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1.  A qualitative study of patient (dis)trust in public and private hospitals: the importance of choice and pragmatic acceptance for trust considerations in South Australia 
Background
This paper explores the nature and reasoning for (dis)trust in Australian public and private hospitals. Patient trust increases uptake of, engagement with and optimal outcomes from healthcare services and is therefore central to health practice, policy and planning.
Methods
A qualitative study in South Australia, including 36 in-depth interviews (18 from public and 18 from private hospitals).
Results
‘Private patients’ made active choices about both their hospital and doctor, playing the role of the ‘consumer’, where trust and choice went hand in hand. The reputation of the doctor and hospital were key drivers of trust, under the assumption that a better reputation equates with higher quality care. However, making a choice to trust a doctor led to personal responsibility and the additional requirement for self-trust. ‘Public patients’ described having no choice in their hospital or doctor. They recognised ‘problems’ in the public healthcare system but accepted and even excused these as ‘part of the system’. In order to justify their trust, they argued that doctors in public hospitals tried to do their best in difficult circumstances, thereby deserving of trust. This ‘resigned trust’ may stem from a lack of alternatives for free health care and thus a dependence on the system.
Conclusion
These two contrasting models of trust within the same locality point to the way different configurations of healthcare systems, hospital experiences, insurance coverage and related forms of ‘choice’ combine to shape different formats of trust, as patients act to manage their vulnerability within these contexts.
doi:10.1186/s12913-015-0967-0
PMCID: PMC4518638
Trust; Choice; Public hospitals; Private hospitals; Qualitative; Australia
2.  Analysis of social networks supporting the self-management of type 2 diabetes for people with mental illness 
Background
People with mental illness have been identified as being more likely to experience type 2 diabetes and the complications arising from this, necessitating more complex chronic illness self-management. Social support has been identified as a significant factor in the successful adoption of lifestyle change for people with type 2 diabetes, however people with mental illness often have impoverished social networks leading to greater reliance upon professional care givers. This study maps the support provided by formal (paid and professional carers) and informal networks to people with mental illness and type 2 diabetes, comparing the experiences of people with a spouse with those without one.
Methods
Interviews were conducted with 29 clients of a community nursing service with mental health problems who receive professional support to self-manage type 2 diabetes. Participants were asked to complete an egocentric social network map which involved mapping the people and services who support them to manage their health. Demographic data was collected as was data about co-morbidities and service use within the last 6 months. Network maps were supplemented by a series of open-ended questions about self-management practices, who supports these practices and what support they provide.
Results
Participants identified small social networks with few friendship ties. These networks had diminished due to illness. For people with a spouse, this person provided significant support for chronic illness self-management performing a range of daily care and illness management tasks. People without a spouse were more reliant on professional and paid care givers for daily care and illness management. People without a spouse also demonstrated greater reliance upon weak social ties for emotional support and social connection and often developed friendships with formal caregivers.
Conclusions
Spousal support reduces the need for professional services. In the absence of a spouse, participants were more reliant upon paid and professional carers and weaker social ties for chronic illness support and social connection leading to greater vulnerability of loss of support.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-0897-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-0897-x
PMCID: PMC4490681  PMID: 26138825
Chronic illness self-management; Social networks; Mental health; Type 2 diabetes; Health services
3.  Factors Influencing the Quality of Life (Qol) Among Thai Older People in a Rural Area of Thailand 
Iranian Journal of Public Health  2015;44(4):479-485.
Background:
The population prevalence of older people has been growing worldwide. Quality of Life (QoL) among older people is a significant public health concern. Hence, this study aimed to assess level of QoL and factors influencing QoL among rural Thai older people.
Methods:
The study was undertaken in Phayao Province where is one of the top ten provinces with the highest index of Thai aging. A district in this province was purposively selected to be the study area and the quota-sampling technique was used for sample collection, totally 400 older people participated according to Taro Yamane. The WHO QoL-Old was employed to interview elderly QoL. Multivariate linear regression was performed to determine the factors influencing QoL among the older people.
