An analysis of policy success and failure in formal evaluations of Australia's national mental health strategy (1992-2012).

BACKGROUND: Heightened fiscal constraints, increases in the chronic disease burden and in consumer expectations are among several factors contributing to the global interest in evidence-informed health policy. The present article builds on previous work that explored how the Australian Federal Government applied five instruments of policy, or policy levers, to implement a series of reforms under the Australian National Mental Health Strategy (NMHS). The present article draws on theoretical insights from political science to analyse the relative successes and failures of these levers, as portrayed in formal government evaluations of the NMHS. METHODS: Documentary analysis of six evaluation documents corresponding to three National Mental Health Plans was undertaken. Both the content and approach of these government-funded, independently conducted evaluations were appraised. RESULTS: An overall improvement was apparent in the development and application of policy levers over time. However, this finding should be interpreted with caution due to variations in evaluation approach according to Plan and policy lever. Tabulated summaries of the success and failure of each policy initiative, ordered by lever type, are provided to establish a resource that could be consulted for future policy-making. CONCLUSIONS: This analysis highlights the complexities of health service reform and underscores the limitations of narrowly focused empirical approaches. A theoretical framework is provided that could inform the evaluation and targeted selection of appropriate policy levers in mental health.

How do we define the policy impact of public health research? A systematic review.

BACKGROUND: In order to understand and measure the policy impact of research we need a definition of research impact that is suited to the task. This article systematically reviewed both peer-reviewed and grey literature for definitions of research impact to develop a definition of research impact that can be used to investigate how public health research influences policy. METHOD: Keyword searches of the electronic databases Web of Science, ProQuest, PubMed, EMBASE, CINAHL, Informit, PsycINFO, The Cochrane Database of Systematic Reviews and Google Scholar were conducted between August 2015 and April 2016. Keywords included 'definition' and 'policy' and 'research impact' or 'research evidence'. The search terms 'health', public health' or 'mental health' and 'knowledge transfer' or 'research translation' were used to focus the search on relevant health discipline approaches. Studies included in the review described processes, theories or frameworks associated with public health, health services or mental health policy. RESULTS: We identified 108 definitions in 83 publications. The key findings were that literature on research impact is growing, but only 23% of peer-reviewed publications on the topic explicitly defined the term and that the majority (76%) of definitions were derived from research organisations and funding institutions. We identified four main types of definition, namely (1) definitions that conceptualise research impacts in terms of positive changes or effects that evidence can bring about when transferred into policies (example Research Excellence Framework definition), (2) definitions that interpret research impacts as measurable outcomes (Research Councils UK), and (3) bibliometric and (4) use-based definitions. We identified four constructs underpinning these definitions that related to concepts of contribution, change, avenues and levels of impact. CONCLUSION: The dominance of bureaucratic definitions, the tendency to discuss but not define the concept of research impact, and the heterogeneity of definitions confirm the need for conceptual clarity in this area. We propose a working definition of research impact that can be used in a range of health policy contexts.

An analysis of policy levers used to implement mental health reform in Australia 1992-2012.

BACKGROUND: Over the past two decades, mental health reform in Australia has received unprecedented government attention. This study explored how five policy levers (organisation, regulation, community education, finance and payment) were used by the Australian Federal Government to implement mental health reforms. METHODS: Australian Government publications, including the four mental health plans (published in 1992, 1998, 2003 and 2008) were analysed according to policy levers used to drive reform across five priority areas: [1] human rights and community attitudes; [2] responding to community need; [3] service structures; [4] service quality and effectiveness; and [5] resources and service access. RESULTS: Policy levers were applied in varying ways; with two or three levers often concurrently used to implement a single initiative or strategy. For example, changes to service structures were achieved using various combinations of all five levers. Attempts to improve service quality and effectiveness were instead made through a single lever-regulation. The use of some levers changed over time, including a move away from prescriptive, legislative use of regulation, towards a greater focus on monitoring service standards and consumer outcomes. CONCLUSIONS: Patterns in the application of policy levers across the National Mental Health Strategy, as identified in this analysis, represent a novel way of conceptualising the history of mental health reform in Australia. An improved understanding of the strategic targeting and appropriate utilisation of policy levers may assist in the delivery and evaluation of evidence-based mental health reform in the future.

Factors influencing women's decisions to drink alcohol during pregnancy: findings of a qualitative study with implications for health communication.

