A critical account of the policy context shaping perinatal survival in Nepal: policy tension of socio-cultural versus a medical approach.

BACKGROUND: Nepal formulated a range of policies related to maternal and neonatal survival, especially after the year 2000. Nevertheless, Nepal's perinatal mortality remains high, particularly in disadvantaged regions. Policy analysis can uncover the underlying values, strategies and policy formulation processes that shape the potential to reduce in-country health inequities. This paper provides a critical account of the main policy documents relevant to perinatal survival in Nepal. METHODS: Six key policy documents covering the period 2000-2015 were reviewed using an adapted framework and were analyzed through qualitative content analysis. RESULTS: The analysis shows that the policies focused mainly on the system: improvement in provision of birthing facilities; targeting staff (Skilled Birth Attendants) and health service users by providing cash incentives to staff for bringing patients to services, and to users (pregnant women) to attend health institutions. Despite a growing focus on saving women and newborn babies, there is a poor policy focus and direction on preventing stillbirth. The policy documents were found to emphasize tensions between birthing at home and at health institutions on the one hand, and between strategies to provide culturally appropriate, woman-centered care in communities and medically orientated services on the other. Policies acknowledge the need to provide and address woman-centered care, equity, social inclusion, and a rights-based approach, and identify the community based approach as the mode of service delivery. Over and above this, all policy documents are aimed at the national level, and there is no specific policy direction for the separate ecological, cultural or geographic regions such as the mountainous region, which continues to exhibit higher mortality rates and has different cultural and demographic characteristics to the rest of Nepal. CONCLUSIONS: To better address the continuing high perinatal mortality rates, particularly in disadvantaged areas, national health policies should pay more attention to the inequity in healthcare access and in perinatal outcomes by integrating both stillbirth prevention and neonatal survival as policy agenda items. To ensure effective translation of policy into practice, it is imperative to tailor the strategies according to acknowledged policy values such as rights, inclusion and socio-cultural identity.

A qualitative study about the gendered experiences of motherhood and perinatal mortality in mountain villages of Nepal: implications for improving perinatal survival.

BACKGROUND: We aim to examine the gendered contexts of poor perinatal survival in the remote mountain villages of Nepal. The study setting comprised two remote mountain villages from a mid-western mountain district of Nepal that ranks lowest on the Human Development Index (0.304), and is reported as having the lowest child survival rates in the country. METHODS: The findings are taken from a larger study of perinatal survival in remote mountain villages of Nepal, conducted through a qualitative methodological approach within a framework of social constructionist and critical theoretical perspectives. Data were collected through in-depth interviews with 42 women and their families, plus a range of healthcare providers (nurses/auxiliary nurses, female health volunteers, support staff, Auxiliary Health Worker and a traditional healer) and other stakeholders from February to June, 2015. Data were analysed with a comprehensive coding process utilising the thematic analysis technique. RESULTS: The social construction of gender is one of the key factors influencing poor perinatal survival in the villages in this study. The key emerging themes from the qualitative data are: (1) Gendered social construct and vulnerability for poor perinatal survival: child marriages, son preference and repeated child bearing; (2) Pregnancy and childbirth in intra-familial dynamics of relationships and power; and (3) Perception of birth as a polluted event: birth in Gotha (cowshed) and giving birth alone. CONCLUSIONS: Motherhood among women of a low social position is central to women and their babies experiencing vulnerabilities related to perinatal survival in the mountain villages. Gendered constructions along the continuum from pre-pregnancy to postnatal (girl settlement, a daughter-in-law, ritual pollution about mother and child) create challenges to ensuring perinatal survival in these villages. It is imperative that policies and programmes consider such a context to develop effective working strategies for sustained reduction of future perinatal deaths.

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.

Applying Health in All Policies to obesity in South Australia.

