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26.  Working in disadvantaged communities: What additional competencies do we need? 
Residents of socioeconomically disadvantaged locations are more likely to have poor health than residents of socioeconomically advantaged locations and this has been comprehensively mapped in Australian cities. These inequalities present a challenge for the public health workers based in or responsible for improving the health of people living in disadvantaged localities. The purpose of this study was to develop a generic workforce needs assessment tool and to use it to identify the competencies needed by the public health workforce to work effectively in disadvantaged communities.
A two-step mixed method process was used to identify the workforce needs. In step 1 a generic workforce needs assessment tool was developed and applied in three NSW Area Health Services using focus groups, key stakeholder interviews and a staff survey. In step 2 the findings of this needs assessment process were mapped against the existing National Health Training Package (HLT07) competencies, gaps were identified, additional competencies described and modules of training developed to fill identified gaps.
There was a high level of agreement among the AHS staff on the nature of the problems to be addressed but less confidence indentifying the work to be done. Processes for needs assessments, community consultations and adapting mainstream programs to local needs were frequently mentioned as points of intervention. Recruiting and retaining experienced staff to work in these communities and ensuring their safety were major concerns. Workforce skill development needs were seen in two ways: higher order planning/epidemiological skills and more effective working relationships with communities and other sectors. Organisational barriers to effective practice were high levels of annual compulsory training, balancing state and national priorities with local needs and giving equal attention to the population groups that are easy to reach and to those that are difficult to engage. A number of additional competency areas were identified and three training modules developed.
The generic workforce needs assessment tool was easy to use and interpret. It appears that the public health workforce involved in this study has a high level of understanding of the relationship between the social determinants and health. However there is a skill gap in identifying and undertaking effective intervention.
PMCID: PMC2684114  PMID: 19393091
27.  Educating the public health workforce: Issues and challenges 
In public health, as well as other health education contexts, there is increasing recognition of the transformation in public health practice and the necessity for educational providers to keep pace. Traditionally, public health education has been at the postgraduate level; however, over the past decade an upsurge in the growth of undergraduate public health degrees has taken place.
This article explores the impact of these changes on the traditional sphere of Master of Public Health programs, the range of competencies required at undergraduate and postgraduate levels, and the relevance of these changes to the public health workforce. It raises questions about the complexity of educational issues facing tertiary institutions and discusses the implications of these issues on undergraduate and postgraduate programs in public health.
The planning and provisioning of education in public health must differentiate between the requirements of undergraduate and postgraduate students – while also addressing the changing needs of the health workforce. Within Australia, although significant research has been undertaken regarding the competencies required by postgraduate public health students, the approach is still somewhat piecemeal, and does not address undergraduate public health. This paper argues for a consistent approach to competencies that describe and differentiate entry-level and advanced practice.
PMCID: PMC2673231  PMID: 19358714
28.  The future of public health: the importance of workforce 
Health workforce has become a major concern and a significant health policy issue around the world in recent years. With recent international and national initiatives and models being developed and implemented in Australia and other countries, it is timely to understand the need and the rationale for a better trained and educated public health workforce for the future. Much more attention should also be given to evaluation and research in this field.
Through this thematic series on Workforce and Public Health, we have drawn on the diverse nature of public health, workforce implications, education and training and national and international case examples of ongoing improvements and issues in this sector.
PMCID: PMC2673230  PMID: 19358709
29.  Educating public health physicians for the future: a current perspective from Aotearoa New Zealand 
Persisting, and in some cases widening, inequalities in health within and between countries present significant challenges to the focus and practice of contemporary public health, and by association, to public health education. As public health physicians and academic educators of medically- and non-medically trained public health practitioners, we call for a radical re-think of current approaches to public health medicine education and training in order to address these challenges. The public health physicians of the future, we argue, require not merely technical knowledge and skills but also a set of values that underpin a commitment to ethical principles, social equity, human rights, compassionate action, advocacy and leadership. Furthermore, while they will need to have their action firmly grounded in local realities they should think, if not speak and act, from an informed awareness of global issues. Drawing from our experience in Aotearoa New Zealand, as well as with marginalised communities overseas, we proffer our suggestions for the process and content of public health physician education and training for the future, with the intention of stimulating debate.
