable blood stabilizer when used for delayed CD4(+) quantification with a low-cost manual CD4(+) bead-based method.

Care for chronic conditions for indigenous Australians: key informants' perspectives on policy.

BACKGROUND: The WHO's 2002 global report, Innovative Care for Chronic Conditions proposes a comprehensive framework for health systems to meet the challenges posed by chronic conditions. This paper uses the policy environment component of the WHO framework as a lens through which to examine key informants' perspectives on the management and prevention of chronic conditions in rural and remote Aboriginal communities in Australia. METHODS: Twenty one semi-structured telephone interviews were conducted with a purposive sample of stakeholders, including senior commonwealth, state/territory and regional public servants and health service staff. All of the interviews were audio recorded, from which written summaries were produced. These summaries were then content analysed to build a composite picture of this area. FINDINGS: The results indicate substantial success in developing national and sub-national strategies and refining funding and reporting arrangements. But much work remains to be done in strengthening partnerships, developing and retaining the workforce, and further shifting the focus from acute to chronic conditions. CONCLUSIONS: This paper provides a snapshot of the main policy issues, as identified by key informants, facing chronic disease management in rural and remote Indigenous communities in Australia. It has the potential to contribute to new national policy directions in Indigenous health.

Being around and knowing the players: networks of influence in health policy.

The accumulation and use of power is crucial to the health policy process. This paper examines the power of the medical profession in the health policy arena, by analysing which actors are perceived as influential, and how influence is structured in health policy. It combines an analysis of policy networks and social networks, to examine positional and personal influence in health policy in the state of Victoria, Australia. In the sub-graph of the influence network examined here, those most widely regarded as influential are academics, medically qualified and male. Positional actors (the top politician, political advisor and bureaucrat in health and the top nursing official) form part of a core group within this network structure. A second central group consists of medical influentials working in academia, research institutes and health-related NGOs. In this network locale overall, medical academics appear to combine positional and personal influence, and play significant intermediary roles across the network. While many claim that the medical profession has lost power in health policy and politics, this analysis yields few signs that the power of medicine to shape the health policy process has been greatly diminished in Victoria. Medical expertise is a potent embedded resource connecting actors through ties of association, making it difficult for actors with other resources and different knowledge to be considered influential. The network concepts and analytical techniques used here provide a novel means for uncovering different types of influence in health policy.

Reform and autonomy: perceptions of the Australian general practice community.

Reforms in health care in the 1990s across industrialised nations have had profound consequences for the autonomy of general/family practitioners (GPs). Research suggests that the professional autonomy of GPs is declining across countries, related to policy reform processes and to challenges from other actors. Important questions remain, however, around appropriate ways to conceptualise autonomy, and about the perceptions that GPs themselves have of their autonomy. It is these questions in the context of more than a decade of general practice reform in Australia that are the focus of this paper. Using a multi-component model of autonomy, which separates out micro, meso and macro dimensions of autonomy, we undertook an analysis of 343 items on autonomy and reform collected from 3 key general practice journals. We argue that members of the GP community profess an enjoyment for general practice, and operate with an ideal of what it means to be a GP. However, the reform process is perceived to challenge this enjoyment and the ideal of professional practice. In particular, there exists uncertainty as to what it means to be a GP, with members of the GP community expressing a loss of control across important dimensions of autonomy. While numerically most discussion focused on control over earnings, the intensity of feeling was most evident around control over clinical practice. Our results suggest the importance of using a multi-component model of autonomy, as it allows for a nuanced analysis of the relationship between the reform process and autonomy. At the same time, however, our analysis indicates that it is also crucial to recognise autonomy is constituted by the interaction of these components.

The impact of financial constraints and incentives on professional autonomy.

General practice has been the subject of extensive reforms over the 1990s in Australia as elsewhere. Reforms have attempted to improve quality and contain the overall cost of health care, and have often been seen as reducing the autonomy of medical professionals. This paper examines the impact of financial constraints and incentives introduced during the 1990s on Australian GPs' perceptions of autonomy. An existing seven component definition of autonomy and six themes that emerged from reviewing publications were used to construct focus group questions. A total of 25 GPs participated in four focus groups. Those who participated believe that their financial autonomy has been diminished by policy changes and consumer expectations. They also perceive that their ability to control clinical decisions, which they regard as the most important aspect of professional autonomy, has been reduced along with financial autonomy. Organized medicine in Australia sees financial accountability and clinical decision making as polar opposites, and has continued to argue that fee-for-service payment is the only appropriate method of remuneration, despite increasing evidence that this does not guarantee clinical autonomy. Major changes to the financing of general practice in Australia are required to address the concerns of GPs, governments and patients.

Policy and profession: elite perspectives on redefining general practice in Australia and England.

OBJECTIVES: To understand how general (family) practice is being redefined and is redefining itself, from the perspective of policy elites, and to build an analytical framework. METHODS: Politicians, senior bureaucrats and executives of professional organisations were interviewed (1998-2000) about the impact of general practice reforms on the profession. The information gathered was thematically coded and used to advance an understanding of profession from an elite perspective. RESULTS: Four main aspects of profession were discussed by interviewees. These were cultural authority, profession's authority, social authority and professional autonomy. The elites interviewed reported a potential challenge to the cultural authority of general practice in both countries through moves to redefine it as something broader. The profession's authority was seen as having shifted, especially in Australia where new forms of representation for the profession have been established. Medicine was viewed variously as having its social authority challenged, maintained, or extended in the granting of expertise in health, and professional autonomy was regarded as having been restructured through policy change. CONCLUSIONS: Policy elites perceive that the authority and autonomy of general practitioners has changed but reform has not resulted in generalised losses for the profession. The framework developed here, which employed aspects of profession that arose as major themes, proved useful for examining the redefinition of profession and for generating policy insights in regard to possibilities for change and likely impacts.