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1.  Development and evaluation of a youth mental health community awareness campaign – The Compass Strategy 
BMC Public Health  2006;6:215.
Early detection and treatment of mental disorders in adolescents and young adults can lead to better health outcomes. Mental health literacy is a key to early recognition and help seeking. Whilst a number of population health initiatives have attempted to improve mental health literacy, none to date have specifically targeted young people nor have they applied the rigorous standards of population health models now accepted as best practice in other health areas. This paper describes the outcomes from the application of a health promotion model to the development, implementation and evaluation of a community awareness campaign designed to improve mental health literacy and early help seeking amongst young people.
The Compass Strategy was implemented in the western metropolitan Melbourne and Barwon regions of Victoria, Australia. The Precede-Proceed Model guided the population assessment, campaign strategy development and evaluation. The campaign included the use of multimedia, a website, and an information telephone service. Multiple levels of evaluation were conducted. This included a cross-sectional telephone survey of mental health literacy undertaken before and after 14 months of the campaign using a quasi-experimental design. Randomly selected independent samples of 600 young people aged 12–25 years from the experimental region and another 600 from a comparison region were interviewed at each time point. A series of binary logistic regression analyses were used to measure the association between a range of campaign outcome variables and the predictor variables of region and time.
The program was judged to have an impact on the following variables, as indicated by significant region-by-time interaction effects (p < 0.05): awareness of mental health campaigns, self-identified depression, help for depression sought in the previous year, correct estimate of prevalence of mental health problems, increased awareness of suicide risk, and a reduction in perceived barriers to help seeking. These effects may be underestimated because media distribution error resulted in a small amount of print material "leaking" into the comparison region.
We believe this is the first study to apply the rigorous standards of a health promotion model including the use of a control region to a mental health population intervention. The program achieved many of its aims despite the relatively short duration and moderate intensity of the campaign.
PMCID: PMC1564138  PMID: 16923195
2.  Coeur en santé St-Henri--a heart health promotion programme in a low income, low education neighbourhood in Montreal, Canada: theoretical model and early field experience. 
STUDY OBJECTIVE--Coeur en santé St-Henri is a five year, community based, multifactorial, heart health promotion programme in a low income, low education neighbourhood in Montreal, Canada. The objectives of this programme are to improve heart-healthy behaviours among adults of St-Henri. This paper describes the theoretical model underlying programme development as well as our early field experience implementing interventions. DESIGN--The design of the intervention programme is based on a behaviour change model adapted from social learning theory, the reasoned action model, and the precede-proceed model. The Ottawa charter for health promotion provided the framework for the development of specific interventions. Each intervention is submitted to formative, implementation, and impact evaluations using simple and inexpensive methods. PARTICIPANTS--The target population consists of adults living in St-Henri, a neighbourhood of 23,360 residents. Because of costs constraints, the intervention strategy targets women more specifically. The community is one of the poorest in Canada with 46% of the population living below the poverty line and 20% being very poor. The age-sex adjusted ischaemic heart disease mortality in 1985-87 was 317 per 100,000 compared with 126 per 100,000 in an affluent adjacent neighbourhood. RESULTS--Thirty nine distinct interventions have been developed and tested in the community, eight related to tobacco, 10 to diet, seven to physical activity, and 14 which are multifactorial. The interventions include smoking cessation and healthy recipes contests, a menu labelling and healthy food discount programme in restaurants, a point of choice nutrition education campaign, healthy eating and smoking cessation workshops, a walking club, educational material, print and electronic media campaigns, heart health fairs, and community events. CONCLUSION--An integrated heart health promotion programme is feasible in low income urban neighbourhoods but not all interventions are successful. Such a programme requires substantial energy and resources as well as long term commitment from public health departments.
PMCID: PMC1060155  PMID: 7499994
3.  Supporting Self-Care for Families of Children With Eczema With a Web-Based Intervention Plus Health Care Professional Support: Pilot Randomized Controlled Trial 
Childhood eczema, or childhood atopic dermatitis, causes significant distress to children and their families through sleep disturbance and itch. The main cause of treatment failure is nonuse of prescribed treatments.
The objective of this study was to develop and test a Web-based intervention to support families of children with eczema, and to explore whether support from a health care professional (HCP) is necessary to engage participants with the intervention.
We followed the PRECEDE-PROCEED model: regular emollient use was the target behavior we were seeking to promote and we identified potential techniques to influence this. LifeGuide software was used to write the intervention website. Carers of children with eczema were invited through primary care mail-out and randomized to 3 groups: (1) website only, (2) website plus HCP support, or (3) usual care. Patient-Oriented Eczema Measure (POEM) scores were measured online by carer report at baseline and at 12 weeks. Qualitative interviews were carried out with 13 HCPs (primarily practice nurses) and 26 participants to explore their experiences of taking part in the study.
A total of 143 carers were recruited through 31 practices. We found a decrease of ≥2 in follow-up compared with baseline POEM score in 23 of 42 (55%) participants in the website only group, 16 of 49 (33%) in the usual care group, and 18 of 47 (38%) in the website plus HCP group. Website use data showed that 75 of 93 (81%) participants allocated to the website groups completed the core modules, but less than half used other key components (videos: 35%; regular text reminders: 39%). There were no consistent differences in website use between the website only or the website plus HCP groups. Qualitative feedback showed that most HCPs had initial concerns about providing support for eczema self-care because this was not a condition that they felt expert in. However, HCPs reported productive consultations and that they found it helpful to use the website in consultations, while observing that some participants seemed to need more support than others. Qualitative interviews with participants suggested that HCP support was valued highly only by a minority, generally those who were less confident in their management of eczema or less confident using the Internet.
