The First Nations experience of accessing rheumatology services in a metropolitan hospital: A qualitative study.

OBJECTIVE: First Nations Australians experience a higher burden and severity of Rheumatic Disease with poorer outcomes than the general population. Despite a widely acknowledged need to improve health outcomes, there has been minimal research assessing existing models of care from a First Nations perspective in Australia. The objective of this study was to describe First Nations experiences and barriers and enablers to accessing a hospital-based adult Rheumatology service in Sydney. METHODS: A qualitative study using semi-structured interviews was undertaken. Patients who self-identified as First Nations attending the Prince of Wales Hospital Rheumatology Clinic in 2021 were invited to participate. Interviews were conducted face-to-face or by telephone using culturally-appropriate Yarning methods with an Aboriginal Health Worker (AHW) at the request of participants. Thematic analysis was done in consultation with an Aboriginal Reference Group (ARG). RESULTS: Four categories, which encapsulated 11 themes were identified. Participants reported barriers to care such as logistics of the referral process, not feeling culturally safe because of uncomfortable clinic environments and health worker behaviours, inadequate cultural support and community perceptions of the specialty. Enabling factors included family member involvement, AHW support and telehealth consultation. CONCLUSION: The current model of care perpetuates access challenges for First Nations Australians within rheumatology. Barriers to care include the delayed referral process, limited cultural responsivity in the clinic environment and poor cross-cultural communication. There is a need for models of care that are co-designed with First Nations Peoples to address these barriers. PATIENT AND PUBLIC CONTRIBUTION: Participants were First Nations Australians with lived experience attending the rheumatology clinic. All interviewees were offered the opportunity to review their transcripts to ensure trustworthiness of the data. Preliminary thematic analysis was conducted in partnership with the AHW who has over 20 years experience. Following preliminary coding, a list of themes were presented to the ARG for iterative discussion and refinement. The ARG provided community representation and ensured that First Nations voices were privileged in the analysis. It's intended that the findings of this study will support the upcoming co-design of a First Nations health service for Rheumatology patients.

Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019.

PURPOSE: Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality. METHOD: Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10-24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index. RESULTS: One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (-28.9% vs. -12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings. DISCUSSION: Social identities, relationships, and attitudes to violence are established in adolescence, which is an inflection point marking the emergence of disproportionate burdens of interpersonal violence. Our findings affirm that global agendas must be expanded to address interrelated factors driving multiple forms of interpersonal violence experienced by adolescents and reverberating to the next generation.

Value-based public health: Moving beyond value-based health care to support a wellbeing economy.

While value-based health care (VBHC) is transforming Australia's health system, with its focus on patient-centred care and outcomes, it cannot transform Australia's health without policy action to address the social determinants of health. Australia is moving towards a wellbeing economy, but governments have not been explicit in the methods by which the health system will contribute to the development of a wellbeing economy at a macro level. It is also unclear how governments will ensure that approaches to valuing wellbeing will complement current health care innovations in defining and evaluating value in relation to health outcomes. To address this gap, we present a value-based public health (VBPH) framework to conceptualise a health-informed model to expand current thinking about defining, delivering and evaluating the value of population health and wellbeing. The framework provides a critical and innovative approach beyond VBHC for improving population health and wellbeing outcomes, in alignment with principles and measures being put forth in early examples of governments using wellbeing economy policies. In VBPH, the focus is on ensuring value in interventions to improve population outcomes. VBPH offers an approach for joined-up policy across government, using Health in All Policies for multi-sector public health interventions in response to population needs, across full cycles of policy development, implementation and evaluation. It promotes social return on investment methods to measure outcomes that matter to diverse stakeholders within and across communities. VBPH also requires cost estimation from a whole of government perspective, across complete cycles and stages of policy.

Health policy evaluation in rural and remote Australia: a qualitative exploration and lessons from the Northern Territory.

Objective This study explored approaches of government policymakers to health policy evaluation (HPE) in Australian rural and remote settings. Methods Semi-structured interviews captured experiences and insights of 25 policymakers in the Northern Territory Department of Health. Data were thematically analysed using an inductive approach to coding and theme development. Results We identified five main themes about HPE in rural and remote settings: (1) centring the rural and remote context; (2) balancing ideology, power and evidence; (3) working with community; (4) strengthening policy workforce capabilities in monitoring and evaluation; and (5) valuing evaluation through leadership. Conclusion HPE is complex in any setting, however, policymakers navigate unique complexities in rural and remote health contexts. HPE can be enabled by developing policymaker and leadership capabilities in rural and remote settings and supporting co-design with communities.

