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.

Improving child literacy using South Australia's Health in All Policies approach.

The Health in All Policies (HiAP) approach aims to create coherent policy across government that will improve population health, wellbeing and equity while progressing the goals of other sectors. The quest to achieve policy coherence across government has focused interest on processes that facilitate collaboration between health and many other sectors. Health and education sectors have long been seen as natural partners with mutually beneficial goals. This article focuses on a case study of HiAP work, undertaken between health and education in South Australia to increase parental engagement in children's literacy among lower socio-economic families. It draws on a document analysis of 71 documents, seven in-depth interviews with senior policy actors and a programme logic model. The project began with the intention of using policy levers to improve long-term health outcomes through addressing child literacy, a proven social determinant of health. Because of the context in which it was operating, the project extended from a focus on policy to working directly with four schools implementing strategies to facilitate parental engagement, with the intention of finally influencing system-wide education policy. We use an institutional framework to support our analysis through a discussion of ideas, actors and institutions and how these influenced the project. The article provides insight into the facilitators and impediments to intersectoral efforts to progress shared educational and health goals and achieve sustainable change, and identifies lessons for others intending to use this approach.

To what extent can the activities of the South Australian Health in All Policies initiative be linked to population health outcomes using a program theory-based evaluation?

BACKGROUND: This paper reports on a five-year study using a theory-based program logic evaluation, and supporting survey and interview data to examine the extent to which the activites of the South Australian Health in All Policies initiative can be linked to population health outcomes. METHODS: Mixed-methods data were collected between 2012 and 2016 in South Australia (144 semi-structured key informant interviews; two electronic surveys of public servants in 2013 (n = 435) and 2015 (n = 483); analysis of state government policy documents; and construction of a program logic model to shape assessment of the feasibility of attribution to population health outcomes). RESULTS: Multiple actions on social determinants of health in a range of state government sectors were reported and most could be linked through a program logic model to making some contribution to future population health outcomes. Context strongly influences implementation; not all initiatives will be successful and experimentation is vital. Successful initiatives included HiAP influencing the urban planning department to be more concerned with the health impacts of planning decisions, and encouraging the environment department to be concerned with the health impacts of its work. CONCLUSIONS: The theory-based program logic suggests that SA HiAP facilitated improved population health through working with multiple government departments. Public servants came to appreciate how their sectors impact on health. Program logic is a mechanism to evaluate complex public health interventions in a way that takes account of political and economic contexts. SA HiAP was mainly successful in avoiding lifestyle drift in strategy. The initiative encouraged a range of state government departments to tackle conditions of daily living. The broader underpinning factors dictating the distribution of power, money and resources were not addressed by HiAP. This reflects HiAP's use of a consensus model which was driven by (rather than drove) state priorities and sought 'win-win' strategies.

Understanding Australian policies on public health using social and political science theories: reflections from an Academy of the Social Sciences in Australia Workshop.

There is strong, and growing, evidence documenting health inequities across the world. However, most governments do not prioritize policies to encourage action on the social determinants of health and health equity. Furthermore, despite evidence concerning the benefits of joined-up, intersectoral policy to promote health and health equity, it is rare for such policy approaches to be applied systematically. To examine the usefulness of political and social science theory in understanding the reasons for this disjuncture between evidence and practice, researchers and public servants gathered in Adelaide for an Academy of the Social Sciences in Australia (ASSA) Workshop. This paper draws together the learnings that emerged from the Workshop, including key messages about the usefulness of various theories as well as insights drawn from policy practice. Discussions during the Workshop highlighted that applying multiple theories is particularly helpful in directing attention to, and understanding, the influence of all stages of the policy process; from the construction and framing of policy problems, to the implementation of policy and evaluation of outcomes, including those outcomes that may be unintended. In addition, the Workshop emphasized the value of collaborations among public health researchers, political and social scientists and public servants to open up critical discussion about the intersections between theory, research evidence and practice. Such critique is vital to render visible the processes through which particular sources of knowledge may be privileged over others and to examine how political and bureaucratic environments shape policy proposals and implementation action.

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.

Change management in an environment of ongoing primary health care system reform: A case study of Australian primary health care services.