Our pilot trial demonstrated the potential for greater improvements in POEM scores in both website intervention groups and that a full-scale trial is feasible. Such a trial would quantify the effectiveness and cost-effectiveness of this intervention to determine whether it should be widely promoted to families of children with newly diagnosed eczema. In this study population, HCP support was not strongly valued by participants and did not lead to better outcomes or website use than use of the Web-based intervention alone.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 98560867; (Archived by WebCite at
PMCID: PMC3961807  PMID: 24594972
child; primary care; randomized controlled trial; eczema; Internet; self-care
4.  The PRECEDE-PROCEED model: application to planning a child pedestrian injury prevention program. 
Injury Prevention  1997;3(4):282-287.
OBJECTIVES: The objectives were first, to modify the PRECEDE-PROCEED model and to use it is as a basis for planning a three year intervention trial that aims to reduce injury to child pedestrians. A second objective was to assess the suitability of this process for planning such a relatively complex program. SETTING: The project was carried out in 47 primary schools in three local government areas, in the Perth metropolitan area. METHODS: The program was developed, based on extensive needs assessment incorporating formative evaluations. Epidemiological, psychosocial, environmental, educational, and demographic information was gathered, organised, and prioritised. The PRECEDE-PROCEED model was used to identify the relevant behavioural and environmental risk factors associated with child pedestrian injuries in the target areas. Modifiable causes of those behavioural and environmental factors were delineated. A description of how the model facilitated the development of program objectives and subobjectives which were linked to strategy objectives, and strategies is provided. RESULTS: The process used to plan the child pedestrian injury prevention program ensured that a critical assessment was undertaken of all the relevant epidemiological, behavioural, and environmental information. The gathering, organising, and prioritising of the information was facilitated by the process. CONCLUSIONS: The use of a model such as PRECEDE-PROCEED can enhance the development of a child injury prevention program. In particular, the process can facilitate the identification of appropriate objectives which in turn facilitates the development of suitable interventions and evaluation methods.
PMCID: PMC1067855  PMID: 9493625
5.  The role of information technology in translating educational interventions into practice: an analysis using the PRECEDE/PROCEED model 
The evidence base for information technology (IT) has been criticized, especially with the current emphasis on translational science. The purpose of this paper is to present an analysis of the role of IT in the implementation of a geriatric education and quality improvement (QI) intervention.
A mixed-method three-group comparative design was used. The PRECEDE/PROCEED implementation model was used to qualitatively identify key factors in the implementation process. These results were further explored in a quantitative analysis.
Thirty-three primary care clinics at three institutions (Intermountain Healthcare, VA Salt Lake City Health Care System, and University of Utah) participated. The program consisted of an onsite, didactic session, QI planning and 6 months of intense implementation support.
Completion rate was 82% with an average improvement rate of 21%. Important predisposing factors for success included an established electronic record and a culture of quality. The reinforcing and enabling factors included free continuing medical education credits, feedback, IT access, and flexible support. The relationship between IT and QI emerged as a central factor. Quantitative analysis found significant differences between institutions for pre–post changes even after the number and category of implementation strategies had been controlled for.
The analysis illustrates the complex dependence between IT interventions, institutional characteristics, and implementation practices. Access to IT tools and data by individual clinicians may be a key factor for the success of QI projects. Institutions vary widely in the degree of access to IT tools and support. This article suggests that more attention be paid to the QI and IT department relationship.
PMCID: PMC3197988  PMID: 21571745
Electronic health records; medical informatics; adoption; evaluation studies; education; medical; continuing; cognitive study; uncertain reasoning and decision theory; process modeling and hypothesis generation; knowledge acquisition and knowledge management; information storage and retrieval (text and images); machine learning; implementation
6.  Development of a Rheumatoid Arthritis Education Program using the PRECEDE_PROCEED Model 
Health Promotion Perspectives  2011;1(2):118-129.
Background: In order to help rheumatoid arthritis (RA) patients in carrying out and at­taining relevant self-care behaviors and adaptation to the physical limitations of this dis­ease and, conse­quently, promoting their level of health status, an education program based on the PRECEDE component of the PRECEDE–PROCEED model targeting patients with RA was developed. This paper describes the planning of a RA Patient Education Program (RAPEP) designed to promote their quality of life.
Methods: The development of the program began with a comprehensive review of the li­terature. This included a review of the signs and symptoms of RA, accompanying func­tional disabilities, previous educational programs and the effect of the disease on the pa­tient’s quality of life. Be­sides, in order to help inform RAPEP program development, and organize the survey according to the factors identified in the PRECEDE model a cross-sectional survey was applied on a non-prob­ability sample of 181 outpatients in Yazd, center of Iran.
Results: The quality of life (QOL) problem identified was the considerable low role func­tioning, health perception and physical functioning due to chronic pain. One of the most significant modi­fiable behavioral factors impacting pain and functional limitations was self-care behaviors in RA patients. Higher level of knowledge, attitude, self-efficacy, enabling factors and social support is associated with better self-care behavior.