Healing journeys: experiences of young Aboriginal people in an urban Australian therapeutic community drug and alcohol program.

Disproportionately high numbers of Aboriginal young people access residential alcohol and other drug programs in Australia. While demand is high, these programs often have low numbers of Aboriginal staff. Residential programs, however, generally offer supports that reflect features of Aboriginal health care - holistic, group-based, connected to local communities, and addressing determinants of health. The qualitative research outlined in this paper was a collaboration between a mainstream residential therapeutic community program and two Aboriginal community-controlled organisations, and Aboriginal young people and researchers, with Aboriginal research leadership. It used an Aboriginal healing framework to understand the experiences of 12 young Aboriginal people in the program, triangulated with 19 key informant interviews. This provided an opportunity to understand how Indigenous knowledge about healing related to mainstream programs and the experiences of Aboriginal young people. This moves beyond individualist and deficit-focused conceptions of youth alcohol and drug use and centres Aboriginal cultures as healing. Findings point to the need for critically self-reflective mainstream organisations, a larger Aboriginal workforce with leadership roles, partnerships with Aboriginal Elders and organisations, and an investment in Aboriginal community-controlled alcohol and other drug services.

Barriers and enablers to Aboriginal and Torres Strait Islander careers in health: A qualitative, multisector study in western New South Wales.

OBJECTIVE: Growing a strong Aboriginal and Torres Strait Islander health workforce is key to closing the gap in health outcomes between Indigenous and non-Indigenous Australians. This study sought to explore barriers and enablers to career development for Aboriginal health staff and potential strategies to enhance career pathways. DESIGN: Qualitative study, with data collected primarily through focus group discussions (yarning circles) at different health workplaces. SETTING: Western New South Wales. PARTICIPANTS: Aboriginal health staff (n = 54) from Aboriginal Community Controlled Health Services, a Local Health District and a Primary Health Network, and their managers (Aboriginal and non-Aboriginal; n = 28). MAIN OUTCOME MEASURES: Identified barriers and enablers and regional strategies for improving career pathways. RESULTS: Aboriginal people interested in pursuing a career in health face barriers in: pre-employment, recruitment, the workplace and further education and training. Being given practical and emotional support, as well as opportunities, makes a difference at every stage. Family and community are very influential in career decisions. Within the workplace, culturally appropriate human resource systems and management structures are vital. The ability to obtain employment and access education and training locally is important to rural and remote communities. CONCLUSION: To enhance health career pathways for Aboriginal people, strategies are needed at all levels: community, organisation, system and society. Aboriginal leadership and self-determination are crucial, as are partnerships within the health sector and between the health and the education and training sectors. Cultural safety is essential to expansion of the Aboriginal workforce, and to health care experiences and outcomes for Aboriginal community members.

The sexual behaviours of adolescents aged between 14 and 17 years involved with the juvenile justice system in Australia: A community-based survey.

OBJECTIVES: To overcome key knowledge gaps in relation to justice involved and vulnerable young people and their sexual health and to compare this group with their peers from other youth health surveys in Australia to determine the extent of the issues. METHODS: Young people, aged between 14 and 17 years, who had ever been or were currently involved with the criminal justice system were purposively sampled. The survey was anonymous and delivered using Computer Assisted Telephone Interview (CATI). RESULTS: A total of 465 justice involved MeH-JOSH young people, aged between 14 and 17 years, participated in the study: 44% Aboriginal and/or Torres Strait Islander (Indigenous) and 37% not attending school. Of the total valid responses, 76% (n = 348) reported having ever had sex, with sexual initiation at a median age of 14 years. We compared these data with their peers in other Australian surveys and found that young people in our study had a higher engagement in sex and start having sex at a younger age, reporting more sexual partners at all ages. CONCLUSIONS: The sexual behaviours of young people involved in the justice system in this study suggest they may be at a greater risk for sexually transmissible infections than their age-matched peers in the general population. Policymakers should elevate them to a priority population for targeting sexual health services and health promotion.

Why is influenza vaccine uptake so low among Aboriginal adults?