PMCID: PMC2672091  PMID: 19358712
30.  Strengthening field-based training in low and middle-income countries to build public health capacity: Lessons from Australia's Master of Applied Epidemiology program 
The International Health Regulations (2005) and the emergence and global spread of infectious diseases have triggered a re-assessment of how rich countries should support capacity development for communicable disease control in low and medium income countries (LMIC). In LMIC, three types of public health training have been tried: the university-based model; streamed training for specialised workers; and field-based programs. The first has low rates of production and teaching may not always be based on the needs and priorities of the host country. The second model is efficient, but does not accord the workers sufficient status to enable them to impact on policy. The third has the most potential as a capacity development measure for LMIC, but in practice faces challenges which may limit its ability to promote capacity development.
We describe Australia's first Master of Applied Epidemiology (MAE) model (established in 1991), which uses field-based training to strengthen the control of communicable diseases. A central attribute of this model is the way it partners and complements health department initiatives to enhance workforce skills, health system performance and the evidence-base for policies, programs and practice.
The MAE experience throws light on ways Australia could collaborate in regional capacity development initiatives. Key needs are a shared vision for a regional approach to integrate training with initiatives that strengthen service and research, and the pooling of human, financial and technical resources. We focus on communicable diseases, but our findings and recommendations are generalisable to other areas of public health.
PMCID: PMC2672090  PMID: 19358710
31.  How do government health departments in Australia access health economics advice to inform decisions for health? A survey 
Government anticipates that health economic analysis will contribute to evidence-based policy development. Early examples in Australia where this expectation has been met include the economic evaluations of breast and cervical screening. However, the level of integration of health economics within health services that require this advice appears uneven. We sought to describe how government health departments in Australia use specialist health economic advice to inform policy and planning and the mechanisms through which they access this advice.
Information describing the arrangements for gaining health economics input into health decision-making was sought through interviews with a purposeful sample of economists and non-economists employed by all departments of health in Australia (state, territories and national). The survey was undertaken in August 2004. To aid interpretation of the results eight health economic functions were identified. As a comparison, four other government departments in NSW provided information about their access to economic advice.
All health departments except one reported being current users of health economics expertise. A variety of arrangements were described to source this, from building organisational capacity with self-sufficient in-house units to forging links with external sources. However, specialist positions for economists or health economists employed within health were few. A framework mapping these arrangements for sourcing advice with the eight common health economic functions to be met is presented. All other non-health government departments approached accessed economic advice, with three having in-house units.
A small health economics capacity in Australia has been established over the past 30 years through a variety of structural and strategic mechanisms. Health departments value health economic advice and use a variety of arrangements to obtain this. These arrangements have strengths and weaknesses depending upon the task to be undertaken. The lack of uniformity of approach suggests that health departments are still seeking the best ways to incorporate this form of specialist advice into mainstream decision-making.
Summarises ways that governments source specialist services. Demonstrates how to describe an organisation's need for specialist services as a set of functions. This approach could be applied to assessing need for other specialist areas of advice.
PMCID: PMC2674050  PMID: 19358711
32.  A multidimensional classification of public health activity in Australia 
At present, we have very limited ability to compare public health activity across jurisdictions and countries, or even to ascertain differences in what is considered to be a public health activity. Existing standardised health classifications do not capture important dimensions of public health, which include its functions, the methods and interventions used to achieve these, the health issues and determinants of health that public health activities address, the resources and infrastructure they use, and the settings in which they occur. A classification that describes these dimensions will promote consistency in collecting and reporting information about public health programs, expenditure, workforce and performance. This paper describes the development of an initial version of such a classification.
We used open-source Protégé software and published procedures to construct an ontology of public health, which forms the basis of the classification. We reviewed existing definitions of public health, descriptions of public health functions and classifications to develop the scope, domain, and multidimensional class structure of the ontology. These were then refined through a series of consultations with public health experts from across Australia, culminating in an initial classification framework.
The public health classification consists of six top-level classes: public health 'Functions'; 'Health Issues'; 'Determinants of Health'; 'Settings'; 'Methods' of intervention; and 'Resources and Infrastructure'. Existing classifications (such as the international classifications of diseases, disability and functioning and external causes of injuries) can be used to further classify large parts of the classes 'Health Issues', 'Settings' and 'Resources and Infrastructure', while new subclass structures are proposed for the classes of public health 'Functions', 'Determinants of Health' and 'Interventions'.