INTRODUCTION/BACKGROUND: Globally, health reforms continue to be high on the health policy agenda to respond to the increasing health care costs and managing the emerging complex health conditions. Many countries have emphasised PHC to prevent high cost of hospital care and improve population health and equity. The existing tension in PHC philosophies and complexity of PHC setting make the implementation and management of these changes more difficult. This paper presents an Australian case study of PHC restructuring and how these changes have been managed from the viewpoint of practitioners and middle managers. METHODS: As part of a 5-year project, we interviewed PHC practitioners and managers of services in 7 Australian PHC services. FINDINGS: Our findings revealed a policy shift away from the principles of comprehensive PHC including health promotion and action on social determinants of health to one-to-one disease management during the course of study. Analysis of the process of change shows that overall, rapid, and top-down radical reforms of policies and directions were the main characteristic of changes with minimal communication with practitioners and service managers. The study showed that services with community-controlled model of governance had more autonomy to use an emergent model of change and to maintain their comprehensive PHC services. CONCLUSIONS: Change is an inevitable feature of PHC systems continually trying to respond to health care demand and cost pressures. The implementation of change in complex settings such as PHC requires appropriate change management strategies to ensure that the proposed reforms are understood, accepted, and implemented successfully.

Ideas, actors and institutions: lessons from South Australian Health in All Policies on what encourages other sectors' involvement.

BACKGROUND: This paper examines the extent to which actors from sectors other than health engaged with the South Australian Health in All Policies (HiAP) initiative, determines why they were prepared to do so and explains the mechanisms by which successful engagement happened. This examination applies theories of policy development and implementation. METHODS: The paper draws on a five year study of the implementation of HiAP comprising document analysis, a log of key events, detailed interviews with 64 policy actors and two surveys of public servants. RESULTS: The findings are analysed within an institutional policy analysis framework and examine the extent to which ideas, institutional factors and actor agency influenced the willingness of actors from other sectors to work with Health sector staff under the HiAP initiative. In terms of ideas, there was wide acceptance of the role of social determinants in shaping health and the importance of action to promote health in all government agencies. The institutional environment was initially supportive, but support waned over the course of the study when the economy in South Australia became less buoyant and a health minister less supportive of health promotion took office. The existence of a HiAP Unit was very helpful for gaining support from other sectors. A new Public Health Act offered some promise of institutionalising the HiAP approach and ideas. The analysis concludes that a key factor was the operation of a supportive network of public servants who promoted HiAP, including some who were senior and influential. CONCLUSIONS: The South Australian case study demonstrates that despite institutional constraints and shifting political support within the health sector, HiAP gained traction in other sectors. The key factors that encouraged the commitment of others sectors to HiAP were the existence of a supportive, knowledgeable policy network, political support, institutionalisation of the ideas and approach, and balancing of the economic and social goals of government.

Correction to: Ideas, actors and institutions: lessons from South Australian Health in All Policies on what encourages other sectors' involvement.

After publication of the article [1], it has been brought to our attention that Table 1 has been formatted poorly in the original version so that the columns are not aligned with their corresponding information. The correct version of the table is presented below. The original version of the article has now been revised.

Health in All Policies in South Australia: what has supported early implementation?

Health in All Policies (HiAP) is a policy development approach that facilitates intersectoral responses to addressing the social determinants of health and health equity whilst, at the same time, contributing to policy priorities across the various sectors of government. Given that different models of HiAP have been implemented in at least 16 countries, there is increasing interest in how its effectiveness can be optimized. Much of the existing literature on HiAP remains descriptive, however, and lacks critical, empirically informed analyses of the elements that support implementation. Furthermore, literature on HiAP, and intersectoral action more generally, provides little detail on the practical workings of policy collaborations. This paper contributes empirical findings from a multi-method study of HiAP implementation in South Australia (SA) between 2007 and 2013. It considers the views of public servants and presents analysis of elements that have supported, and impeded, implementation of HiAP in SA. We found that HiAP has been implemented in SA using a combination of interrelated elements. The operation of these elements has provided a strong foundation, which suggests the potential for HiAP to extend beyond being an isolated strategy, to form a more integrated and systemic mechanism of policy-making. We conclude with learnings from the SA experience of HiAP implementation to inform the ongoing development and implementation of HiAP in SA and internationally.

Service providers' views of community participation at six Australian primary healthcare services: scope for empowerment and challenges to implementation.