OBJECTIVES: Determine major barriers to, and facilitators of, influenza vaccination of Aboriginal adults, in order to improve coverage from the current level of 30%. METHODS: i) A focus group with 13 Aboriginal Immunisation Healthcare Workers; and ii) a cross-sectional survey of Aboriginal people aged ≥18 years at the 2017 New South Wales Koori Knockout (29 September-2 October). RESULTS: The focus group nominated poor identification of Aboriginality in general practice. Of 273 survey respondents, a substantial minority (30%) were unaware of their eligibility for free influenza vaccination. More than half (52%) believed the vaccine could cause influenza, 40% reported there were better ways than vaccination for avoiding infection and 30% said they would not have the vaccine if it was offered to them. Regarding health service access, few reported experiencing difficulty (17%), feeling uncomfortable (15%) or being discriminated against (8%), but 53% reported not receiving a reminder from a health professional. CONCLUSIONS: Misconceptions about influenza disease and vaccine among Aboriginal people and inadequate identification of Aboriginality in general practice appear to be the greatest barriers to vaccination, rather than health service access in general. Implications for public health: More active communication to and targeting of Aboriginal adults is required; this is even more urgent following the arrival of COVID-19.

Learning about Aboriginal health and wellbeing at the postgraduate level: novel application of the Growth and Empowerment Measure.

INTRODUCTION: Public health education strives to transform and empower students to engage in policy and practice improvement. However, little is known of the nature of such change among students, especially when studying Aboriginal health and wellbeing, which may involve disrupting long held assumptions and prejudices. This article reports findings regarding the feasibility, specificity and sensitivity of the Growth and Empowerment Measure (GEM) in the evaluation of two innovative Australian 13-week postgraduate public health electives focused on Aboriginal health and wellbeing. The GEM's 14-item Emotional Empowerment Scale (EES14) and its subscales Inner Peace and Self-Capacity, and 12 Scenarios (S12) and its subscales Healing and Growth and Connection and Purpose were used to examine transformative experiences. A new short form of the S12, the Core6, was also trialled as a briefer measure of functional empowerment. METHODS: Pre-course GEM responses and demographic information were collected from consenting students during the mandatory, face-to-face workshops of the Aboriginal public health Perspectives course and the Aboriginal empowerment and wellbeing Lifespan course. The two-day Perspectives course workshop introduced a group scenario-building activity towards ending health inequality. Lifespan students experienced a 3-day immersion based on Stage 1 of the Aboriginal Family Well Being empowerment program. Insights from both workshops were further integrated through structured online discussions and written assessments. At the end of semester, a post-course GEM was mailed to students for completion and return. Students could also provide feedback through evaluation surveys and semi-structured focus groups. Effect sizes were assessed using paired t-tests, Wilcoxon signed-rank tests and multiple ANOVA. Cronbach's alpha confirmed internal consistency. RESULTS: Baseline GEM data was provided for 147 out of a total of 194 workshop experiences from participating students. Twenty students attended workshops for both Perspectives and Lifespan. Fifty-five matched pairs (representing 52 individual participants) were obtained from 170 students who completed one or both courses. Statistically significant positive change of small to medium effect size was detected in all GEM scales, subscales and some individual items. Lifespan yielded larger effects than Perspectives, most markedly on two subscales: Inner Peace, and Connection and Purpose. Participating students reported significant growth in the Scenario item 'knowing and being who I am' following Perspectives and Lifespan. Those completing Perspectives also reported a significant increase in 'gaining voice and being heard', consistent with its action-oriented scenario-building assessment. In contrast, the psychosocial development approach embedded in Lifespan stimulated strong development in spirituality, responding constructively to judgement, appreciating empowerment in their communities and skills to make changes in their lives. Feedback indicated that students valued these personal and professional growth experiences. CONCLUSION: The GEM was sensitive and specific in measuring components of empowering change among participants. Challenges included low post-course response rates that limited extrapolation to overall course impact, and attention needed to starting point when comparing the increment of change. The GEM is a promising tool for studying postgraduate courses designed to stimulate transformative learning, wellbeing and cultural competence through empowerment, and relevant in the education of health professionals in the fields of Aboriginal and rural health.

Adopting healthier cooking oils: Findings from a qualitative study among independent food outlets in a rural district in Australia.