BACKGROUND: Despite Australian guidelines advising abstinence from alcohol during pregnancy, a relatively high number of Australian women continue to drink alcohol while pregnant. While some call for greater advocacy of the need for abstinence, others have expressed concern that abstinence messages may be harmful to pregnant women and their unborn babies due to the anxiety they could provoke. We present findings on women's deliberations over drinking alcohol during pregnancy, particularly their emotional dimensions, to inform debates about public health messages and practitioner-patient discussions regarding alcohol use during pregnancy. METHODS: Semi-structured face-to-face interviews were conducted with 40 women in their homes. Our sample comprised women aged 34-39, drawn from the Australian Longitudinal Study on Women's Health, living in the Greater Brisbane Area who were pregnant, or had recently given birth, in 2009. An inductive qualitative framework analysis approach was used to identify and interpret themes explaining why pregnant women choose to drink or not. RESULTS: Women generally described drinking small amounts of alcohol during pregnancy as being a low risk activity and talked about the importance of alcohol to their social lives as a reason for continuing to drink or finding abstinence a burden; sensitisation to the judgements of others was not widespread. Women predominantly assessed the risk of their drinking in terms of the kinds of alcoholic beverages consumed rather than alcohol content. In reflecting on the advice they recalled receiving, women described their healthcare practitioners as being relaxed about the risks of alcohol consumption. CONCLUSIONS: The significance of alcohol to women's identity appeared to be an important reason for continued alcohol use during pregnancy among otherwise risk averse women. Anxiety about alcohol consumption during pregnancy was not widespread. However, obstetricians were an important mediator of this. Health messages that dispel the notion that wine is a "healthy" choice of alcoholic beverage, that provide women with strategies to help them avoid drinking, that advise the broader public not to pressure women to drink if they do not want to, and educate women about the effects of ethanol on maternal and fetal bodies, should be considered.

A cohort profile of children and adolescents who had a suicide-related contact with police or paramedics in Queensland (Australia).

OBJECTIVE: Suicide is a leading cause of death in children and adolescents worldwide and a major public health concern. While suicidal behaviours place a significant demand on mental health and emergency services, data regarding suicide-related contacts with police and paramedics are an underutilised resource. The aim of the present study was to identify the demographic profile of young individuals (aged 5-17) and had a suicide-related contact with police or paramedics in Queensland (Australia). METHODS: The present study utilised a population-wide linked dataset, including data from police and paramedics and health administrative data, between 1 February 2013 and 31 January 2018. RESULTS: The identified cohort of 7929 children had a median age of 15 years and mainly comprised females (63.2%). Over the study period, 64 children died, most by suicide (76.6%). Less than a third of the cohort were responsible for almost two-thirds of the total number of contacts with police or paramedics. CONCLUSION: Findings provide a comprehensive profile of children and adolescents in suicidal crisis and highlight the substantial number of interactions that occur with police and paramedics. Due to the way the linked dataset was constructed, it must be assumed that the number of young persons in suicidal crisis is higher. Findings highlight the value of considering pre-hospital alternatives to presenting to emergency departments (EDs) for this cohort, to reduce impost on EDs and improve outcomes. Further examination of re-presentations by young persons is warranted to inform prevention and intervention strategies.

Can automated content analysis be used to assess and improve the use of evidence in mental health policy? A systematic review.

BACKGROUND: This review assesses the utility of applying an automated content analysis method to the field of mental health policy development. We considered the possibility of using the Wordscores algorithm to assess research and policy texts in ways that facilitate the uptake of research into mental health policy. METHODS: The PRISMA framework and the McMaster appraisal tools were used to systematically review and report on the strengths and limitations of the Wordscores algorithm. Nine electronic databases were searched for peer-reviewed journal articles published between 2003 and 2016. Inclusion criteria were (1) articles had to be published in public health, political science, social science or health services disciplines; (2) articles had to be research articles or opinion pieces that used Wordscores; and (3) articles had to discuss both strengths and limitations of using Wordscores for content analysis. RESULTS: The literature search returned 118 results. Twelve articles met the inclusion criteria. These articles explored a range of policy questions and appraised different aspects of the Wordscores method. DISCUSSION: Following synthesis of the material, we identified the following as potential strengths of Wordscores: (1) the Wordscores algorithm can be used at all stages of policy development; (2) it is valid and reliable; (3) it can be used to determine the alignment of health policy drafts with research evidence; (4) it enables existing policies to be revised in the light of research; and (5) it can determine whether changes in policy over time were supported by the evidence. Potential limitations identified were (1) decreased accuracy with short documents, (2) words constitute the unit of analysis and (3) expertise is needed to choose 'reference texts'. CONCLUSIONS: Automated content analysis may be useful in assessing and improving the use of evidence in mental health policies. Wordscores is an automated content analysis option for comparing policy and research texts that could be used by both researchers and policymakers.

Developing a service platform definition to promote evidence-based planning and funding of the mental health service system.

Ensuring that a mental health system provides 'value for money' requires policy makers to allocate resources to the most cost-effective interventions. Organizing cost-effective interventions into a service delivery framework will require a concept that can guide the mapping of evidence regarding disorder-level interventions to aggregations of services that are meaningful for policy makers. The 'service platform' is an emerging concept that could be used to this end, however no explicit definition currently exists in the literature. The aim of this study was to develop a service platform definition that is consistent with how policy makers conceptualize the major elements of the mental health service system and to test the validity and utility of this definition through consultation with mental health policy makers. We derived a provisional definition informed by existing literature and consultation with experienced mental health researchers. Using a modified Delphi method, we obtained feedback from nine Australian policy makers. Respondents provided written answers to a questionnaire eliciting their views on the acceptability, comprehensibility and usefulness of a service platform definition which was subject to qualitative analysis. Overall, respondents understood the definition and found it both acceptable and useful, subject to certain conditions. They also provided suggestions for its improvement. Our findings suggest that the service platform concept could be a useful way of aggregating mental health services as a means for presenting priority setting evidence to policy makers in mental health. However, further development and testing of the concept is required.