Conclusions: The PRECEDE component of the PRECEDE–PROCEED model provided a com­prehensive conceptual framework for the development of RAPEP aiming at RA pa­tients in Yazd. Further research to evaluate this educational program is suggested.
PMCID: PMC3963622  PMID: 24688908
Rheumatoid Arthritis; Educational Program; PRECEDE Model
7.  Medical community involvement in a breast cancer screening promotional project. 
Public Health Reports  1994;109(4):491-499.
The analysis, mobilization, and involvement of medical communities in two counties targeted for intervention by the Washington State Community Breast Cancer Screening Project is described. Principles of community organization were applied to the health care sectors in the counties, and the PRECEDE-PROCEED model was used as a conceptual framework for considering individual physician behavior. Quantitative and qualitative medical community assessment methods included a demographic study, a survey of primary care physicians, personal interviews with physicians, and medical office staff focus groups. In both intervention areas, physician planning groups selected, developed, and helped implement intervention activities targeting the health care sectors. These activities included informational mailings to physicians, training of medical office staff members and clinical mammographers, and support for a reminder system. The experience demonstrated that physicians practicing in medium-sized cities are willing to be active in community disease prevention programs.
PMCID: PMC1403525  PMID: 8041848
8.  Just regionalisation: rehabilitating care for people with disabilities and chronic illnesses 
BMC Medical Ethics  2006;7:9.
Regionalised models of health care delivery have important implications for people with disabilities and chronic illnesses yet the ethical issues surrounding disability and regionalisation have not yet been explored. Although there is ethics-related research into disability and chronic illness, studies of regionalisation experiences, and research directed at improving health systems for these patient populations, to our knowledge these streams of research have not been brought together. Using the Canadian province of Ontario as a case study, we address this gap by examining the ethics of regionalisation and the implications for people with disabilities and chronic illnesses. The critical success factors we provide have broad applicability for guiding and/or evaluating new and existing regionalised health care strategies.
Ontario is in the process of implementing fourteen Local Health Integration Networks (LHINs). The implementation of the LHINs provides a rare opportunity to address systematically the unmet diverse care needs of people with disabilities and chronic illnesses. The core of this paper provides a series of composite case vignettes illustrating integration opportunities relevant to these populations, namely: (i) rehabilitation and services for people with disabilities; (ii) chronic illness and cancer care; (iii) senior's health; (iv) community support services; (v) children's health; (vi) health promotion; and (vii) mental health and addiction services. For each vignette, we interpret the governing principles developed by the LHINs – equitable access based on patient need, preserving patient choice, responsiveness to local population health needs, shared accountability and patient-centred care – and describe how they apply. We then offer critical success factors to guide the LHINs in upholding these principles in response to the needs of people with disabilities and chronic illnesses.
This paper aims to bridge an important gap in the literature by examining the ethics of a new regionalisation strategy with a focus on the implications for people with disabilities and chronic illnesses across multiple sites of care. While Ontario is used as a case study to contextualize our discussion, the issues we identify, the ethical principles we apply, and the critical success factors we provide have broader applicability for guiding and evaluating the development of – or revisions to – a regionalised health care strategy.
PMCID: PMC1569849  PMID: 16939654
9.  The Effect of an Intervention Based on the PRECEDE- PROCEED Model on Preventive Behaviors of Domestic Violence Among Iranian High School Girls 
Domestic violence is one of the major health problems among women. Promoting preventive behaviors of domestic violence among women and girls can play crucial role in reducing this health problem.
This study was conducted to evaluate the effect of an intervention based on PRECEDE-PROCEED Model on preventive behaviors of domestic violence among Iranian high school girls.
Patients and Methods
An interventional study was completed during 2010-2011 in 10 high schools in the district 17 of Tehran municipality with 510 female students. We used the components of the PRECEDE-PROCEED Model for planning, implementation and evaluation of the program. Based on the results of need assessment, an appropriate environmental and educational intervention was implemented in the intervention group. Changes in predisposing, reinforcing, enabling factors and especially preventive behaviors immediately and two months after the intervention activities were assessed by questionnaires based on PRECEDE-PROCEED Model.
The intervention had significantly positive effect on predisposing, enabling and reinforcing factors immediately and two months after the intervention (P < 0.05). Repeated measures Analysis of variance showed a significant positive increase in preventive behaviors score in the intervention group from baseline to two months.
The PRECEDE-PROCEED Model can be applied as a conceptual framework for identifying the relevant behavioral and environmental risk factors associated with domestic violence. Development and implementation the skills-based education using this model can lead to the promotion of preventive behaviors of domestic violence and reduction in domestic violence cases.
PMCID: PMC3589774  PMID: 23486646
Domestic Violence; Health Education; Health Promotion; Iran
10.  There’s an App for That: Content Analysis of Paid Health and Fitness Apps 
The introduction of Apple’s iPhone provided a platform for developers to design third-party apps, which greatly expanded the functionality and utility of mobile devices for public health.
This study provides an overview of the developers’ written descriptions of health and fitness apps and appraises each app’s potential for influencing behavior change.
Data for this study came from a content analysis of health and fitness app descriptions available on iTunes during February 2011. The Health Education Curriculum Analysis Tool (HECAT) and the Precede-Proceed Model (PPM) were used as frameworks to guide the coding of 3336 paid apps.
