Assessing cultural safety in Aboriginal and Torres Strait Islander Health.

OBJECTIVE: The aim of this study was to explore how nurses and midwives (trained at Flinders University in Adelaide) from rural, remote and urban locations view the impact of cultural safety training on their practice and the extent to which they incorporated cultural safety principles into their practice. DESIGN: qualitative research study. SETTING: rural, remote and urban locations across Australia. PARTICIPANTS: Nurses and midwives who had undertaken cultural safety training at Flinders University as part of their undergraduate degree. METHODS: Participants were recruited for semi-structured interviews. Interviews were recorded and transcribed verbatim. Transcripts were coded independently by members of the research team. MAIN OUTCOME MEASURES: The use of cultural safety principles in participants' practice, and the extent to which they were applied, was determined. Barriers and enablers to enacting cultural safety in the workplace were also identified. RESULTS: 10 individuals participated in an interview (7 nurses and 3 midwives). The Modified Monash Model was used to classify participant location with the following observed: MM1, six; MM2, two; MM5, one; MM6, one. 3 participants were from the Northern Territory and 7 from South Australia. Participants were at varying stages in their journey of cultural safety, ranging from early stages to those able to embody the Cultural Safety Principles and negotiate barriers to provide culturally safe care. Educational strategies for participants to progress their cultural safety journey were also identified. CONCLUSION: The extent to which cultural safety principles are applied in practice is diverse amongst the nurses and midwives that participated in this study, demonstrating that cultural safety is a journey and ongoing support is needed.

Two-eyed seeing: A useful gaze in Indigenous medical education research.

CONTEXT: Medical education has a role in preparing future health care practitioners to have the skills to meaningfully address health disparities while providing effective clinical care considerate of diversity in our societies. This calls for medical education researchers to approach their craft in ways that prioritise and value inputs from a broader range of perspectives and worldviews in an effort to redress the negative impacts of social, political and structural forces on health outcomes. METHODS: Given the entrenched health inequities experienced by Indigenous populations across the globe, this paper details an approach to medical education research put forward by Canadian Mi'kmaw Elders Murdena and Albert Marshall and named 'two-eyed seeing'. This approach provides the opportunity for medical education researchers to address the ongoing impacts of colonisation, racism and marginalisation on health outcomes by prioritising Indigenous worldviews in medical curricula. The need for researchers and medical academies to critically consider Indigenous governance and processes of respectful knowledge sharing within the wider institutional and societal contexts is addressed. CONCLUSIONS: The benefits of two-eyed seeing in the context of better preparing the future workforce to effectively meet the needs of those most vulnerable, and to action change against health inequities, situate it as a promising research approach in medical education.

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.

Intersectoral action on SDH and equity in Australian health policy.

Intersectoral action between public agencies across policy sectors, and between levels of government, is seen as essential for effective action by governments to address social determinants of health (SDH) and to reduce health inequities. The health sector has been identified as having a crucial stewardship role, to engage other policy sectors in action to address the impacts of their policies on health. This article reports on research to investigate intersectoral action on SDH and health inequities in Australian health policy. We gathered and individually analysed 266 policy documents, being all of the published, strategic health policies of the national Australian government and eight State/Territory governments, current at the time of sampling in late 2012-early 2013. Our analysis showed that strategies for intersectoral action were common in Australian health policy, but predominantly concerned with extending access to individualized medical or behavioural interventions to client groups in other policy sectors. Where intersectoral strategies did propose action on SDH (other than access to health-care), they were mostly limited to addressing proximal factors, rather than policy settings affecting the distribution of socioeconomic resources. There was little evidence of engagement between the health sector and those policy sectors most able to influence systemic socioeconomic inequalities in Australia.

To what extent do Australian child and youth health policies address the social determinants of health and health equity?: a document analysis study.