Community participation is a key principle of comprehensive primary health care (PHC). There is little literature on how community participation is implemented at Australian PHC services. As part of a wider study conducted in partnership with five South Australian PHC services, and one Aboriginal community controlled health service in the Northern Territory, 68 staff, manager, regional health executives, and departmental funders were interviewed about community participation, perceived benefits, and factors that influenced implementation. Additional data were collected through analysis of policy documents, service reports on activity, and a web-based survey completed by 130 staff. A variety of community participation strategies was reported, ranging from consultation and participation as a means to improve service quality and acceptability, to substantive and structural participation strategies with an emphasis on empowerment. The Aboriginal community controlled health service in our study reported the most comprehensive community participation. Respondents from all services were positive about the benefits of participation but reported that efforts to involve service users had to compete with a centrally directed model of care emphasising individual treatment services, particularly at state-managed services. More empowering substantive and structural participation strategies were less common than consultation or participation used to achieve prescribed goals. The most commonly reported barriers to community participation were budget and lack of flexibility in service delivery. The current central control of the state-managed services needs to be replaced with more local management decision making if empowering community participation is to be strengthened and embedded more effectively in the culture of services.

Revisiting the ability of Australian primary healthcare services to respond to health inequity.

Equity of access and reducing health inequities are key objectives of comprehensive primary health care. However, the supports required to target equity are fragile and vulnerable to changes in the fiscal and political environment. Six Australian primary healthcare services, five in South Australia and one in the Northern Territory, were followed over 5 years (2009-2013) of considerable change. Fifty-five interviews were conducted with service managers, staff, regional health executives and health department representatives in 2013 to examine how the changes had affected their practice regarding equity of access and responding to health inequity. At the four state government services, seven of 10 previously identified strategies for equity of access and services' scope to facilitate access to other health services and to act on the social determinants of health inequity were now compromised or reduced in some way as a result of the changing policy environment. There was a mix of positive and negative changes at the non-government organisation. The community-controlled service increased their breadth of strategies used to address health equity. These different trajectories suggest the value of community governance, and highlight the need to monitor equity performance and advocate for the importance of health equity.

Medicare Local-Local Health Network partnerships in South Australia: lessons for Primary Health Networks.

OBJECTIVES: To examine the partnerships in population health planning between Medicare Locals (MLs) and Local Health Networks (LHNs) in South Australia, and the factors that facilitated or constrained collaborations, to offer lessons for LHNs and Primary Health Networks. DESIGN, PARTICIPANTS AND SETTING: We conducted a qualitative study using individual interviews with key informants (executive or program leader staff) from the five South Australian MLs and the five South Australian LHNs. A total of 34 interviews were conducted between March and July 2014. RESULTS: Significant work was undertaken by MLs in the process of population health planning and needs assessment. Participants from both MLs and LHNs described examples of collaborative work, including data sharing and synthesis, program implementation and community consultation. The focus of LHNs on acute and intermediate care, the lack of system-level strategies to support collaboration, and constant policy and structural changes leading to uncertainty in the primary health care landscape were perceived as key barriers to collaboration. CONCLUSIONS: The experience of MLs and their achievements in building relationships and trust with stakeholders in their regions, including LHNs, provide valuable lessons for the new Primary Health Networks in Australia.

Health Impact Assessment in New South Wales & Health in All Policies in South Australia: differences, similarities and connections.

BACKGROUND: Policy decisions made within all sectors have the potential to influence population health and equity. Recognition of this provides impetus for the health sector to engage with other sectors to facilitate the development of policies that recognise, and aim to improve, population outcomes. This paper compares the approaches implemented to facilitate such engagement in two Australian jurisdictions. These are Health Impact Assessment (HIA) in New South Wales (NSW) and Health in All Policies (HiAP) in South Australia (SA). METHODS: The comparisons presented in this paper emerged through collaborative activities between stakeholders in both jurisdictions, including critical reflection on HIA and HiAP practice, joint participation in a workshop, and the preparation of a discussion paper written to inform a conference plenary session. The plenary provided an opportunity for the incorporation of additional insights from policy practitioners and academics. RESULTS: Comparison of the approaches indicates that their overall intent is similar. Differences exist, however, in the underpinning principles, technical processes and tactical strategies applied. These differences appear to stem mainly from the organisational positioning of the work in each state and the extent to which each approach is linked to government systems. CONCLUSIONS: The alignment of the HiAP approach with the systems of the SA Government increases the likelihood of influence within the policy cycle. However, the political priorities and sensitivities of the SA Government limit the scope of HiAP work. The implementation of the HIA approach from outside government in NSW means greater freedom to collaborate with a range of partners and to assess policy issues in any area, regardless of government priorities. However, the comparative distance of HIA from NSW Government systems may reduce the potential for impact on government policy. The diversity in the technical and tactical strategies that are applied within each approach provides insight into how the approaches have been tailored to suit the particular contexts in which they have been implemented.