Compared to apps with a cost less than US $0.99, apps exceeding US $0.99 were more likely to be scored as intending to promote health or prevent disease (92.55%, 1925/3336 vs 83.59%, 1411/3336; P<.001), to be credible or trustworthy (91.11%, 1895/3336 vs 86.14%, 1454/3349; P<.001), and more likely to be used personally or recommended to a health care client (72.93%, 1517/2644 vs 66.77%, 1127/2644; P<.001). Apps related to healthy eating, physical activity, and personal health and wellness were more common than apps for substance abuse, mental and emotional health, violence prevention and safety, and sexual and reproductive health. Reinforcing apps were less common than predisposing and enabling apps. Only 1.86% (62/3336) of apps included all 3 factors (ie, predisposing, enabling, and reinforcing).
Development efforts could target public health behaviors for which few apps currently exist. Furthermore, practitioners should be cautious when promoting the use of apps as it appears most provide health-related information (predisposing) or make attempts at enabling behavior, with almost none including all theoretical factors recommended for behavior change.
PMCID: PMC3799565  PMID: 22584372
mHealth; iPhone; app
11.  Factors influencing performance of health workers in the management of seriously sick children at a Kenyan tertiary hospital - participatory action research 
Implementation of World Health Organization case management guidelines for serious childhood illnesses remains a challenge in hospitals in low-income countries. Facilitators of and barriers to implementation of locally adapted clinical practice guidelines (CPGs) have not been explored.
This ethnographic study based on the theory of participatory action research (PAR) was conducted in Kenyatta National Hospital, Kenya’s largest teaching hospital. The primary intervention consisted of dissemination of locally adapted CPGs. The PRECEDE-PROCEED health education model was used as the conceptual framework to guide and examine further reinforcement activities to improve the uptake of the CPGs. Activities focussed on introduction of routine clinical audits and tailored educational sessions. Data were collected by a participant observer who also facilitated the PAR over an eighteen-month period. Naturalistic inquiry was utilized to obtain information from all hospital staff encountered while theoretical sampling allowed in-depth exploration of emerging issues. Data were analysed using interpretive description.
Relevance of the CPGs to routine work and emergence of a champion of change facilitated uptake of best-practices. Mobilization of basic resources was relatively easily undertaken while activities that required real intellectual and professional engagement of the senior staff were a challenge. Accomplishments of the PAR were largely with the passive rather than active involvement of the hospital management. Barriers to implementation of best-practices included i) mismatch between the hospital’s vision and reality, ii) poor communication, iii) lack of objective mechanisms for monitoring and evaluating quality of clinical care, iv) limited capacity for planning strategic change, v) limited management skills to introduce and manage change, vi) hierarchical relationships, and vii) inadequate adaptation of the interventions to the local context.
Educational interventions, often regarded as ‘quick-fixes’ to improve care in low-income countries, may be necessary but are unlikely to be sufficient to deliver improved services. We propose that an understanding of organizational issues that influence the behaviour of individual health professionals should guide and inform the implementation of best-practices.
PMCID: PMC3942276  PMID: 24507629
Clinical audits; Clinical practice guidelines; Continuous medical educational sessions; ETAT+; Ethnographic study; Implementation of best-practices; Interpretive description; Participatory action research; Participant observer; Performance of health workers
12.  Physicians Taking Action Against Smoking: an intervention program to optimize smoking cessation counselling by Montreal general practitioners 
In 1997 the Direction del la santé publique de Montréal-Centre initiated “Physicians Taking Action Against Smoking,” a 5-year intervention program to improve the smoking cessation counselling practices of general practitioners (GPs) in Montreal. Program development was guided by the precede-proceed model. This model advocates identifying factors influencing the outcome, in this case counselling practices. These factors are then used to determine the program objectives, to develop and tailor program activities and to design the evaluation. Program activities during the first 3 years included cessation counselling workshops and conferences for GPs, publication of articles in professional interest journals, publication of clinical guidelines for smoking cessation counselling and dissemination of educational material for both GPs and smokers. The program also supported activities encouraging smokers to ask their GPs to help them stop smoking. Results from 2 cross-sectional surveys, conducted in 1998 and 2000, of random samples of approximately 300 GPs suggest some improvements over time in several counselling practices, including offering counselling to more patients and discussing setting a quit date. More improvements were observed among female than male GPs in both psychosocial factors related to counselling and specific counselling practices. For example, improvements were noted among female GPs in self-perceived ability to provide effective counselling and in the belief that it is important to schedule specific appointments to help patients quit; in addition, the perceived importance of several barriers to counselling decreased among female GPs. A greater proportion of the female respondents to the 2000 survey offered written educational material than was the case in 1998, and a greater proportion of the male GPs devoted more time to counselling in 2000 than in 1998; however, among male GPs the proportion who discussed the pros and cons of smoking with patients in the precontemplation stage declined between 1998 and 2000, as did the proportion who referred patients in the preparation stage to community resources. Our experience suggests that an integrated, theory-based program to improve physicians' counselling practices could be a key component of a comprehensive strategy to reduce tobacco use.
PMCID: PMC81419  PMID: 11563213
13.  Using prediction to improve elective surgery scheduling 
The Australasian Medical Journal  2013;6(5):287-289.
