Mergers may enhance the legitimacy of community health organisations in neoliberal environments.

PURPOSE: Comprehensive primary health care (PHC) models are seldom implemented in high income countries, in part due to their contested legitimacy in neoliberal policy environments. This article explores how merging affected the perceived legitimacy of independent community health organisations in Victoria, Australia, in providing comprehensive PHC services. DESIGN/METHODOLOGY/APPROACH: A longitudinal follow-up study (2-3 years post-merger) of two amalgamations among independent community health organisations from the state of Victoria, Australia, was conducted. This article explores the perceived effects of merging on (1) the pragmatic, normative and cognitive legitimacy of studied organisations and (2) the collective legitimacy of these organisations in Victoria's health care system. Data were collected through 19 semi-structured interviews with key informants and subjected to template and thematic analyses. FINDINGS: Merging enabled individual organisations to gain greater overall legitimacy as regional providers of comprehensive PHC services and thus retain some capacity to operationalise a social model of health. Normative legitimacy was most enhanced by merging, through acquisition of a large organisational size and adoption of business practices favoured by neoliberal norms. However, mergers may have destabilised the already contested cognitive legitimacy of community health services as a group of organisations and as a comprehensible state-wide platform of service delivery. PRACTICAL IMPLICATIONS: Over-reliance on individual organisational behaviour to maintain the legitimacy of comprehensive PHC as a model of organising health and social care could lead to inequities in access to such models across communities. ORIGINALITY/VALUE: This study shows that organisations can manage their perceived legitimacy in order to ensure the survival of their preferred model of service delivery.

A system dynamic perspective of stop-start prevention interventions in Australia.

Time-limited prevention initiatives are frequently used to address complex and persisting public health issues, such as non-communicable diseases. This often creates issues in terms of achieving sustainable change. In this study, we use a system dynamic perspective to explore the effects of stop-start funding over system behaviour in two community-based initiatives designed to prevent chronic diseases and obesity. We conducted a qualitative exploratory study using complexity theory as an analytical lens of two Healthy Together Communities (HTCs) initiatives in Victoria, Australia. Data were generated from 20 semi-structured interviews with health promotion practitioners and managers, from community health and local government organizations. Template analysis based on properties of complex systems informed the inductive identification of system behaviour narratives across the stop-start life-course of HTCs. A central narrative of system behaviour emerged around relationships. Within it, we identified pre-existing contextual conditions and intervention design elements that influenced non-linearity of system self-organization and adaptation, and emergence of outcomes. Examples include cynicism, personal relationships and trust, and history of collaboration. Feedback loops operated between HTCs and these conditions, in a way that could influence long-term system behaviour. Taking a dynamic life-course view of system behaviour helps understand the pre-existing contextual factors, design and implementation influences, and feedback loops which shape the long-term legacy of short-lived interventions aimed at solving complex issues. In turn, greater awareness of such interactions can inform better design and implementation of community-based interventions.

Together stronger: boundary work within an Australian systems-based prevention initiative.

Complexity and systems science are increasingly used to devise interventions to address health and social problems. Boundaries are important in systems thinking, as they bring attention to the power dynamics that guide decision-making around the framing of a situation, and how it is subsequently tackled. Using complexity theory as an analytical frame, this qualitative exploratory study examined boundary interactions between local government and community health organizations during the operationalization of a systems-based initiative to prevent obesity and chronic diseases (Healthy Together Communities-HTCs) in Victoria, Australia. Across two HTC sites, data was generated through semi-structured interviews with 20 key informants, in mid-2015. Template analysis based on properties of complex systems was applied to the data. The dynamics of boundary work are explored using three case illustrations: alignment, boundary spanning and boundary permeability. Alignment was both a process and an outcome of boundary work, and occurred at strategic, operational and individual levels. Boundary spanning was an important mechanism to develop a unified collaborative approach, and ensure that mainstream initiatives reached disadvantaged groups. Finally, some boundaries exhibited different levels of permeability for local government and community health organizations. This influenced how each organization could contribute to HTC interventions in unique, yet complementary ways. The study of boundary work offers potential for understanding the mechanisms that contribute to the nonlinear behaviour of complex systems. The complementarity of partnering organizations, and boundary dynamics should be considered when designing and operationalizing multilevel, complex systems-informed prevention initiatives.