Public policy strategies impact on population health by acting on the effectiveness, availability and distribution of the social determinants of health. Reducing obesity and promoting healthy weight is a key focus of governments, health promoters and researchers, and can benefit from a systems approach with 'upstream' policy action beyond the health sector. Although the literature identifies many areas for hypothetical non-health policy action, and in particular relating to food and activity environments, few have identified practical, politically viable and relatively cost-free processes by which non-health sectors would want to commit to such action. This article details how the Government of South Australia used the Health in All Policies (HiAP) approach in the SA HiAP Healthy Weight Project. It mapped the core business and policy directions of 44 state departments against research on 'what works' to address obesity. Negotiations then developed high-level policy commitments to address factors promoting healthy weight which predominantly changed ways of working rather than requiring new expenditure and also assisted departments in meeting their own goals; departmental chief executives endorsed the commitments. By starting from departmental documents, and not restricting the project to departments with more 'obvious' obesity prevention potential, we gained commitment to a broader range of policy actions than identified elsewhere; for example, for prisons, environment and botanic gardens, housing and vocational education. The SA HiAP Healthy Weight Project provides one example of a workable, evidence-based systems approach to increase commitment to practical and politically viable opportunities across government to address the non-health environments supporting healthy weight.

Addressing social determinants of health inequities through settings: a rapid review.

Changing settings to be more supportive of health and healthy choices is an optimum way to improve population health and health equity. This article uses the World Health Organisation's (1998) (WHO Health Promotion Glossary. WHO Collaborating Centre for Health Promotion, Department of Public Health and Community Medicine, University of Sydney, NSW) definition of settings approaches to health promotion as those focused on modifying settings' structure and nature. A rapid literature review was undertaken in the period June-August 2014, combining a systematically conducted search of two major databases with targeted searches. The review focused on identifying what works in settings approaches to address the social determinants of health inequities, using Fair Foundations: the VicHealth framework for health equity. This depicts the social determinants of health inequities as three layers of influence, and entry points for action to promote health equity. The evidence review identified work in 12 settings (cities; communities and neighbourhoods; educational; healthcare; online; faith-based; sports; workplaces; prisons; and nightlife, green and temporary settings), and work at the socioeconomic, political and cultural context layer of the Fair Foundations framework (governance, legislation, regulation and policy). It located a relatively small amount of evidence that settings themselves are being changed in ways which address the social determinants of health inequities. Rather, many initiatives focus on individual behaviour change within settings. There is considerable potential for health promotion professionals to focus settings work more upstream and so replace or integrate individual approaches with those addressing daily living conditions and higher level structures, and a significant need for programmes to be evaluated for differential equity impacts and published to provide a more solid evidence base.

Vicious cycles: digital technologies and determinants of health in Australia.

Digital technologies are increasingly important as ways to gain access to most of the important social determinants of health including employment, housing, education and social networks. However, little is known about the impact of the new technologies on opportunities for health and well-being. This paper reports on a focus group study of the impact of these technologies on people from low socio-economic backgrounds. We use Bourdieu's theories of social inequities and the ways in which social, cultural and economic capitals interact to reinforce and reproduce inequities to examine the ways in which digital technologies are contributing to these processes. Six focus group discussions with 55 people were held to examine their access to and views about using digital technologies. These data are analysed in light of Bourdieu's theory to determine how people's existing capitals shape their access to and use of digital technologies and what the implications of exclusion from the technologies are likely to be for the social determinants of health. The paper concludes that some people are being caught in a vicious cycle whereby lack of digital access or the inability to make beneficial use reinforces and amplifies existing disadvantage including low levels of reading and writing literacy. The paper concludes with a consideration of actions health promoters could take to interrupt this cycle and so contribute to reducing health inequities.

The interplay between structure and agency in shaping the mental health consequences of job loss.

BACKGROUND: Job loss is a discrete life event, with multiple adverse consequences for physical and mental health and implications for agency. Our research explores the consequences of job loss for retrenched workers' mental health by examining the interplay between their agency and the structures shaping their job loss experiences. METHODS: We conducted two waves of in-depth, semi-structured interviews with a sample of 33 of the more than 1000 workers who lost their jobs at Mitsubishi Motors in South Australia during 2004 and 2005 as a result of industry restructuring. Interviews capturing the mental health consequences of job loss were recorded and transcribed verbatim. Thematic analysis was employed to determine the health consequences of the job loss and the impact of structural factors. RESULTS: Main themes that emerged from the qualitative exploration of the psychological distress of job loss included stress, changes to perceived control, loss of self-esteem, shame and loss of status, experiencing a grieving process, and financial strain. Drawing on two models of agency we identified the different ways workers employed their agency, and how their agency was enabled, but mainly constrained, when dealing with job loss consequences. CONCLUSIONS: Respondents' accounts support the literature on the moderating effects of economic resources such as redundancy packages. The results suggest the need for policies to put more focus on social, emotional and financial investment to mediate the structural constraints of job loss. Our study also suggests that human agency must be understood within an individual's whole of life circumstances, including structural and material constraints, and the personal or interior factors that shape these circumstances.