An ageing population and higher rates of chronic disease increase the demand on health services. The Australian Institute of Health and Welfare reports a 3.6% per year increase in total elective surgery admissions over the past four years.1 The newly introduced National Elective Surgery Target (NEST) stresses the need for efficiency and necessitates the development of improved planning and scheduling systems in hospitals.
To provide an overview of the challenges of elective surgery scheduling and develop a prediction based methodology to drive optimal management of scheduling processes.
Our proposed two stage methodology initially employs historic utilisation data and current waiting list information to manage case mix distribution. A novel algorithm uses current and past perioperative information to accurately predict surgery duration. A NEST-compliance guided optimisation algorithm is then used to drive allocation of patients to the theatre schedule.
It is expected that the resulting improvement in scheduling processes will lead to more efficient use of surgical suites, higher productivity, and lower labour costs, and ultimately improve patient outcomes.
Accurate prediction of workload and surgery duration, retrospective and current waitlist as well as perioperative information, and NEST-compliance driven allocation of patients are employed by our proposed methodology in order to deliver further improvement to hospital operating facilities.
PMCID: PMC3674420  PMID: 23745150
Surgery scheduling; Predictive optimisation; Waiting list
14.  Developing a good practice model to evaluate the effectiveness of comprehensive primary health care in local communities 
BMC Family Practice  2014;15:99.
This paper describes the development of a model of Comprehensive Primary Health Care (CPHC) applicable to the Australian context. CPHC holds promise as an effective model of health system organization able to improve population health and increase health equity. However, there is little literature that describes and evaluates CPHC as a whole, with most evaluation focusing on specific programs. The lack of a consensus on what constitutes CPHC, and the complex and context-sensitive nature of CPHC are all barriers to evaluation.
The research was undertaken in partnership with six Australian primary health care services: four state government funded and managed services, one sexual health non-government organization, and one Aboriginal community controlled health service. A draft model was crafted combining program logic and theory-based approaches, drawing on relevant literature, 68 interviews with primary health care service staff, and researcher experience. The model was then refined through an iterative process involving two to three workshops at each of the six participating primary health care services, engaging health service staff, regional health executives and central health department staff.
The resultant Southgate Model of CPHC in Australia model articulates the theory of change of how and why CPHC service components and activities, based on the theory, evidence and values which underpin a CPHC approach, are likely to lead to individual and population health outcomes and increased health equity. The model captures the importance of context, the mechanisms of CPHC, and the space for action services have to work within. The process of development engendered and supported collaborative relationships between researchers and stakeholders and the product provided a description of CPHC as a whole and a framework for evaluation. The model was endorsed at a research symposium involving investigators, service staff, and key stakeholders.
The development of a theory-based program logic model provided a framework for evaluation that allows the tracking of progress towards desired outcomes and exploration of the particular aspects of context and mechanisms that produce outcomes. This is important because there are no existing models which enable the evaluation of CPHC services in their entirety.
PMCID: PMC4038362  PMID: 24885812
15.  Physical activity and nutrition program for seniors (PANS): protocol of a randomized controlled trial 
BMC Public Health  2010;10:751.
Along with reduced levels of physical activity, older Australian's mean energy consumption has increased. Now over 60% of older Australians are considered overweight or obese. This study aims to confirm if a low-cost, accessible physical activity and nutrition program can improve levels of physical activity and diet of insufficiently active 60-70 year-olds.
This 12-month home-based randomised controlled trial (RCT) will consist of a nutrition and physical activity intervention for insufficiently active people aged 60 to 70 years from low to medium socio-economic areas. Six-hundred participants will be recruited from the Australian Federal Electoral Role and randomly assigned to the intervention (n = 300) and control (n = 300) groups. The study is based on the Social Cognitive Theory and Precede-Proceed Model, incorporating voluntary cooperation and self-efficacy. The intervention includes a specially designed booklet that provides participants with information and encourages dietary and physical activity goal setting. The booklet will be supported by an exercise chart, calendar, bi-monthly newsletters, resistance bands and pedometers, along with phone and email contact. Data will be collected over three time points: pre-intervention, immediately post-intervention and 6-months post-study.
This trial will provide valuable information for community-based strategies to improve older adults' physical activity and dietary intake. The project will provide guidelines for appropriate sample recruitment, and the development, implementation and evaluation of a minimal intervention program, as well as information on minimising barriers to participation in similar programs.
Trial Registration
Australian and New Zealand Clinical Trials Registry ACTRN12609000735257
PMCID: PMC3016383  PMID: 21129226
16.  Tailoring a family-based alcohol intervention for Aboriginal Australians, and the experiences and perceptions of health care providers trained in its delivery 
BMC Public Health  2014;14:322.
Aboriginal Australians experience a disproportionately high burden of alcohol-related harm compared to the general Australian population. Alcohol treatment approaches that simultaneously target individuals and families offer considerable potential to reduce these harms if they can be successfully tailored for routine delivery to Aboriginal Australians. The Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT) are two related interventions that are consistent with Aboriginal Australians’ notions of health and wellbeing. This paper aims to describe the process of tailoring CRA and CRAFT for delivery to Aboriginal Australians, explore the perceptions of health care providers participating in the tailoring process, and their experiences of participating in CRA and CRAFT counsellor certification.