The public health classification captures the important dimensions of public health activity. It will facilitate the organisation of information so that it can be used to address questions relating to any of these dimensions, either singly or in combination. The authors encourage readers to use the classification, and to suggest improvements.
PMCID: PMC2674448  PMID: 19358715
33.  Evaluating health policy capacity: Learning from international and Australian experience 
The health sector in Australia faces major challenges that include an ageing population, spiralling health care costs, continuing poor Aboriginal health, and emerging threats to public health. At the same time, the environment for policy-making is becoming increasingly complex. In this context, strong policy capacity – broadly understood as the capacity of government to make "intelligent choices" between policy options – is essential if governments and societies are to address the continuing and emerging problems effectively.
This paper explores the question: "What are the factors that contribute to policy capacity in the health sector?" In the absence of health sector-specific research on this topic, a review of Australian and international public sector policy capacity research was undertaken. Studies from the United Kingdom, Canada, New Zealand and Australia were analysed to identify common themes in the research findings. This paper discusses these policy capacity studies in relation to context, models and methods for policy capacity research, elements of policy capacity and recommendations for building capacity.
Based on this analysis, the paper discusses the organisational and individual factors that are likely to contribute to health policy capacity, highlights the need for further research in the health sector and points to some of the conceptual and methodological issues that need to be taken into consideration in such research.
PMCID: PMC2657149  PMID: 19245704
34.  Health research policy: a case study of policy change in Aboriginal and Torres Strait Islander health research 
There is considerable potential for health research to contribute to improved health services, programs, and outcomes; the policies of health research funding agencies are critical to achieving health gains from research. The need for research to better address health disparities in Indigenous people has been widely recognised. This paper: (i) describes the policy changes made by the National Health and Medical Research Council (NHMRC) from 1997 to 2002 to improve funding of Aboriginal health research (ii) examines catalysts for the policy changes (iii) describes the extent to which policy changes were followed by new models of research and (iv) outlines issues for Indigenous health policy in the future.
This study had two parts: (i) semi-structured interviews were conducted over a four -month period with seven individuals who played a leading role in the policy changes at NHMRC during the period 1997–2002, to describe policy changes and to examine the catalysts for the changes; (ii) a case study was undertaken to evaluate projects by recipients of NHMRC People Support awards and NHMRC Capacity Building Grants in Population Health Research to examine the types of research being undertaken five years after the policy changes were implemented. The proposals of these researchers were assessed in terms of whether they reported intending to: evaluate interventions; engage Indigenous community members and organisations; and build research capacity among Indigenous people.
Seven policy changes over a period of five years were identified, including those to: establish an ethical approach to working with Indigenous people; increase the influence of Indigenous people within NHMRC; encourage priority research directed at improving Indigenous health; and recognise Aboriginal and Torres Strait Islander health research as a priority area including a commitment to an expenditure target of 5% of annual funds. Seven catalysts for this change were identified. These included: a perceived lack of effective response to the health needs of Indigenous people; a changed perception of the role of NHMRC in encouraging research to maximise health gains; and leadership within the organisation.
The case study analysis demonstrated that 45% of all People Support recipients intend to engage Indigenous community members and organisations in consultation, 26% included an evaluation of an intervention and two (6.5%) were granted to an individual from an Indigenous background. Six of seven Population Health Capacity Building Grants that were awarded to study Indigenous health between 2004 and 2006 included an intervention component; these grants supported 34 researchers from Indigenous backgrounds.
NHMRC made significant policy changes from 1997 to 2002 to better support Indigenous health as a result of external pressure and internal commitment.
The policy changes have made some progress in supporting better research models particularly in improving engagement with Indigenous communities. However, there remains a need for further reform to optimise research outcomes for Indigenous people from research.
PMCID: PMC2657148  PMID: 19245696
35.  Regulatory axes on food advertising to children on television 
This article describes and evaluates some of the criteria on the basis of which food advertising to children on television could be regulated, including controls that revolve around the type of television programme, the type of product, the target audience and the time of day. Each of these criteria potentially functions as a conceptual device or "axis" around which regulation rotates. The article considers examples from a variety of jurisdictions around the world, including Sweden and Quebec. The article argues that restrictions centring on the time of day when a substantial proportion of children are expected to be watching television are likely to be the easiest for consumers to understand, and the most effective in limiting children's exposure to advertising.