ISSUE ADDRESSED: This study explored key factors that motivated independent food outlets to voluntarily adopt healthier cooking oils following a health promotion intervention. METHODS: Sixteen food outlet managers from the Cessnock Local Government Area (LGA) participated in semi-structured interviews and a brief questionnaire which explored factors determining what cooking oils they use in preparing deep-fried foods. Interviews were analysed thematically and closed responses to survey questions using descriptive statistics. RESULTS: Four main reasons emerged around decisions relating to oil choice: fry life, cost, taste and general health. Health implications, Council advice, competitive price and maintaining a good relationship with the Council were the most frequently reported motivators for swapping to a healthier oil. CONCLUSION: Behaviour change among food outlet managers to switch cooking oils is influenced by a number of health-related and non-health-related factors. Council Environmental Health Officers (EHOs) can be a catalyst for food outlets to adopt healthier food preparation practices. SO WHAT?: This study highlights the factors which may motivate the switch to healthier oils by independent food outlets. EHOs are critical partners for health promotion initiatives that target the independent food service sector.

A Partnership Model for Improving Service Delivery in Remote Papua New Guinea: A Mixed Methods Evaluation.

BACKGROUND: The Community Mine Continuation Agreement Middle (CMCA) and South Fly Health Program (the Health Program) is a partnership for improving health service delivery in remote Papua New Guinea (PNG). The Health Program is delivered by a private contractor working in partnership with existing health service providers to improve service delivery using existing government systems, where possible, and aligns with national policies, plans and strategies. A midline evaluation was conducted to determine changes in health service delivery since commencement of the Health Program. METHODS: A mixed methods evaluation was undertaken mid-way through implementation of the Health Program, including a pre/post analysis of health service delivery indicators, semi-structured interviews with health workers and assessment of health facility equipment and infrastructure. RESULTS: Improvements in many of the long-term expected outcomes of the Health Program were observed when compared to the pre-program period. The number of outpatient visits per person per year and number of outreach clinics per 1000 children under 5 years increased by 15% and 189% respectively (P<.001). Increases in vaccination coverage for infants aged <1 year were observed: 58 % for pentavalent 1st dose (P<.001) and 75% for 1st dose Sabin (P<.001), 30% for 3rd dose pentavalent (P<.001) and 26% for measles vaccination (P<.001). Family planning coverage remained at similar levels (increasing 5%, P=.095) and antenatal care coverage increased by 26% (P<.001). Supervised deliveries coverage declined by 32% (P<.001), a continuation of the pre-Program trend. The proportion of facilities with standard equipment items, transport and lighting increased. Health worker training, in particular obstetric training, was most commonly cited by health workers as leading to improved services. CONCLUSION: Following implementation, substantial improvements in health service delivery indicators were observed in the Health Program area as compared with pre-program period and the stagnating or declining national performance. This model could be considered for similar contexts where existing health service providers require external assistance to provide basic health services to the community.

Contextual factors and health service performance from the perspective of the provincial health administrators in Papua New Guinea.

INTRODUCTION: The Rural Primary Health Services Delivery Project aims to improve the quality and coverage of health services to rural populations in Papua New Guinea. There are limitations in measuring performance of such projects through analysis of health information system data alone due to data quality issues and a multitude of unmeasured factors that affect performance. A mixed methods study was undertaken to understand the contextual factors that affect health service performance. METHODS: A performance assessment framework was developed including service delivery indicators derived from the National Health Information System. Prior to implementation, a baseline analysis of the indicators was undertaken. Subsequently, semi-structured interviews were conducted with health administrators, in which they were asked about factors they perceived to influence health facility performance. During the interviews, key informants were provided with health indicators for their province and asked to interpret the performance of facilities. Interviews were transcribed and inductive thematic analysis performed. RESULTS: Performance indicators varied greatly within and between districts. Key informants cited a number of reasons for this variation. Health facilities accessible by road in urban areas, with competent and/or higher level staff and health services operated by churches or private companies, were cited as contributors to high performance. For high performing districts, key informants also discussed use of health information, planning and targeted strategies to improve performance. Inadequate numbers of staff, poorly skilled staff, funding delays and challenging geography were major contributors noted for poor performance. CONCLUSION: Analysis of quantitative indicators needs to be performed at health facility level in order to understand district level performance. Interpretation of performance through key informant interviews provided useful insight into previously undocumented contextual factors affecting health delivery performance. The sequential explanatory mixed methods design could be applied to evaluations of other health service delivery programs in similar contexts.

Lessons for health program monitoring and evaluation in a low resource setting.