The perspectives of older Greek-Australians toward changes in the nature of family support: implications for family care policies.

Internationally, public policies encourage "aging in place," and the majority of older Australians requiring care in the community receive informal care, supplemented by publicly subsidized formal services. The effect of contemporary social changes on informal care in aging migrant communities is poorly understood. This articles explores the perceptions of older Greek-Australians toward changes in the nature of family support. Bicultural and bilingual researchers carried out in-depth interviews (n = 27) and five focus groups (n = 63 total participants) with older Greek-Australians in modern Greek. While "cultures of care" remain among Greek-Australian families, the means for a family to assist have shifted, and these compromises are met with considerable powerlessness among older Greek-Australians. Implications for policy include the need to better involve older migrants and their families in decisions about their care needs, potentially involving consumer-directed care models. Service providers may also need to adopt the use of new technologies to communicate with increasingly time-pressured family members.

Analysis of breastfeeding policies and practices in childcare centres in Adelaide, South Australia.

Breastfeeding policies and practices were analysed in childcare settings in the metropolitan area of Adelaide, South Australia. Childcare centres were purposively selected based on their geographical location, type and socioeconomic score of the area. Qualitative inquiry approach was employed by undertaking interviews with childcare centres' director or baby house coordinator to explore their perception towards breastfeeding practice and support within their centre. Breastfeeding related policy documents, where available, were also collected during the interviews to triangulate data. A total of 15 face-to-face interviews were conducted. Six childcare centres had a written policy specifically on breastfeeding support, although the technical issues of handling breastmilk were included in most centres' food and nutrition guidelines. Most participants believed that decision to breastfeed is the personal choice of parents, and hence saw the childcare centre's role as supporting parental choice whether it is breastfeeding or not. The provision of physical space to breastfeed and facilities to store the expressed breast milk were the most common practices in support of parents who had chosen to continue breastfeeding. Participants perceived mothers' work-related issues such as distance from the centre, time, and unsupportive workplace the most important barriers that led to early introduction of bottle feeding or breastfeeding cessation. Most childcare centres support breastfeeding in a more passive than active way. Breastfeeding promotion needs to be an integral part of childcare centres training, policy and practice if an increased rate of breastfeeding is to be achieved particularly amongst working mothers.

Digital technology use among disadvantaged Australians: implications for equitable consumer participation in digitally-mediated communication and information exchange with health services.

OBJECTIVE: To present research findings on access to, and use of, digital information and communication technologies (ICTs) by Australians from lower income and disadvantaged backgrounds to determine implications for equitable consumer access to digitally-mediated health services and information. METHODS: Focus groups were held in 2008-09 with 80 residents from lower income and disadvantaged backgrounds in South Australia, predominantly of working- and family-formation age (25 to 55 years). Qualitative analysis was conducted on a-priori and emergent themes to describe dominant categories. RESULTS: Access to, and use of, computers, the Internet and mobile phones varied considerably in extent, frequency and quality within and across groups due to differences in abilities, resources and life experience. Barriers and facilitators included English literacy (including for native speakers), technological literacy, education, income, housing situation, social connection, health status, employment status, and trust. Many people gained ICT skills by trial and error or help from friends, and only a few from formal programs, resulting in varied skills. CONCLUSION: The considerable variation in ICT access and use within lower income and disadvantaged groups must be acknowledged and accommodated by health initiatives and services when delivering digitally-mediated consumer-provider interaction, online health information, or online self-management of health conditions. If services require consumers to participate in a digitally-mediated communication exchange, then we suggest they might support skills and technology acquisition, or provide non-ICT alternatives, in order to avoid exacerbating health inequities.

Can a regional government's social inclusion initiative contribute to the quest for health equity?

Despite decades of concern about reducing health inequity, the Commission on the Social Determinants of Health (CSDH) painted a picture of persistent and, in some cases, increasing health inequity. It also made a call for increased evaluation of interventions that might reduce inequities. This paper describes such an intervention-the Social Inclusion Initiative (SII) of the South Australian Government-that was documented for the Social Exclusion Knowledge Network of the CSDH. This initiative is designed to increase social inclusion by addressing key determinants of health inequity-in the study period these were education, homelessness and drug use. Our paper examines evidence from a rapid appraisal to determine whether a social inclusion initiative is a useful aspect of government action to reduce health inequity. It describes achievements in each specific area and the ways they can be expected to affect health equity. Our study highlighted four factors central to the successes achieved by the SII. These were the independent authority and influence of the leadership of the SII, the whole of government approach supported by an overarching strategic plan which sets clear goals for government and the clear and unambiguous support from the highest level of government. We conclude that a social inclusion approach can be valuable in the quest to reduce inequities and that further research on innovative social policy approaches is required to examine their likely impact on health equity.