PMCID: PMC2646738  PMID: 19159485
36.  Selecting interventions to promote fruit and vegetable consumption: from policy to action, a planning framework case study in Western Australia 
The Department of Health in Western Australia identified access to, and daily consumption of recommended amounts of fruit and vegetables, as priority health determinants. The numerous factors that influence supply and consumption of fruit and vegetables indicated that a comprehensive approach would be required.
A government and non-government sector steering group was set up to select priority interventions using the National Public Health Partnership's Framework for Implementing Public Health Strategies. This structured framework was used for developing strategies to improve fruit and vegetable consumption and supply, and to identify implementation priorities.
After one year a desktop audit of progress on framework interventions was undertaken.
The structured framework led to a plan for defined actions, partners, costs, and performance indicators for strategies to improve fruit and vegetable consumption and supply. Lead agency custodians for management of the selected interventions were identified.
After one year there was significant progress in the implementation of a number of the high-ranking interventions. The exception was interventions that provide the infrastructure support such as research and development capacity, information systems.
A structured framework and stakeholder participation assisted in developing a fruit and vegetable implementation strategy. Engagement and commitment of influential and diverse stakeholders is needed, not just for program support, but particularly in the areas of food and nutrition policy development and providing the infrastructure support required. Further work is required to develop performance outcomes and cost effectiveness measures for many of the strategies that have been proposed to address portfolio objectives.
PMCID: PMC2621230  PMID: 19108736
37.  Using performance-based regulation to reduce childhood obesity 
Worldwide, the public health community has recognized the growing problem of childhood obesity. But, unlike tobacco control policy, there is little evidence about what public policies would work to substantially reduce childhood obesity. Public health leaders currently tend to support traditional "command and control" schemes that order private enterprises and governments to stop or start doing specific things that, is it hoped, will yield lower childhood obesity rates. These include measures such as 1) taking sweetened beverages out of schools, 2) posting calorie counts on fast-food menu boards, 3) labeling foods with a "red light" if they contain high levels of fat or sugar, 4) limiting the density of fast food restaurants in any neighborhood, 5) requiring chain restaurants to offer "healthy" alternatives, and 6) eliminating junk food ads on television shows aimed at children. Some advocates propose other regulatory interventions such as 1) influencing the relative prices of healthy and unhealthy foods through taxes and/or subsidies and 2) suing private industry for money damages as a way of blaming childhood obesity on certain practices of the food industry (such as its marketing, product composition, or portion size decisions). The food industry generally seeks to deflect blame for childhood obesity onto others, such as parents and schools.
PMCID: PMC2596772  PMID: 19017402
38.  Increasing the options for reducing adverse events: Results from a modified Delphi technique 
The aim of this paper is to illustrate a simple method for increasing the range of possible options for reducing adverse events in Australian hospitals, which could have been, but was not, adopted in the wake of the landmark 1995 'Quality in Australian Health Care' study, and to report the suggestions and the estimated lapse time before they would impact upon mortality and morbidity.
The study used a modified Delphi technique that first elicited options for reducing adverse events from an invited panel selected on the basis of their knowledge of the area of adverse events and quality assurance. Initial suggestions were collated and returned to them for re-consideration and comment.
Completed responses from both stages were obtained from 20 of those initially approached. Forty-one options for reducing AEs were identified with an average lapse time of 3.5 years. Hospital regulation had the least delay (2.4 years) and out of hospital information the greatest (6.4 years).
Following identification of the magnitude of the problem of adverse events in the 'Quality in Australian Health Care' study a more rapid and broad ranging response was possible than occurred. Apparently viable options for reducing adverse events and associated mortality and morbidity remain unexploited.
PMCID: PMC2596159  PMID: 19014562
39.  Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals? 
In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.
Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.
The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.
PMCID: PMC2588611  PMID: 18990236
40.  By invitation only – the case for breast cancer screening reminders for women over 69 years 
Breast cancer is the leading cause of cancer death in women in Australia. Early detection provides the best chance of reducing mortality and morbidity from the disease. Mammographic screening is a population health strategy for the early detection of breast cancer in Australia. Recruitment strategies such as regular advertising and biannual screening invitations are exclusively targeted at women aged 50 – 69 years. Even though they can participate, women 70 years or over are not invited or actively encouraged to undertake screening. Research has found that a routine letter of invitation increases the number of women participating in breast cancer screening.
