Understanding and Responding to Health Literacy as a Social Determinant of Health.

Evidence of a social gradient in health literacy has been found in all reported national population surveys. Health literacy is a midstream determinant of health but not a panacea for addressing health inequities created by the maldistribution of opportunity and resources. It is possible to optimize the contribution health literacy makes in mediating the causes and effects of established social determinants of health. Existing interventions demonstrate the feasibility of improving health literacy among higher-risk populations, but research remains underdeveloped and effects on health inequity are largely untested. Future health literacy intervention research should focus on (a) improving the quality of health communication that reaches a diversity of populations, especially by improving frontline professional skills and support; (b) enabling people to develop transferable skills in accessing, understanding, analyzing, and applying health information; and (c) ensuring that priority is proportionate to need by reaching and engaging the population groups who are disproportionately affected by low health literacy.

Do programs for Aboriginal and Torres Strait Islander people leaving prison meet their health and social support needs?

The objective of this review was to synthesise evidence on the health and social support needs of Aboriginal and Torres Strait Islander people leaving prison and on programs which aid successful community re-entry. A systematic literature review was undertaken of peer-reviewed and grey literature published between 2001 and 2013, focusing on the post-release needs of Aboriginal and Torres Strait Islander adults and pre- and post-release programs. Aboriginal and Torres Strait Islander people have high health and social support needs on leaving prison. There is little literature evidence that re-entry programs commonly consider health needs, support linkages with primary care or Aboriginal Medical Services, or are designed in consideration of the particular needs of Aboriginal and Torres Strait Islander people. In the absence of evaluative evidence on re-entry programs in this group, we have synthesised the best practice recommendations. Re-entry programs must be culturally competent in design and delivery, holistic, take a long-term view, involve families and communities, demonstrate interagency coordination and promote linkages between prison and community-based services. There is an urgent need for accessible pre- and post-release programs which meet the particular needs of Aboriginal and Torres Strait Islander people, including their health needs. Programs must be flexible, comprehensive and accessible to those on remand or with short sentences. Stronger linkage with primary care and Aboriginal and Torres Strait Islander community controlled health organisations is recommended.

Aboriginal and non-aboriginal Australian former prisoners' patterns of morbidity and risk of hospitalisation.

BACKGROUND: People who have been in custody are more likely to experience multiple, long standing health issues. They are at high risk of illness and injury post release and experience poor access to health services both of which contribute to high rates of recidivism. The study was conducted to examine Aboriginal and non-Aboriginal former prisoners' risk of hospitalisation and rehospitalisation in the five years post release from custody and identified the common reasons for hospitalisations. METHODS: Common reasons for hospital admission were identified by conducting descriptive analysis of linked data, related to former prisoners, from NSW Ministry of Health and Corrective Services NSW. This relied upon admitted patient data for 1899 patients. Of this cohort, 1075 people had been admitted to hospital at least once and remained out of custody over a five year period. The independent variables we studied included age, sex, and whether or not the person was Aboriginal. We conducted univariate and multivariate analysis on the following dependent variables: number of admissions over five years after release; more than one admission; days between custody and first hospitalisation; and days between first and second hospitalisation. RESULTS: Mental and behavioural disorders, injuries and poisoning, and infectious or parasitic diseases were the three most common reasons for admission. Aboriginal and non-Aboriginal former prisoners had a broadly similar pattern of reasons for admission. Yet Aboriginal former prisoners were more likely than non-Aboriginal former prisoners to have a shorter mean interval between hospital admission and readmission (187 days compared to 259 days, t = 2.90, p-0.004). CONCLUSIONS: Despite poorer health among Aboriginal people, there were broadly similar patterns of reasons for admission to hospital among Aboriginal and non-Aboriginal former prisoners. There may be a number of explanations for this. The cohort was not a representative sample of the NSW prison population. There was an overrepresentation of individuals with cognitive disability (intellectual disability, acquired brain injury, dementia, fetal alcohol spectrum disorder) in the study population, which may have impacted on this group accessing hospital health care. Alternatively perhaps there were fewer presentations to hospital by Aboriginal former prisoners despite a greater need. The shorter interval between hospital admission and readmission for Aboriginal former prisoners may suggest the need for better follow up care in the community after discharge from hospital. This presents an opportunity for primary health care services to work more closely with hospitals to identify and manage Aboriginal former prisoners discharged from hospital so as to prevent readmission.

The role of primary health care services to better meet the needs of Aboriginal Australians transitioning from prison to the community.