Use of information and communication technology to provide health information: what do older migrants know, and what do they need to know?

BACKGROUND: Governments and businesses are increasingly using the internet and mobile telephones to disseminate information about services and products. However, not all population groups have the resources and capabilities to support equality of access to and use of these technologies. While Australia's ageing population receives attention in a wide variety of literatures, the ageing migrant population has received very little attention in relation to understanding their place in the 'digital divide'. It is not known how this group gathers information used in everyday living, or what role the internet or mobile phones plays within this. At a time when the population is ageing and there is an increasing use of the internet to deliver services and information, there is little research on the effects of ethnicity, migration, socio-economic status, education or gender of older people on the use of information and communication technology (ICT). Addressing this should be a priority in Australia, which has an old and ageing population that includes many post-war migrants from non-English speaking European countries. AIMS: To analyse the views of older migrants living in South Australia with respect to their current information sources, their use of ICT and any barriers and enablers to future use of ICT for accessing health information. METHODS: A qualitative study employing eight focus groups involving 43 older Italian and Greek migrants living in the community in metropolitan or regional settings in South Australia. Interviews were held and audio-recorded and the English language components transcribed. Transcriptions were analysed manually using a grounded theory approach. RESULTS: Older migrants do not use ICT to a great extent to access information in their everyday lives, with many expressing no interest in learning how to do so. However, they access the information they need to function in society with a desired quality of life from multiple sources by various means. Sources include electronic and print media from Australia and their home countries, family and acquaintances, government departments or service providers. Many expressed a preference for receiving information as printed material or directly from another person. DISCUSSION: Governments or primary healthcare organisations planning to make health information solely available via ICT should be aware that doing so may lead to an increase in 'information exclusion' and the formation of functional knowledge deficits for older migrants. At the moment at least, our participants do not perceive any functional knowledge deficits as they engage multiple sources to access the information they need for everyday life. We recommend that governments and healthcare organisations evaluate the appropriateness of using ICT to directly provide information to older migrants and consider non-digital means or the engagement of 'information brokers' when communicating with groups identified as low or non-users of ICT.

Consumer involvement in the South Australian state policy for planned home birth.

Two consumer representatives were participants in the development of their state government's Policy for Planned Birth At Home in South Australia. It was released in November 2007 to guide staff in public hospital and community midwifery programs, and the first hospital-based home birth service is commencing in February 2009. Consumer experiences of policy development and perceived benefits of consumer involvement for policy and transparency processes are described. Inclusion of consumers widely and actively during development and reform of maternity care is essential if real consumer participation is to occur and contribute to care that is truly woman-centered.

The health care system as a social determinant of health: qualitative insights from South Australian maternity consumers.

Health systems and policies are important determinants of health because they influence the type and quality of health care available to a population. This study included semi-structured qualitative interviews and a questionnaire to collect demographic data and household details for a purposeful sample of 38 mothers and 24 fathers from four socioeconomic areas of metropolitan South Australia who had at least one child aged between 1 and 6 years of age. The participants reported that birth experiences within the predominantly medicalised maternity system were at odds with the expectations of a significant proportion of contemporary consumers that maternity care will leave them not only with a healthy mother and baby, but also with no undue adverse impacts on their physical, mental and relationship health. There appears to be no formal mechanism in place for regular consumer feedback of experiences into system and service planning.

Why planned attended homebirth should be more widely supported in Australia.

This article argues that the continuing reluctance on the part of professional and bureaucratic bodies in Australia to provide for and support planned attended homebirth for low-risk women is unfounded according to the research evidence. It also suggests that such lack of support might be encouraging some planned but intentionally unattended homebirths to occur in Australia, particularly as in recent years there appears to have been an increase in popularity in freebirth (or do-it-yourself homebirth). The article calls for RANZCOG and Australian state health departments to support planned attended homebirth for low-risk women in the face of what is now a considerable amount of evidence showing its safety, when compared with unplanned homebirth and hospital birth. The article raises a number of challenging issues for obstetricians, midwives and managers or planners of maternity services.