Numerous guidelines outline best practices for health program monitoring and evaluation (M&E). However, health programs are often implemented in less than ideal circumstances where these best practices may not be resourced or feasible. This article describes how M&E has been conducted for a health service delivery improvement program in remote Papua New Guinea and outlines lessons learned. The lessons learned were to integrate M&E into every aspect of the program, strengthen existing health information data, link primary data collection with existing program activities, conduct regular monitoring and feedback for early identification of implementation issues, involve the program team in evaluation, and communicate M&E data through multiple mediums to stakeholders. These lessons could be applied to other health programs implemented in low resource settings.

Differentials in Cardiovascular Risk Factors and Diabetes by Socioeconomic Status and Sex in Kalutara, Sri Lanka.

Since 1950, cardiovascular disease (CVD) has emerged as a leading cause of mortality in Sri Lanka, especially in men. In 2014, a survey in Kalutara to assess CVD and type 2 diabetes mellitus (T2DM) risk factors in adults aged 25 to 64 years (n = 1011), and associations with sex and socioeconomic status (SES), found similar CVD risk factors in both sexes, except for daily tobacco smoking at 19% in men and nil in women, and higher body mass index (BMI) in women than men. With increasing SES in men, there were significant linear increases in mean BMI, waist circumference, mean systolic and diastolic blood pressure, mean fasting plasma glucose, and T2DM prevalence, but decreases in tobacco smoking. Whereas in women higher SES was associated with a significant increase in mean BMI, but a significant decrease in hypertension prevalence. Tobacco smoking is the main risk factor explaining higher CVD mortality in men compared with women.

Examining the pathways for young people with drug and alcohol dependence: a mixed-method design to examine the role of a treatment programme.

INTRODUCTION: Young people with drug and alcohol problems are likely to have poorer health and other psychosocial outcomes than other young people. Residential treatment programmes have been shown to lead to improved health and related outcomes for young people in the short term. There is very little robust research showing longer term outcomes or benefits of such programmes. This paper describes an innovative protocol to examine the longer term outcomes and experiences of young people referred to a residential life management and treatment programme in Australia designed to address alcohol and drug issues in a holistic manner. METHODS AND ANALYSIS: This is a mixed-methods study that will retrospectively and prospectively examine young people's pathways into and out of a residential life management programme. The study involves 3 components: (1) retrospective data linkage of programme data to health and criminal justice administrative data sets, (2) prospective cohort (using existing programme baseline data and a follow-up survey) and (3) qualitative in-depth interviews with a subsample of the prospective cohort. The study will compare findings among young people who are referred and (a) stay 30 days or more in the programme (including those who go on to continuing care and those who do not); (b) start, but stay fewer than 30 days in the programme; (c) are assessed, but do not start the programme. ETHICS AND DISSEMINATION: Ethics approval has been sought from several ethics committees including a university ethics committee, state health departments and an Aboriginal-specific ethics committee. The results of the study will be published in peer-reviewed journals, presented at research conferences, disseminated via a report for the general public and through Facebook communications. The study will inform the field more broadly about the value of different methods in evaluating programmes and examining the pathways and trajectories of vulnerable young people.

The role of community representatives on health service committees: staff expectations vs. reality.

OBJECTIVE This paper examines staff views about legitimacy of different roles for community representatives sitting on health service committees as part of a formal Community Participation Program (CPP) in an Area Health Service (AHS) in Australia. DESIGN A cross-sectional survey using a self-completed questionnaire by staff on committees with community representation in the AHS in 2008. SETTING The study site has a population of approximately 1.4 million and covers 6000 km(2) . The population is ethnically and socio-economically diverse. RESULTS There are generally positive staff attitudes at this AHS for community participation as part of the CPP with positive impacts identified, including on service delivery and the conduct of health service meetings. Most saw community representatives having legitimate roles in representing the community, improving communication between the health service and the community and providing constructive feedback. However, staff expectations about the community's role on committees do not match the reality they say they observe and less than half the staff thought the community and health service agree on the role of community representatives. CONCLUSIONS As well as reviewing and enhancing training and support for representatives and staff as part of the CPP, there is a need to question staff expectations about community members who sit on health service committees and whether these expectations are shared by other key stakeholders, most notably the community representatives themselves. These expectations have implications for the CPP and for similar programs designed to engage community members on committees and working groups with health professionals.

Social cohesion through football: a quasi-experimental mixed methods design to evaluate a complex health promotion program.