BACKGROUND: There is a significant body of evidence that highlights the importance of addressing the social determinants of child and youth health. In order to tackle health inequities Australian governments are being called upon to take action in this area at a policy level. Recent research suggests that the health and well-being of children and youth in Australia is 'middle of the road' when compared to other OECD countries. To date, there have been no systematic analyses of Australian child/youth health policies with a social determinants and health equity focus and this study aimed to contribute to addressing this gap. METHODS: Document analysis of seventeen strategic level child/youth health policies across Australia used an a priori coding framework specifically developed to assess the extent to which health departments address the social determinants of child/youth health and health equity. Policies were selected from a review of all federal and state/territory strategic health department policies dated between 2008 and 2013. They were included if the title of the policy addressed children, youth, paediatric health or families directly. We also included whole of government policies that addressed child/youth health issues and linked to the health department, and health promotion policies with a chapter or extensive section dedicated to children. RESULTS: Australian child/youth health policies address health inequities to some extent, with the best examples in Aboriginal or child protection policies, and whole of government policies. However, action on the social determinants of child/youth health was limited. Whilst all policies acknowledge the SDH, strategies were predominantly about improving health services delivery or access to health services. With some exceptions, the policies that appeared to address important SDH, such as early childhood development and healthy settings, often took a narrow view of the evidence and drifted back to focus on the individual. CONCLUSIONS: This research highlights that policy action on the social determinants of child/youth health in Australia is limited and that a more balanced approach to reducing health inequities is needed, moving away from a dominant medical or behavioural approach, to address the structural determinants of child/youth health.

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.

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.

Risk and protective factors for pregnancy outcomes for urban Aboriginal and non-Aboriginal mothers and infants: the Gudaga cohort.

This paper aims to describe delivery and birth outcomes of Aboriginal infants and their mothers in an urban setting on the east coast of Australia. The paper uses a causal pathway approach to consider the role of risk and protective factors for low birthweight. All mothers who delivered at Campbelltown Hospital between October 2005 and May 2007 were eligible. The study included 1,869 non-Aboriginal infants and 178 Aboriginal infants and their mothers. Information on delivery and birthweight was extracted from electronic medical records. Risk factors for poor outcomes were explored using regression and causal pathway analysis. Mothers of Aboriginal infants were younger than mothers of non-Aboriginal infants, and were more likely to be single, less educated, unemployed prior to pregnancy, and live in a disadvantaged neighbourhood. Health and service use was similar. They were significantly more likely to have a vaginal delivery than mothers of non-Aboriginal infants (77% cf 62.5%; χ (1) (2)  = 14.6, P < 0.001) and less likely to receive intervention during delivery. Aboriginal infants (3,281.1 g) weighed 137.5 g (95%CI: 54-221 g; P = 0.001) less then non-Aboriginal infants (3,418.7 g). Gestational age, and single mother with incomplete education, prior unemployment, smoking, and living in a disadvantaged neighbourhood were associated with lower birthweight. Maternal vulnerability had a cumulative impact on birthweight. A causal pathway analysis demonstrated the associations between risk factors.

"Big Sister" Wisdom: How might non-Indigenous speech-language pathologists genuinely, and effectively, engage with Indigenous Australia?

Speech Pathology Australia, through its landmark project for the profession, "Speech Pathology 2030 - making futures happen" (SP 2030), calls for speech-language pathologists to "respond (to presenting clients) in ways that respect each person's culture, language, life experiences, and preferences" (Speech Pathology Australia, 2016, p. viii). Such engagement, it holds, is central to successful practice. Meeting the needs of Aboriginal and/or Torres Strait Islander (Indigenous) clients and communities, however, requires a skilled response to client wholeness, to their indissoluble, and unique, immersion in their: indigeneity; lived cultural experience; and the social, geographical, economic and political realities that surround them. Equally, the achievement of a truly-effective engagement, one able to engender desired outcomes, is also dependent on the challenging achievement of culturally-safe practice. Given that the relevant literature is, historically, based on a privileging of western purviews, this article asserts the validity of incorporating (pan-)Indigenous epistemologies and perspectives. As well as the Indigenous health and cultural safety literature, then, this article draws on particular Indigenous professional experience as a locus of good-practice evidence, one capable of contributing additional insights to best address the question: "How might Non-Indigenous speech-language pathologists really engage, effectively, with Indigenous Australia?". It introduces a guiding rubric, "Meet People in their Own Reality", as a tool with which to examine how engagement, in the service of more-effective practice, can be optimised in four exemplar domains of SP 2030.

Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia.

BACKGROUND: The importance of evaluating policy processes to achieve health equity is well recognised but such evaluation encounters methodological, theoretical and political challenges. This paper describes how a program theorybased evaluation framework can be developed and tested, using the example of an evaluation of the South Australian Health in All Policies (HiAP) initiative. METHODS: A framework of the theorised components and relationships of the HiAP initiative was produced to guide evaluation. The framework was the product of a collaborative, iterative process underpinned by a policy-research partnership and drew on social and political science theory and relevant policy literature. RESULTS: The process engaged key stakeholders to capture both HiAP specific and broader bureaucratic knowledge and was informed by a number of social and political science theories. The framework provides a basis for exploring the interactions between framework components and how they shape policy-making and public policy. It also enables an assessment of HiAP's success in integrating health and equity considerations in policies, thereby laying a foundation for predicting the impacts of resulting policies. CONCLUSION: The use of a program theory-based evaluation framework developed through a consultative process and informed by social and political science theory has accommodated the complexity of public policy-making. The framework allows for examination of HiAP processes and impacts, and for the tracking of contribution towards distal outcomes through the explicit articulation of the underpinning program theory.

Qualitative protocol for understanding the contribution of Australian policy in the urban planning, justice, energy and environment sectors to promoting health and health equity.

INTRODUCTION: A well-established body of literature demonstrates that health and equity are strongly influenced by the consequences of governments' policy and resultant actions (or inactions) outside the health sector. Consequently, the United Nations, and its agency the WHO, have called for national leadership and whole-of-government action to understand and address the health impacts of policies in all sectors. This research responds to that call by investigating how policymaking in four sectors-urban planning, justice, energy and environment-may influence the social determinants of health and health equity (SDH/HE). METHODS AND ANALYSIS: The research design is informed by a critical qualitative approach. Three successive stages are included in the design. The first involves analysing all strategic policy documents and selected legislative documents from the four sectors (n=583). The document analysis is based on a coding framework developed to identify alignment between the documents and the SDH/HE. Two policies that demonstrate good practice in regard to SDH/HE will be selected from each sector during the second stage for embedded case study analysis (total n=8). This is intended to illuminate which factors have supported recognition and action on SDH/HE in the selected policies. The third stage involves progressive theoretical integration and development to understand political and institutional facilitators and barriers to action on SDH/HE, both within and between sectors. ETHICS AND DISSEMINATION: The research will provide much needed evidence about how coherent whole-of-government action on SDH/HE can be advanced and contribute knowledge about how health-enhancing policy activity in the four sectors may be optimised. Learnings from the research will be shared via a project advisory group, policy briefings, academic papers, conference presentations and research symposia. Ethics approval has been secured for the embedded case studies, which involve research participants.

CHALLENGES TO INDIGENOUS HEALTH CURRICULUM DESIGN -- BRINGING THE ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH CURRICULUM FRAMEWORK TO LIFE.

While it is our responsibility to produce culturally safe graduates with a nuanced grasp of Aboriginal and Torres Strait Islander health needs, there are central challenges in curriculum writing for indigenous health today.

New norms new policies: Did the Adelaide Thinkers in Residence scheme encourage new thinking about promoting well-being and Health in All Policies?

Health systems have long been criticised for focussing on curing rather than preventing disease. This paper examines to what extent the Adelaide Thinkers in Residence (ATiR) scheme contributed to the change in norms whereby promoting well-being and a strategy to achieve this - Health in All Policies (HiAP)--was adopted by the South Australian (SA) State Government from 2007. The data presented in this paper are drawn from a five year (2012-2016) detailed mixed methods case study of the SA HiAP initiative which involved document analysis, interviews and workshops with public servants and political actors. We adapt the framework used by Finnemore and Sikkink (1998) which explains how norm changes can lead to political changes in international affairs. We also use Kingdon's concept of policy entrepreneurs to determine whether these ideas moved to an implementable initiative with the help of both a specific ATiR program on HiAP and the broader TiR scheme which promoted a series of innovations relevant to health. The process involved the ATiR reinforcing the work of local norm entrepreneurs with that of powerful external policy entrepreneurs, adapting the discourse about the value of prevention and promoting well-being so that it fitted with the dominant economic one. The powerful organisational platform of the ATiR, which was under the Department of the Premier and Cabinet and linked to the South Australian Strategic Plan (SASP) was used to advance these ideas. The case study offers important lessons for other jurisdictions on how to shift policy to encourage intersectoral approaches to health.