Data sources included notes recorded from eight working group meetings with 22 health care providers of a drug and alcohol treatment agency and Aboriginal Community Controlled Health Service (November 2009-February 2013), and transcripts of semi-structured interviews with seven health care providers participating in CRA and CRAFT counsellor certification (May 2012). Qualitative content analysis was used to categorise working group meeting notes and interview transcripts were into key themes.
Modifying technical language, reducing the number of treatment sessions, and including an option for treatment of clients in groups, were key recommendations by health care providers for improving the feasibility and applicability of delivering CRA and CRAFT to Aboriginal Australians. Health care providers perceived counsellor certification to be beneficial for developing their skills and confidence in delivering CRA and CRAFT, but identified time constraints and competing tasks as key challenges.
The tailoring process resulted in Aboriginal Australian-specific CRA and CRAFT resources. The process also resulted in the training and certification of health care providers in CRA and CRAFT and the establishment of a local training and certification program.
PMCID: PMC3996136  PMID: 24708838
Indigenous; Aboriginal; Alcohol; Intervention; CRA; CRAFT; Tailor
17.  Cost-Effectiveness of a Telephone-Delivered Intervention for Physical Activity and Diet 
PLoS ONE  2009;4(9):e7135.
Given escalating rates of chronic disease, broad-reach and cost-effective interventions to increase physical activity and improve dietary intake are needed. The cost-effectiveness of a Telephone Counselling intervention to improve physical activity and diet, targeting adults with established chronic diseases in a low socio-economic area of a major Australian city was examined.
Methodology/Principal Findings
A cost-effectiveness modelling study using data collected between February 2005 and November 2007 from a cluster-randomised trial that compared Telephone Counselling with a “Usual Care” (brief intervention) alternative. Economic outcomes were assessed using a state-transition Markov model, which predicted the progress of participants through five health states relating to physical activity and dietary improvement, for ten years after recruitment. The costs and health benefits of Telephone Counselling, Usual Care and an existing practice (Real Control) group were compared. Telephone Counselling compared to Usual Care was not cost-effective ($78,489 per quality adjusted life year gained). However, the Usual Care group did not represent existing practice and is not a useful comparator for decision making. Comparing Telephone Counselling outcomes to existing practice (Real Control), the intervention was found to be cost-effective ($29,375 per quality adjusted life year gained). Usual Care (brief intervention) compared to existing practice (Real Control) was also cost-effective ($12,153 per quality adjusted life year gained).
This modelling study shows that a decision to adopt a Telephone Counselling program over existing practice (Real Control) is likely to be cost-effective. Choosing the ‘Usual Care’ brief intervention over existing practice (Real Control) shows a lower cost per quality adjusted life year, but the lack of supporting evidence for efficacy or sustainability is an important consideration for decision makers. The economics of behavioural approaches to improving health must be made explicit if decision makers are to be convinced that allocating resources toward such programs is worthwhile.
Trial Registration
This paper uses data collected in a previous clinical trial registered at the Australian Clinical Trials Registry, Australian New Zealand Clinical Trials Registry: ACTRN012607000195459
PMCID: PMC2744997  PMID: 19779611
18.  Reducing inequalities in access to health care: developing a toolkit through action research 
Quality & safety in health care  2005;14(5):336-339.

Problem: Healthcare organisations are expected both to monitor inequalities in access to health services and also to act to improve access and increase equity in service provision.
Design: Locally developed action research projects with an explicit objective of reducing inequalities in access.
Setting: Eight different health care services in the Yorkshire and Humber region, including community based palliative care, general practice asthma care, hospital based cardiology clinics, and termination of pregnancy services.
Key measures for improvement: Changes in service provision, increasing attendance rates in targeted groups.
Strategies for change: Local teams identified the population concerned and appropriate interventions using both published and grey literature. Where change to service provision was achieved, local data were collected to monitor the impact of service change.
Effects of change: A number of evidence based changes to service provision were proposed and implemented with variable success. Service uptake increased in some of the targeted populations.
Lessons learnt: Interventions to improve access must be sensitive to local settings and need both practical and managerial support to succeed. It is particularly difficult to improve access effectively if services are already struggling to meet current demand. Key elements for successful interventions included effective local leadership, identification of an intervention which is both evidence based and locally practicable, and identification of additional resources to support increased activity. A "toolkit" has been developed to support the identification and implementation of appropriate changes.
PMCID: PMC1744068  PMID: 16195566
19.  A model for analysis, systemic planning and strategic synthesis for health science teaching in the Democratic Republic of the Congo: a vision for action 
The problem of training human resources in health is a real concern in public health in Central Africa. What can be changed in order to train more competent health professionals? This is of utmost importance in primary health care.
Taking into account the level of training of secondary-level nurses in the Democratic Republic of the Congo (DRC), a systemic approach, based on the PRECEDE PROCEED model of analysis, led to a better understanding of the educational determinants and of the factors favourable to a better match between training in health sciences and the expected competences of the health professionals. This article must be read on two complementary levels: one reading, focused on the methodological process, should allow our findings to be transferred to other problems (adaptation of a health promotion model to the educational sphere). The other reading, revolving around the specific theme and results, should provide a frame of reference and specific avenues for action to improve human resources in the health field (using the results of its application in health science teaching in the DRC).