UNLABELLED: Social isolation and disengagement fragments local communities. Evidence indicates that refugee families are highly vulnerable to social isolation in their countries of resettlement. Research to identify approaches to best address this is needed. Football United is a program that aims to foster social inclusion and cohesion in areas with high refugee settlement in New South Wales, Australia, through skills and leadership development, mentoring, and the creation of links with local community and corporate leaders and organisations. The Social Cohesion through Football study's broad goal is to examine the implementation of a complex health promotion program, and to analyse the processes involved in program implementation. The study will consider program impact on individual health and wellbeing, social inclusion and cohesion, as well as analyse how the program by necessity interacts and adapts to context during implementation, a concept we refer to as plasticity. The proposed study will be the first prospective cohort impact study to our knowledge to assess the impact of a comprehensive integrated program using football as a vehicle for fostering social inclusion and cohesion in communities with high refugee settlement. METHODS/DESIGN: A quasi-experimental cohort study design with treatment partitioning involving four study sites. The study employs a 'dose response' model, comparing those with no involvement in the Football United program with those with lower or higher levels of participation. A range of qualitative and quantitative measures will be used in the study. Study participants' emotional well being, resilience, ethnic identity and other group orientation, feelings of social inclusion and belonging will be measured using a survey instrument complemented by relevant data drawn from in-depth interviews, self reporting measures and participant observation. The views of key informants from the program and the wider community will also be solicited. DISCUSSION: The complexity of the Football United program poses challenges for measurement, and requires the study design to be responsive to the dynamic nature of the program and context. Assessment of change is needed at multiple levels, drawing on mixed methods and multidisciplinary approaches in implementation and evaluation. Attention to these challenges has underpinned the design and methods in the Social Cohesion through Football study, which will use a unique and innovative combination of measures that have not been applied together previously in social inclusion/cohesion and sport and social inclusion/cohesion program research.

Health service staff attitudes to community representatives on committees.

PURPOSE: This paper sets out to report attitudes of staff on key health service committees towards community participation before and after appointment of community representatives. DESIGN/METHODOLOGY/APPROACH: The paper shows a self-completed questionnaire administered to staff on committees as a baseline measure and 12 months after community representatives had been appointed. FINDINGS: The paper finds that significantly more staff at the follow-up survey reported that they and other staff were clear about the role of community representatives and how to work with them on committees. Significantly more staff at follow-up felt that the health service was ready for this type of initiative. There was no significant increase in the percentage of staff who felt that financial and other supports for community representatives were sufficient and no significant changes in staff views about the potential for community representatives to influence decision making, although there were strong trends in a positive direction. RESEARCH LIMITATIONS/IMPLICATIONS: The study in this paper was conducted in one health service and did not follow changes in attitudes of particular staff over time. Larger samples would be necessary to assess generalisability of findings and future studies should examine in more depth staff beliefs about the role and influence of community members on committees. PRACTICAL IMPLICATIONS: The paper implies that the development of ongoing and constructive relationships between health services and communities clearly takes time and, at least in part, results from direct experience working alongside community members. ORIGINALITY/VALUE: The paper shows that this is the first study examining how the attitudes of health service staff to community participation change over time and as a direct result of interaction with community members on committees. A better understanding of health service staff attitudes to community participation is important for health care managers to effectively address structural and attitudinal barriers to community participation.

Closing the gap: building the capacity of non-government organizations as advocates for health equity.

Seeking achievement of health equity has underpinned national government and global health policies for decades. However, major difficulties and challenges faced in the practice of achieving 'Health for All' has led to a recognition of the need to broaden the focus of efforts to improve health equity. Civil society groups have been identified as key stakeholders in attempts to achieve health equity, and the importance of strengthening their capacity to influence relevant government policy and practice has been highlighted. This paper presents the results of a qualitative study which examined the role of organizations outside government in advocating for health equity, and the capacities and conditions that were related to their success. In-depth, unstructured interviews were conducted with 26 non-government organizations (NGOs) who were active in three important health policy debates in Australia. The grounded theory method was used to direct data collection and analysis, and member checking was employed to ensure soundness and build ownership of the findings. Effective advocacy was found to be a dynamic process characterized by flexibility and opportunism within a framework of longer term goals. Two key ways of working were identified--in partnership and in conflict with government, with shifts in emphasis in response to organizational strengths and a changing environment. A number of domains of capacity, which together are termed 'capacity for advocacy', were also identified. It is clear that NGOs can learn a great deal from each other, but there needs to be investment by governments, international agencies and NGOs themselves if advocacy for health equity is to be strengthened.