Cancer data analysis and a literature and policy review was conducted to assess age specific breast cancer mortality rates and the legitimacy of rationale used to limit invitations for breast cancer screening to women younger than 70 years.
The proportion of women over 69 years participating in the BreastScreen program is significantly less than rate of screening in the target age range (50–69 years). Evidence and data indicate that common justifications for limiting screening reminders to the target age range including life expectancy, comorbidities, effectiveness, treatment and cost are, for many women, unreasonable.
There is now sufficient data to support a change in the targeted upper age range for breast cancer screening to improve the existing suboptimal surveillance in women aged over 69 years.
PMCID: PMC2612671  PMID: 18990199
41.  How to make the rhetoric of joined-up government really work 
"Joined-up' government and 'whole-of-government' approaches have evolved over the past two decades from the simple 'one-stop-shop' concept to much more formal organisational structures mandated at the highest levels. In many cases, the participants in these developments were learning on the job, as they responded to community and political demands for better service delivery and more accountability. This paper looks back at some of those developments and proposes a schema to assess and place policies, strategies and programs.
PMCID: PMC2613881  PMID: 18983680
42.  The role of law in the control of obesity in England: looking at the contribution of law to a healthy food culture 
Obesity levels in England are significantly higher than in much of the rest of Europe. This article examines aspects of the physical and cultural context of food consumption in England, and the evolution of government policy on obesity, as a background to an analysis of how law might play a role in obesity prevention. Research suggests that individual food choices are associated with cultural and socio-economic circumstances and that they can be manipulated by advertising, food packaging and presentation. This suggests that there might be ways of using law to manage the influences on food choices, and of using law in support of strategies to redirect food choices towards healthy food products. Law is a particularly useful tool in the protection of the individual against the economic power of the food industry, and there is much that law can do to change the physical, economic and social environment of food consumption.
PMCID: PMC2615029  PMID: 18854038
43.  I don't think general practice should be the front line: Experiences of general practitioners working with refugees in South Australia 
Many refugees arrive in Australia with complex health needs. In South Australia (SA), providing initial health care to refugees is the responsibility of General Practitioners (GPs) in private practice. Their capacity to perform this work effectively for current newly arrived refugees is uncertain. The aim of this study was to document the challenges faced by GPs in private practice in SA when providing initial care to refugees and to discuss the implications of this for policy relating to optimising health care services for refugees.
Semi-structured interviews with twelve GPs in private practice and three Medical Directors of Divisions of General Practice. Using a template analysis approach the interviews were coded and analysed thematically.
Multiple challenges providing care to refugees were found including those related to: (1) refugee health issues; (2) the GP-refugee interaction; and (3) the structure of general practice. The Divisions also reported challenges assisting GPs to provide effective care related to a lack of funding and awareness of which GPs required support. Although respondents suggested a number of ways that GPs could be assisted to provide better initial care to refugees, strong support was voiced for the initial care of refugees to be provided via a specialist refugee health service.
GPs in this study were under-resourced, at both an individual GP level as well as a structural level, to provide effective initial care for refugees. In SA, there are likely to be a number of challenges attempting to increase the capacity of GPs in private practice to provide initial care. An alternative model is for refugees with multiple and complex health care needs as well as those with significant resettlement challenges to receive initial health care via the existing specialist refugee health service in Adelaide.
PMCID: PMC2531177  PMID: 18687150
44.  Is there a crisis in nursing retention in New South Wales? 
There is a severe shortage of nurses in Australia. Policy makers and researchers are especially concerned that retention levels of nurses in the health workforce have worsened over the last decade. There are also concerns that rapidly growing private sector hospitals are attracting qualified nurses away from the public sector. To date no systematic analysis of trends in nursing retention rates over time has been conducted due to the lack of consistent panel data.
A 1.4 percentage point improvement in retention has led to a 10% increase in the overall supply of nurses in NSW. There has also been a substantial aging of the workforce, due to greater retention and an increase in mature age entrants. The improvement in retention is found in all types of premises and is largest in nursing homes. There is a substantial amount of year to year movement in and out of the workforce and across premises. The shortage of nurses in public hospitals is due to a slowdown in entry rather than competition from the rapidly growing private sector hospitals.