Developing a good practice model to evaluate the effectiveness of comprehensive primary health care in local communities.

BACKGROUND: This paper describes the development of a model of Comprehensive Primary Health Care (CPHC) applicable to the Australian context. CPHC holds promise as an effective model of health system organization able to improve population health and increase health equity. However, there is little literature that describes and evaluates CPHC as a whole, with most evaluation focusing on specific programs. The lack of a consensus on what constitutes CPHC, and the complex and context-sensitive nature of CPHC are all barriers to evaluation. METHODS: The research was undertaken in partnership with six Australian primary health care services: four state government funded and managed services, one sexual health non-government organization, and one Aboriginal community controlled health service. A draft model was crafted combining program logic and theory-based approaches, drawing on relevant literature, 68 interviews with primary health care service staff, and researcher experience. The model was then refined through an iterative process involving two to three workshops at each of the six participating primary health care services, engaging health service staff, regional health executives and central health department staff. RESULTS: The resultant Southgate Model of CPHC in Australia model articulates the theory of change of how and why CPHC service components and activities, based on the theory, evidence and values which underpin a CPHC approach, are likely to lead to individual and population health outcomes and increased health equity. The model captures the importance of context, the mechanisms of CPHC, and the space for action services have to work within. The process of development engendered and supported collaborative relationships between researchers and stakeholders and the product provided a description of CPHC as a whole and a framework for evaluation. The model was endorsed at a research symposium involving investigators, service staff, and key stakeholders. CONCLUSIONS: The development of a theory-based program logic model provided a framework for evaluation that allows the tracking of progress towards desired outcomes and exploration of the particular aspects of context and mechanisms that produce outcomes. This is important because there are no existing models which enable the evaluation of CPHC services in their entirety.

Infant mental health promotion and the discourse of risk.

The field of infant mental health promotion has rapidly developed in academia, health policy and practice. Although there are roots in earlier childhood health and welfare movements, recent developments in infant mental health promotion are distinct and different. This article examines the development and practice of infant mental health promotion in South Australia. A regional, intersectoral forum with a focus on families and young children was used as a case study. In-depth interviews with forum members were analysed using a governmentality lens. Participants identified a range of risks to the healthy development of the infant. The study suggests that the construction of risk acts as a technique of governing, providing the rationale for intervention for the child, the mother and the public's good. It places responsibility on parents to self-govern. Although the influence of broader social contexts is acknowledged, the problematisation of mothering as risk shifts the focus to individual capacity, rather than encompassing the systems and social conditions that support healthy relationships. This research suggests that the representations of risk are a pervasive and potent influence that can act to undermine health promotion efforts that seek to empower and enable people to have more control over their own health.

Evaluation of Health in All Policies: concept, theory and application.

This article describes some of the crucial theoretical, methodological and practical issues that need to be considered when evaluating Health in All Policies (HiAP) initiatives. The approaches that have been applied to evaluate HiAP in South Australia are drawn upon as case studies, and early findings from this evaluative research are provided. The South Australian evaluation of HiAP is based on a close partnership between researchers and public servants. The article describes the South Australian HiAP research partnership and considers its benefits and drawbacks in terms of the impact on the scope of the research, the types of evidence that can be collected and the implications for knowledge transfer. This partnership evolved from the conduct of process evaluations and is continuing to develop through joint collaboration on an Australian National Health & Medical Research Council grant. The South Australian research is not seeking to establish causality through statistical tests of correlations, but instead by creating a 'burden of evidence' which supports logically coherent chains of relations. These chains emerge through contrasting and comparing findings from many relevant and extant forms of evidence. As such, program logic is being used to attribute policy change to eventual health outcomes. The article presents the preliminary program logic model and describes the early work of applying the program logic approach to HiAP. The article concludes with an assessment of factors that have accounted for HiAP being sustained in South Australia from 2008 to 2013.

Health promotion in Australian multi-disciplinary primary health care services: case studies from South Australia and the Northern Territory.