BACKGROUND: Aboriginal Australians are more likely than other Australians to cycle in and out of prison on remand or by serving multiple short sentences-a form of serial incarceration and institutionalisation. This cycle contributes to the over-representation of Aboriginal Australians in prison and higher rates of recidivism. Our research examined how primary health care can better meet the health care and social support needs of Aboriginal Australians transitioning from prison to the community. METHODS: Purposive sampling was used to identify 30 interviewees. Twelve interviews were with Aboriginal people who had been in prison; ten were with family members and eight with community service providers who worked with former inmates. Thematic analysis was conducted on the interviewees' description of their experience of services provided to prisoners both during incarceration and on transition to the community. RESULTS: Interviewees believed that effective access to primary health care on release and during transition was positively influenced by providing appropriate healthcare to inmates in custody and by properly planning for their release. Further, interviewees felt that poor communication between health care providers in custody and in the community prior to an inmate's release, contributed to a lack of comprehensive management of chronic conditions. System level barriers to timely communication between in-custody and community providers included inmates being placed on remand which contributed to uncertainty regarding release dates and therefore difficulties planning for release, cycling in and out of prison on short sentences and being released to freedom without access to support services. CONCLUSIONS: For Aboriginal former inmates and family members, release from prison was a period of significant emotional stress and commonly involved managing complex needs. To support their transition into the community, Aboriginal former inmates would benefit from immediate access to culturally- responsive community -primary health care services. At present, however, pre-release planning is not always available, especially for Aboriginal inmates who are more likely to be on remand or in custody for less than six months.

Efficient funding: a path to improving Aboriginal healthcare in Australia?

OBJECTIVES: To identify the factors that contribute to the under-resourcing of Aboriginal health and to explore the impact that funding arrangements have on the implementation of Aboriginal health policy. DESIGN, SETTINGS AND PARTICIPANTS: Qualitative study based on 35 in-depth interviews with a purposive sample of frontline health professionals involved in health policy and service provision in the Northern Territory. RESULTS: Participants described three factors that contributed to the under-resourcing of Aboriginal health: inefficient funding arrangements, mainstream programs being inappropriate for Aboriginal Australians, and competing interests determining the allocation of resources. Insufficient capacity within the healthcare system undermines the multilevel implementation process whereby organisations need to have the capacity to recognise new policy ideas, assess their relevance to their existing work and strategic plan and to be able to incorporate the relevant new ideas into day-to-day practice. CONCLUSION: Insufficient resources for Aboriginal health were found to be a barrier to implementing Aboriginal health policy. Inadequate resources result from the cumbersome allocation of funding rather than simply the amount of funding provided to Aboriginal healthcare. Monitoring government performance and ensuring the efficient allocation of funds would allow us to develop the delivery system for Aboriginal healthcare and therefore provide greater opportunities to capitalise on current interventions and future efforts.

Changing shape: workforce and the implementation of Aboriginal health policy.

Thirty-five interviews were conducted in a case study on the implementation of the Northern Territory Preventable Chronic Disease Strategy (PCDS) to explore the role of the health workforce in the implementation of Aboriginal health policy. There was a tendency for the workforce to implement those aspects of the policy that drew on existing skills in treatment and management and to avoid or delay implementation that required the acquisition of new skills in primary prevention. Factors that facilitated the implementation of the PCDS included the addition of new resources, employment of additional staff, training, increased commitment from managers, and the creation of dedicated chronic disease positions. Factors impeding implementation included insufficient numbers of service providers, too little support for current Aboriginal Health Workers, and high staff turnover.

A paucity of strategies for developing health literate organisations: A systematic review.

INTRODUCTION: People with low health literacy are more likely to delay seeking care and experience adverse outcomes. While health literacy is the product of individuals' capacities, it is also affected by the complexities of the health care system. System-level changes are needed to align health care demands better with the public's skills and abilities. We aimed to identify the evidence base for effective strategies for creating health literate organisations. METHODS: A systematic review and narrative synthesis of empirical studies was performed. Medline, Embase, PsychInfo and CINHAL databases were searched for empirical studies from OECD countries published from 2008 onwards, focusing on health literacy interventions at the organisational level. Analysis of the findings was informed by the National Academies' five-dimensional framework for the attributes of a health literate organisation, which include: organisational commitment, accessible education and technology infrastructure, augmented workforce, embedded policies and practices, and effective bidirectional communication. RESULTS: The title and abstract of 867 records were screened according to the selection criteria, leading to full text review of 125 articles. Seven studies were identified in the peer review literature. Adapting health literacy guidelines and tools was the most common approach to addressing organisational health literacy. CONCLUSION: While the use of health literacy tools proved important for raising awareness of health literacy issues within organisations, these tools were insufficient for generating the organisational changes necessary to improve organisational health literacy.