Policy Implications
The finding of an improvement (rather than a worsening) in retention suggests that additional improvements may be difficult to achieve as further retention must involve individuals more and more dissatisfied with nursing relative to other opportunities. Hence policies targeting entry such as increased places in nursing programs and additional subsidies for training costs may be more effective in dealing with the workforce shortage. This is also the case for shortages in public sector hospitals as retention in nursing is found to be relatively high in this sector. However, the large amount of year to year movements across nursing jobs, especially among the younger nurses, also suggests that policies aimed at reducing job switches and increasing the number who return to nursing should also be pursued. More research is needed in understanding the relative importance of detailed working conditions and the problems associated with combining family responsibilities and nursing jobs.
PMCID: PMC2546412  PMID: 18681970
45.  The rise and fall of Australian physical activity policy 1996 – 2006: a national review framed in an international context 
This paper provides an historical review of physical activity policy development in Australia for a period spanning a decade since the release of the US Surgeon General's Report on Physical Activity and Health in 1996 and including the 2004 WHO Global Strategy on Diet, Physical Activity and Health. Using our definition of 'HARDWIRED' policy criteria, this Australian review is compared with an international perspective of countries with established national physical activity policies and strategies (New Zealand, Canada, Brazil, Scotland, Switzerland, the Netherlands and Finland). Methods comprised a literature and policy review, audit of relevant web sites, document searches and surveys of international stakeholders.
All these selected countries embraced multi-strategic policies and undertook monitoring of physical activity through national surveys. Few committed to policy of more than three years duration and none undertook systematic evaluation of national policy implementation. This Australian review highlights phases of innovation and leadership in physical activity-related policy, as well as periods of stagnation and decline; early efforts were amongst the best in the world but by the mid-point of this review (the year 2000), promising attempts towards development of a national intersectoral policy framework were thwarted by reforms in the Federal Sport and Recreation sector. Several well received reviews of evidence on good practices in physical activity and public health were produced in the period but leadership and resources were lacking to implement the policies and programs indicated. Latterly, widespread publicity and greatly increased public and political interest in chronic disease prevention, (especially in obesity and type 2 diabetes) have dominated the framework within which Australian policy deliberations have occurred. Finally, a national physical activity policy framework for the Health sector emerged, but not as a policy vision that was inclusive of the other essential sectors such as Education, Transport, Urban Planning as well as Sport and Recreation.
Despite some progression of physical activity policy in the decade since 1995/6, this review found inconsistent policy development, both in Australia and elsewhere. Arguably, Australia has done no worse than other countries, but more effective responses to physical inactivity in populations can be built only on sustainable multi-sectoral public health policy partnerships that are well informed by evidence of effectiveness and good practice. In Australia and elsewhere prerequisites for success are political support, long-term investment and commitment to program implementation and evaluation. An urgent priority is media and political advocacy for physical activity focussed on these factors.
PMCID: PMC2525635  PMID: 18667088
46.  Collaborative review of pilot projects to inform policy: A methodological remedy for pilotitis? 
In rural health and other health service development contexts, there is frustration with a reliance on pilot projects as a means of informing policy and service innovation. There is also an emerging recognition that existing research methods do not draw lessons from the failed sustainability that characterises many of these pilots and demonstration projects.
This article describes critical aspects of the methodology of a successful collaborative, multi-method, systematic synthesis of exemplary primary health care pilot projects in rural and remote Australia, which synthesised principles from a number of pilot projects to inform policy makers and planners. Hallmarks of the method were: the nature of the source materials for the research, the subsequent research engagement with the actual pilot projects, the extent of collaboration throughout the study with end-users from policy and planning arenas, and the attention to procedural quality.
The methodology, while time consuming, has resulted in applied, policy-relevant findings, and evidence of consideration by policy-makers.
PMCID: PMC2503987  PMID: 18638412
47.  Using deliberative techniques to engage the community in policy development 
This paper examines work in deliberative approaches to community engagement used in Western Australia by the Department of Planning and Infrastructure and other planning and infrastructure agencies between 2001 and 2005, and considers whether the techniques could be applied to the development of health policy in Australia.
Deliberative processes were used in WA to address specific planning and infrastructure problems. Using deliberative techniques, community participants contributed to joint decision making and policy development. Outcomes from deliberative processes were seriously considered by the Minister and used to influence policy decisions. In many cases, the recommendations generated through deliberative processes were fully adopted by the Minister.