The results show that it is important to start this training with a global and integrated approach shared by all the actors. The strategies of action entail the need for an approach taking into account all the aspects, i.e. sociological, educational, medical and public health.
The analysis of the results shows that one cannot bring any change without integrated strategies of action and a multidisciplinary approach that includes all the complex determinants of health behaviour, and to do it within the organization of local structures and institutions in the ministry of health in the DRC.
PMCID: PMC543448  PMID: 15585060
20.  The protocol of a randomized controlled trial for playgroup mothers: Reminder on Food, Relaxation, Exercise, and Support for Health (REFRESH) Program 
BMC Public Health  2011;11:648.
Mother's physical activity levels are relatively low, while their energy consumption is generally high resulting in 58% of Australian women over the age of 18 years being overweight or obese. This study aims to confirm if a low-cost, accessible playgroup based intervention program can improve the dietary and physical activity behaviours of mothers with young children.
The current study is a randomized controlled trial lifestyle (nutrition and physical activity) intervention for mothers with children aged between 0 to 5 years attending playgroups in Perth, Western Australia. Nine-hundred participants will be recruited and randomly assigned to the intervention (n = 450) and control (n = 450) groups. The study is based on the Social Cognitive Theory (SCT) and the Transtheoretical Model (TTM), and the Precede-Proceed Framework incorporating goal setting, motivational interviewing, social support and self-efficacy. The six month intervention will include multiple strategies and resources to ensure the engagement and retention of participants. The main strategy is home based and will include a specially designed booklet with dietary and physical activity information, a muscle strength and flexibility exercise chart, a nutrition label reading shopping list and menu planner. The home based strategy will be supported by face-to-face dietary and physical activity workshops in the playgroup setting, posted and emailed bi-monthly newsletters, and monthly Short Message Service (SMS) reminders via mobile phones. Participants in the control group receive no intervention materials. Outcome measures will be assessed using data that will be collected at baseline, six months and 12 months from participants in the control and intervention groups.
This trial will add to the evidence base on the recruitment, retention and the impact of community based dietary and physical activity interventions for mothers with young children.
Trial Registration
Australian and New Zealand Clinical Trials Registry ACTRN12609000735257
PMCID: PMC3166931  PMID: 21843366
21.  Improving child health promotion practices in multiple sectors – outcomes of the Swedish Salut Programme 
BMC Public Health  2012;12:920.
To improve health in the population, public health interventions must be successfully implemented within organisations, requiring behaviour change in health service providers as well as in the target population group. Such behavioural change is seldom easily achieved. The purpose of this study was to examine the outcomes of a child health promotion programme (The Salut Programme) on professionals’ self-reported health promotion practices, and to investigate perceived facilitators and barriers for programme implementation.
A before-and-after design was used to measure programme outcomes, and qualitative data on implementation facilitators and barriers were collected on two occasions during the implementation process. The sample included professionals in antenatal care, child health care, dental services and open pre-schools (n=144 pre-implementation) in 13 out of 15 municipalities in a Swedish county. Response rates ranged between 81% and 96% at the four measurement points.
Self-reported health promotion practices and collaboration were improved in all sectors at follow up. Significant changes included: 1) an increase in the extent to which midwives in antenatal care raised issues related to men’s violence against women, 2) an increase in the extent to which several lifestyle topics were raised with parents/clients in child health care and dental services, 3) an increased use of motivational interviewing (MI) and separate ‘fathers visits’ in child health care 4) improvements in the supply of healthy snacks and beverages in open pre-schools and 5) increased collaboration between sectors. Main facilitators for programme implementation included cross-sectoral collaboration and sector-specific work manuals/questionnaires for use as support in everyday practice. Main barriers included high workload, and shortage of time and staff.
This multisectoral programme for health promotion, based on sector-specific intervention packages developed and tested by end users, and introduced via interactive multisectoral seminars, shows potential for improving health promotion practices and collaboration across sectors. Consideration of the key facilitators and barriers for programme implementation as highlighted in this study can inform future improvement efforts.
PMCID: PMC3564907  PMID: 23107349
Antenatal care; Change barriers; Change facilitators; Child health care; Complex interventions; Dental health services; Health promotion; Implementation; Prevention; Primary health care
22.  Organisational development in general practice: lessons from practice and professional development plans (PPDPs) 
Improving the quality and effectiveness of clinical practice is becoming a key task within all health services. Primary medical care, as organised in the UK is composed of clinicians who work in independent partnerships (general practices) that collaborate with other health care professionals. Although many practices have successfully introduced innovations, there are no organisational development structures in place that support the evolution of primary medical care towards integrated care processes. Providing incentives for attendance at passive educational events and promoting 'teamwork' without first identifying organisational priorities are interventions that have proved to be ineffective at changing clinical processes. A practice and professional development plan feasibility study was evaluated in Wales and provided the experiential basis for a summary of the lessons learnt on how best to guide organisational development systems for primary medical care.
Practice and professional development plans are hybrids produced by the combination of ideas from management (the applied behavioural science of organisational development) and education (self-directed adult learning theories) and, in conceptual terms, address the lack of effectiveness of passive educational strategies by making interventions relevant to identified system wide needs. In the intervention, each practice participated in a series of multidisciplinary workshops (minimum 4) where the process outcome was the production of a practice development plan and a set of personal portfolios, and the final outcome was a realised organisational change.