Surviving neoliberalism, maintaining values: Community health mergers in Victoria, Australia.

PURPOSE: Independent, not-for-profit community health services in the state of Victoria, Australia, provide one of that country's few models of comprehensive primary health care (PHC). Recent amalgamations among some such agencies created regional-sized community health organisations, in a departure from this sector's traditionally small local structure. This study explored the motivations, desired outcomes, and decision-making process behind these mergers. METHODOLOGY: Qualitative exploratory study was based on 26 semistructured interviews with key informants associated with 2 community health mergers, which took place in 2014 in Victoria, Australia. Thematic data analysis was influenced by concepts derived from institutional theory. FINDINGS: Becoming bigger by merging was viewed as the best way to respond to mounting external pressures, such as increasingly neoliberal funding mechanisms, perceived as threatening survival. Desired outcomes were driven by comprehensive PHC values, and related to creating organisational capacity to continue providing quality services to disadvantaged communities. ORIGINALITY/VALUE: This study offers insights into decision-making processes geared towards protecting the comprehensiveness of PHC service delivery for disadvantaged communities, ensuring financial viability, and surviving neoliberal economic policy whilst preserving communitarian values. These are relevant to an international audience, within a global context of rising health inequities, increasingly tight fiscal environments, and growing neoliberal influences on health policymaking and funding.

Enhancing health-care workers' understanding and thinking about people living with co-occurring mental health and substance use issues through consumer-led training.

BACKGROUND: Stigma and judgemental assumptions by health workers have been identified as key barriers to accessing health care for people living with co-occurring mental health and substance use issues (dual diagnosis). OBJECTIVE: To evaluate the effectiveness of consumer-led training by people with dual diagnosis in improving the knowledge, understanding and role adequacy of community health staff to work with this consumer group. METHODS: A controlled before-and-after study design with four waves of quantitative data collection was used. Qualitative data were collected to explore participants' views about training. Participants were staff from two community health services from Victoria, Australia. Recruitment occurred across various work areas: reception, oral health, allied health, counselling and health promotion. At baseline, all participants attended a 4-h clinician-led training session. The intervention consisted of a 3-h consumer-led training session, developed and delivered by seven individuals living with dual diagnosis. Outcome measures included understanding of dual diagnosis, participants' feelings of role adequacy and role legitimacy, personal views, and training outcomes and relevance. RESULTS: Consumer-led training was associated with a significant increase in understanding. The combination of clinician-led and consumer-led training was associated with a positive change in role adequacy. CONCLUSIONS: Consumer-led training is a promising approach to enhance primary health-care workers' understanding of the issues faced by dual-diagnosis consumers, with such positive effects persisting over time. Used alongside other organizational capacity building strategies, consumer-led training has the potential to help address stigma and judgemental attitudes by health workers and improve access to services for this consumer group.

Service planning in the Victorian community health sector.

Until now, comprehensive service planning has been uncommon in the Victorian community health sector. Where it has occurred, it has primarily been undertaken by community health services embedded within larger, hospital-based health services. Reflections on the utility and efficacy of community health service planning are largely absent from the Australian peer-reviewed literature. Using a case study focussed on a specific centre in Melbourne's outer suburbs, this paper explores how community health service planning is shaped by the current policy context, the legal status of registered community health services, and the data and methodologies available to inform planning. It argues that regular and systematic service planning could support registered community health centres to better understand their unique position within the primary health-care landscape, having regard to their inherent opportunities and vulnerabilities. Furthermore, consistent and effective service planning is proposed to benefit agencies in establishing themselves as critical players in promoting local population health initiatives and driving improved health outcomes.