The Gudaga Study: establishing an Aboriginal birth cohort in an urban community.

OBJECTIVE: This paper describes the establishment of the Gudaga Study, an Aboriginal birth cohort in south-west Sydney, and our approach to follow-up of participants. The Study describes the health, development, and services use of Aboriginal infants and their mothers. The research team works closely with the local Aboriginal community to implement the research. METHODS: All mothers in the maternity ward of an urban hospital were surveyed to identify mothers with an Aboriginal infant. These and some additional mothers identified through other networks were recruited to the study. RESULTS: The number of mothers were surveyed was 2,108. Mothers of Aboriginal infants were younger (25.3 years compared to 28.4 years, p<0.001), less likely to be married (16.1% cf. 58.4%, p<0.001) and to have completed school (63.2% cf. 77.8%, p=0.002) than mothers of non-Aboriginal infants. Of 155 identified mothers of Aboriginal infants, 136 were recruited and 23 through other networks. At 12 months, 85.5% of infants were followed up. CONCLUSIONS: This study, to our knowledge, is the first cohort study of this kind on the eastern seaboard of Australia. The study has strong community support and follow-up, contrary to views that Aboriginal people are reluctant to participate in research. These data have national and regional significance.

Assessing the differences and similarities between hospital chains and independents regarding revenues, profits, and community contributions.

Hospital systems or chains continue to grow their market share relative to independent hospitals. This trend generates concerns among health care industry observers as historical performance suggests chains charge more for health care services than the independents while providing reduced contributions to their community. This study empirically assesses key performance measures of 67 acute-care hospitals in Virginia by testing if there are differences between chains and independents regarding total patient revenues, revenues per admission, profitability and community support, including charity care, bad debt, taxes paid and Medicaid participation. Implications to industry policy-makers as well as to hospital executives and marketing managers are then presented.

A comparative analysis of the community contributions and profits of Virginia's hospitals.

BACKGROUND: In return for receiving favorable treatment from the government, U.S. general hospitals are expected to provide contributions to their community consisting of charity care, bad debt, and taxes paid. Recently, the Government Accountability Office proposed that an analysis that compares what for-profit and nonprofit hospitals contribute be conducted. PURPOSE: For 72 Virginia hospitals, it is determined whether (a) for-profit hospitals' community contributions exceed their profits and (b) nonprofit hospitals' community contributions exceed the for-profits' contributions in addition to the nonprofits' forgone taxes. METHODOLOGY/APPROACH: Based on audited fiscal year 2004 financial statements, six null hypotheses were tested for significant differences between the two independent variables, namely, hospital charter and size, and the three dependent variables, including (a) operating income, (b) the ratio of community contributions to net patient revenues, and (c) the ratio of community contributions to operating income. FINDINGS: No significant differences were found to exist between (a) hospital charter and operating income, (b) hospital charter and the percentage of community contributions to net patient revenues, and (c) hospital charter and the percentage of community contributions to operating income. The community contributions of nonprofits exceeded their taxes forgone by a wide margin, but they fell short of exceeding the for-profits' community contributions plus the taxes forgone by a very slight margin. PRACTICE IMPLICATIONS: Hospital management, in conjunction with health care policy planners, needs to develop mutually acceptable standards regarding the required level of hospitals' community contributions. It is proposed that the most equitable standard is "quartile comparisons" for a given hospital's financial performance and its level of community contributions. Furthermore, to reduce charity care, it is imperative that high-cost hospital treatment of primary health care for indigent patients be shifted to lower cost delivery systems.