This paper reports on the health promotion and disease prevention conducted at Australian multi-disciplinary primary health care (PHC) services and considers the ways in which the organizational environment affects the extent and type of health promotion and disease prevention activity. The study involves five PHC services in Adelaide and one in Alice Springs. Four are managed by a state health department and two by boards of governance. The study is based on an audit of activities and on 68 interviews conducted with staff. All the sites undertake health promotion and recognize its importance but all report that this activity is under constant pressure resulting from the need to provide services to people who have health problems. We also found an increased focus on chronic disease management and prevention which prioritized individuals and behavioural change strategies rather than addressing social determinants affecting whole communities. There was little health promotion work that reflected a salutogenic approach to the creation of health. Most activity falls under three types: parenting and child development, chronic disease prevention and mental health. Only the non-government organizations reported advocacy on broader policy issues. Health reform and consequent reorganizations were seen to reduce the ability of some services to undertake health promotion. The paper concludes that PHC in Australia plays an important role in disease prevention, but that there is considerable scope to increase the amount of community-based health promotion which focuses on a salutogenic view of health and which engages in community partnerships.

Making the most of open windows: establishing health in all policies in South Australia.

Significant improvements in population health are likely to arise when the social determinants ofhealth are addressed. This creates a challenge for health systems, as the policy levers to influence the determinants largely lie outside of their direct control. Health agencies have been attempting to develop responses that affect these policy levers with mixed success. Success often requires particular conditions or "windows of opportunity" to be present before even small systemic change can be made. The government of South Australia has developed a practical, policy-oriented response to address the determinants of health--Health in All Policies--and has been successfully working across government for the past five years, using a policy learning process to implement this approach. This article will focus on how the South Australian Health in All Policies initiative started and the conditions that enabled South Australia to establish a centralized governance structure, harness a group of cross-sector policy entrepreneurs, and conduct health lens projects across a range of policy issues. The authors will comment on the nature of these conditions and their relevance for other governments struggling to reduce the burden of chronic disease and growing health budgets by addressing the social determinants of health.

Health policy in South Australia 2003-10: primary health care workforce perceptions of the impact of policy change on health promotion.

ISSUE ADDRESSED: This paper examines recent Australian health reform policies and considers how the primary health care (PHC) workforce experiences subsequent change and perceives its impact on health promotion practice. METHODS: Health policy documents were analysed to determine their intended impact on health promotion. Interviews were conducted with 39 respondents from four State-funded PHC services to gain their perceptions of the impact of policy change on health promotion. RESULTS: There have been a plethora of policy and strategy documents over the last decade relevant to PHC, and these suggest an intention to strengthen health promotion. However, respondents report that changes to the role and focus of PHC services have led to fewer opportunities for health promotion. Services are struggling to engage in health promotion activity, while funding and policy directions are prioritised to targeted, individual behaviour change. CONCLUSION: The experience of PHC workforce respondents in South Australia suggests that, despite policy intentions, health promotion practice is much reduced. Our research suggests that rigorous evaluation of health sector reforms should be undertaken to assess both intended and unintended outcomes in terms of service quality and delivery. SO WHAT? Health promoters are experiencing a contradictory policy and practice environment, and this research should assist health promoters in advocating for more government accountability in the implementation of policies in order to advance comprehensive PHC.

The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints.

BACKGROUND: The Commission on the Social Determinants of Health and the World Health Organization have called for action to address the social determinants of health. This paper considers the extent to which primary health care services in Australia are able to respond to this call. We report on interview data from an empirical study of primary health care centres in Adelaide and Alice Springs, Australia. METHODS: Sixty-eight interviews were held with staff and managers at six case study primary health care services, regional health executives, and departmental funders to explore how their work responded to the social determinants of health and the dilemmas in doing so. The six case study sites included an Aboriginal Community Controlled Organisation, a sexual health non-government organisation, and four services funded and managed by the South Australian government. RESULTS: While respondents varied in the extent to which they exhibited an understanding of social determinants most were reflexive about the constraints on their ability to take action. Services' responses to social determinants included delivering services in a way that takes account of the limitations individuals face from their life circumstances, and physical spaces in the primary health care services being designed to do more than simply deliver services to individuals. The services also undertake advocacy for policies that create healthier communities but note barriers to them doing this work. Our findings suggest that primary health care workers are required to transverse "dilemmatic space" in their work. CONCLUSIONS: The absence of systematic supportive policy, frameworks and structure means that it is hard for PHC services to act on the Commission on the Social Determinants of Health's recommendations. Our study does, however, provide evidence of the potential for PHC services to be more responsive to social determinants given more support and by building alliances with communities and social movements. Further research on the value of community control of PHC services and the types of policy, resource and managerial environments that support action on social determinants is warranted by this study's findings.