Religio-cultural factors contributing to perinatal mortality and morbidity in mountain villages of Nepal: Implications for future healthcare provision.

OBJECTIVE AND THE CONTEXT: This paper examines the beliefs and experiences of women and their families in remote mountain villages of Nepal about perinatal sickness and death and considers the implications of these beliefs for future healthcare provision. METHODS: Two mountain villages were chosen for this qualitative study to provide diversity of context within a highly disadvantaged region. Individual in-depth interviews were conducted with 42 women of childbearing age and their family members, 15 health service providers, and 5 stakeholders. The data were analysed using a thematic analysis technique with a comprehensive coding process. FINDINGS: Three key themes emerged from the study: (1) 'Everyone has gone through it': perinatal death as a natural occurrence; (2) Dewata (God) as a factor in health and sickness: a cause and means to overcome sickness in mother and baby; and (3) Karma (Past deeds), Bhagya (Fate) or Lekhanta (Destiny): ways of rationalising perinatal deaths. CONCLUSION: Religio-cultural interpretations underlie a fatalistic view among villagers in Nepal's mountain communities about any possibility of preventing perinatal deaths. This perpetuates a silence around the issue, and results in severe under-reporting of ongoing high perinatal death rates and almost no reporting of stillbirths. The study identified a strong belief in religio-cultural determinants of perinatal death, which demonstrates that medical interventions alone are not sufficient to prevent these deaths and that broader social determinants which are highly significant in local life must be considered in policy making and programming.

Health system barriers influencing perinatal survival in mountain villages of Nepal: implications for future policies and practices.

BACKGROUND: This paper aims to examine the health care contexts shaping perinatal survival in remote mountain villages of Nepal. Health care is provided through health services to a primary health care level-comprising district hospital, village health facilities and community-based health services. The paper discusses the implications for future policies and practice to improve health access and outcomes related to perinatal health. The study was conducted in two remote mountain villages in one of the most remote and disadvantaged mountain districts of Nepal. The district is reported to rank as the country's lowest on the Human Development Index and to have the worst child survival rates. The two villages provided a diversity of socio-cultural and health service contexts within a highly disadvantaged region. METHODS: The study findings are based on a qualitative study of 42 interviews with women and their families who had experienced perinatal deaths. These interviews were supplemented with 20 interviews with health service providers, female health volunteers, local stakeholders, traditional healers and other support staff. The data were analysed by employing an inductive thematic analysis technique. RESULTS: Three key themes emerged from the study related to health care delivery contexts: (1) Primary health care approach: low focus on engagement and empowerment; (2) Quality of care: poor acceptance, feeling unsafe and uncomfortable in health facilities; and (3) Health governance: failures in delivering health services during pregnancy and childbirth. CONCLUSIONS: The continuing high perinatal mortality rates in the mountains of Nepal are not being addressed due to declining standards in the primary health care approach, health providers' professional misbehaviour, local health governance failures, and the lack of cultural acceptance of formalised care by the local communities. In order to further accelerate perinatal survival in the region, policy makers and programme implementers need to immediately address these contextual factors at local health service delivery points.

"I like talking to people on the computer": Outcomes of a home-based intervention to develop social media skills in youth with disabilities living in rural communities.

PURPOSE: To investigate the effectiveness of a home-based social media use intervention to enhance the social networks of rural youth with disabilities. METHOD: Participants were nine youth (mean age = 17.0 years) with disabilities from two rural Australian communities. The intervention consisted of providing appropriate assistive technology and social media training on individualised goals. Using mixed methods, quantitative (a single group pre-post) and qualitative (interviews with participants and their carers) measures were used to examine outcomes of training, individual experiences of the intervention, and changes to online social networks. RESULTS: Participants increased their performance and satisfaction with performance on social media problem areas post-intervention; paired t-tests showed statistical significance at p < .001. There was also a significant increase in the number of online communication partners; Wilcoxon Signed Ranks showed statistical significance at p < .05. The interviews highlighted increased social participation, independence and improvements to literacy. Ongoing parental concerns regarding cyber safety and inappropriate online content were noted. CONCLUSIONS: The findings suggest that social media training is a feasible method for increasing social networks among rural-based youth with disabilities. To sustain ongoing benefits, parents need knowledge and training in integrating assistive technology and social media.