It was apparent during the project that organisational admission to a process of developmental planning needed to be a stepwise process, where initial interest can lead to a fuller understanding, which subsequently develops into motivation and ownership, sufficient to complete the exercise. The advantages of introducing expert external facilitation were clear: evaluations of internal group processes were possible, strategic issues could be raised and explored and financial probity ensured. These areas are much more difficult to examine when only internal stakeholders are engaged in a planning process.
It is not possible to introduce practice and professional development plans (organisational development and organisational learning projects) in a publicly funded health care system without first addressing existing educational and management structures. Existing systems are based on educational credits for attendance and emerging accountability frameworks (criteria checklists) for clinical governance. Moving to systems that are less summative and more formative, and based on the philosophies of continual quality improvement, require changes to be made in the relevant support systems in order achieve policy proposals.
PMCID: PMC29075  PMID: 11178111
23.  Local co-ordination and case management can enhance Indigenous eye care – a qualitative study 
Indigenous adults suffer six times more blindness than other Australians but 94% of this vision loss is unnecessary being preventable or treatable. We have explored the barriers and solutions to improve Indigenous eye health and proposed significant system changes required to close the gap for Indigenous eye health. This paper aims to identify the local co-ordination and case management requirements necessary to improve eye care for Indigenous Australians.
A qualitative study, using semi-structured interviews, focus groups, stakeholder workshops and meetings was conducted in community, private practice, hospital, non-government organisation and government settings. Data were collected at 21 sites across Australia. Semi-structured interviews were conducted with 289 people working in Indigenous health and eye care; focus group discussions with 81 community members; stakeholder workshops involving 86 individuals; and separate meetings with 75 people. 531 people participated in the consultations. Barriers and issues were identified through thematic analysis and policy solutions developed through iterative consultation.
Poorly co-ordinated eye care services for Indigenous Australians are inefficient and costly and result in poorer outcomes for patients, communities and health care providers. Services are more effective where there is good co-ordination of services and case management of patients along the pathway of care. The establishment of clear pathways of care, development local and regional partnerships to manage services and service providers and the application of sufficient workforce with clear roles and responsibilities have the potential to achieve important improvements in eye care.
Co-ordination is a key to close the gap in eye care for Indigenous Australians. Properly co-ordinated care and support along the patient pathway through case management will save money by preventing dropout of patients who haven’t received treatment and a successfully functioning system will encourage more people to enter for care.
PMCID: PMC3716985  PMID: 23822115
Indigenous Australians; Aboriginal and Torres Strait Islander; Eye care; Co-ordination; Case management
24.  The Australian preventive health agenda: what will this mean for workforce development? 
The formation of the National Health and Hospitals Reform Commission (NHHRC) and the National Preventative Task Force in 2008, demonstrate a renewed Australian Government commitment to health reform. The re-focus on prevention, bringing it to the centre of health care has significant implications for health service delivery in the primary health care setting, supportive organisational structures and continuing professional development for the existing clinical and public health workforce. It is an opportune time, therefore, to consider new approaches to workforce development aligned to health policy reform. Regardless of the actual recommendations from the NHHRC in June 2009, there will be an emphasis on performance improvements which are accountable and aligned to new preventive health policy, organisational priorites and anticipated improved health outcomes.
To achieve this objective there will be a need for the existing population health workforce, primary health care and non-government sectors to increase their knowledge and understanding of prevention, promotion and protection theory and practice within new organisational frameworks and linked to the community. This shift needs to be part of a national health services research agenda, infrastructure and funding which is supportive of quality continuing professional development.
This paper discusses policy and practice issues related to workforce development as part of an integrated response to the preventive agenda.
PMCID: PMC2696455  PMID: 19463159
25.  Beyond the limits of clinical governance? The case of mental health in English primary care 
Little research attention has been given to attempts to implement organisational initiatives to improve quality of care for mental health care, where there is a high level of indeterminacy and clinical judgements are often contestable. This paper explores recent efforts made at an organisational level in England to improve the quality of primary care for people with mental health problems through the new institutional processes of 'clinical governance'.
Framework analysis, based on the Normalisation Process Model (NPM), of attempts over a five year period to develop clinical governance for primary mental health services in Primary Care Trusts (PCTs). The data come from a longitudinal qualitative multiple case-study approach in a purposive sample of 12 PCTs, chosen to reflect a maximum variety of organisational contexts for mental health care provision.
The constant change within the English NHS provided a difficult context in which to attempt to implement 'clinical governance' or, indeed, to reconstruct primary mental health care. In the absence of clear evidence or direct guidance about what 'primary mental health care' should be, and a lack of actors with the power or skills to set about realising it, the actors in 'clinical governance' had little shared knowledge or understanding of their role in improving the quality of mental health care. There was a lack of ownership of 'mental health' as an integral, normalised part of primary care.
Despite some achievements in regard to monitoring and standardisation of prescribing practice, mental health care in primary care seems to have so far largely eluded the gaze of 'clinical governance'. Clinical governance in English primary mental health care has not yet become normalised. We make some policy recommendations which we consider would assist in the process normalisation and suggest other contexts to which our findings might apply.
PMCID: PMC2292707  PMID: 18366779

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