The experiences in WA demonstrate that deliberative engagement processes can be successfully implemented by government and can be used to guide policy. The techniques can be adapted to suit the context and issues experienced by a portfolio, and the skills required to conduct deliberative processes can be fostered amongst the portfolio's staff. Health policy makers may be able to learn from the experiences in WA, and adopt approaches to community engagement that allow for informed deliberation and debate in the community about the future of Australia's health system.
PMCID: PMC2500036  PMID: 18631378
48.  Analysis of draft Australian rehabilitation service standards: comparison with international standards 
Following her review of health systems and structures Dwyer [1] suggested that there is a need to evaluate models of care for individuals with chronic diseases. Rehabilitation services aim to optimise the activity and participation of individuals with restrictions due to both acute and chronic conditions. Assessing and optimising the standard of these services is one method of assuring the quality of service delivered to these individuals. Knowledge of baseline standards allows evaluation of the impact of health care reforms in this area of need. The aim of this article is to compare the currently available rehabilitation service standards in Australia with those used in the USA and the UK.
The mixed method qualitative analysis performed on the three sets of standards demonstrated repeatability and convergence via the use of triangulation. Australian Faculty of Rehabilitation Medicine (AFRM) standards were found to be consistent and concise, to provide definitions, and to cover the majority of clinically relevant issues to an extent similar to the other rehabilitation service standards. Inclusion of standards for business practices, the rehabilitation process for the person served, and outpatient and community-based rehabilitation services should be considered by the AFRM.
The AFRM standards are an appropriate way of assessing rehabilitation services in Australia. As suggested by other workers [2,3] there should be ongoing review and field testing of the standards to maximise the relevance and utilisation of the standards.
PMCID: PMC2474639  PMID: 18590530
49.  Legal themes concerning obesity regulation in the United States: Theory and practice 
Despite national health objectives to reduce the incidence of obesity to 15% of the population by 2010, public health data suggest that the incidence of obesity in the United States is actually increasing. The U.S. recognizes that it (like other industrialized countries) faces an epidemic of obesity and related health conditions. How can U.S. jurisdictions (federal, state, and local) and the private sector respond to this epidemic through laws and policies that are directly or indirectly designed to address obesity? This article analyzes the theoretical and practical roles of law as a tool to curb obesity in the U.S. It proffers ten major legal themes to address obesity among the U.S. population, including: (1) use of incentives to encourage healthier behaviors; (2) use of financial disincentives to discourage unhealthy behaviors; (3) requirements to improve food quality, diversity, or availability; (4) compensation for injured persons seeking recourse; (5) restriction of access to unhealthy foods; (6) regulations aimed at influencing consumer choices; (7) control of marketing and advertising; (8) creation of communities that support healthy lifestyles; (9) physical education/fitness requirements; and (10) insurance coverage mandates.
PMCID: PMC2474638  PMID: 18578873
50.  Obesity prevention: the role of policies, laws and regulations 
The commercial drivers of the obesity epidemic are so influential that obesity can be considered a robust sign of commercial success – consumers are buying more food, more cars and more energy-saving machines. It is unlikely that these powerful economic forces will change sufficiently in response to consumer desires to eat less and move more or corporate desires to be more socially responsible. When the free market creates substantial population detriments and health inequalities, government policies are needed to change the ground rules in favour of population benefits.
Concerted action is needed from governments in four broad areas: provide leadership to set the agenda and show the way; advocate for a multi-sector response and establish the mechanisms for all sectors to engage and enhance action; develop and implement policies (including laws and regulations) to create healthier food and activity environments, and; secure increased and continued funding to reduce obesogenic environments and promote healthy eating and physical activity.
Policies, laws and regulations are often needed to drive the environmental and social changes that, eventually, will have a sustainable impact on reducing obesity. An 'obesity impact assessment' on legislation such as public liability, urban planning, transport, food safety, agriculture, and trade may identify 'rules' which contribute to obesogenic environments. In other areas, such as marketing to children, school food, and taxes/levies, there may be opportunities for regulations to actively support obesity prevention. Legislation in other areas such as to reduce climate change may also contribute to obesity prevention ('stealth interventions'). A political willingness to use policy instruments to drive change will probably be an early hallmark of successful obesity prevention.
PMCID: PMC2440375  PMID: 18534000

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