Results:
Over two-thirds of older people (68.5%) had QoL at fair level. The vast majority (96%) had high scores for Activity Daily Living (ADL). Approximately one-fifth (20.5%) reported current smoking and 31.7% reported ever drinking during previous year. Following univariate analysis, nine factors – gender, age, education, working, income, present illness, drinking, ADL, and participating in elderly club were identified as being significantly associated with QoL (P <0.05). Multivariate analysis revealed four factors predictive of QoL among elderly: ADL, income, alcohol drinking, and present illness (P < 0.01).
Conclusion:
Physical function, health status and financial were the predictor of QoL among elderly. Noticeably, drinking was one predictive factor of QoL but only among moderate drinkers. Hence, healthy life style should be considered as key areas in attempts to promote QoL among elderly people.
PMCID: PMC4441960  PMID: 26056666
Influencing factors; Quality of Life; Elderly
4.  “I have never experienced any problem with my health. So far, it hasn’t been harmful”: older Greek-Australian smokers’ views on smoking: a qualitative study 
BMC Public Health  2015;15:304.
Background
Smoking tobacco products is one of the largest preventable health risk factors for older people. Greek-Australians have the highest prevalence of cigarette use in Australia for older people, but there is a lack of knowledge about Greek-Australian’s perspectives on smoking cessation. The purpose of this exploratory, qualitative study was to progress the knowledge base in this area.
Methods
A qualitative study was designed to gather information on participants’ perspectives about, and understanding of, their reasons for smoking and their attitudes to quitting. A snowball sampling technique was used to identify twenty Greek–Australian current smokers, aged ≥50 years. Semi-structured, face-to-face interviews were conducted with the assistance of a Greek translator. The audio-taped interviews were transcribed and then qualitative content analysis was used to categorise responses to the questions.
Results
Participants’ perspectives on three broad topics were identified in the interviews: perceived benefits of smoking, perceptions of smoking and its effect on health, and barriers to cessation. Smoking behaviour was described as contributing to tiredness, and stress, and yet also was also a source of enjoyment. Level of knowledge about smoking-related diseases and the risks of smoking was very low. The number of cigarettes smoked each day, type of smoking (i.e. pipe rather than cigarettes), and previous family history of smoking were identified as indicators that limited harm flows from smoking. Most participants had a positive attitude towards smoking and described their own life experience and cultural norms as supporting smoking acceptability. Low confidence in quitting was linked to advanced age.
Conclusion
Smoking among older Greek-Australian smokers has been associated with a number of influences and these need to be addressed in smoking cessation efforts targeted at this group. Promoting knowledge about the health impacts of smoking, changing attitudes towards smoking, and ultimately, decreasing tobacco consumption are critical to the maintenance of health among older Greek Australians. Cultural and experiential influences may increase the difficulty associated with changing these outcomes, but may also serve as a framework from which to develop and implement an educational intervention tailored for older Greek-Australians.
doi:10.1186/s12889-015-1677-6
PMCID: PMC4391085  PMID: 25885899
Greek-Australian smokers; Older people; Qualitative study; Knowledge; Attitude
5.  Visual and skill effects on soccer passing performance, kinematics, and outcome estimations 
The role of visual information and action representations in executing a motor task was examined from a mental representations approach. High-skill (n = 20) and low-skill (n = 20) soccer players performed a passing task to two targets at distances of 9.14 and 18.29 m, under three visual conditions: normal, occluded, and distorted vision (i.e., +4.0 corrective lenses, a visual acuity of approximately 6/75) without knowledge of results. Following each pass, participants estimated the relative horizontal distance from the target as the ball crossed the target plane. Kinematic data during each pass were also recorded for the shorter distance. Results revealed that performance on the motor task decreased as a function of visual information and task complexity (i.e., distance from target) regardless of skill level. High-skill players performed significantly better than low-skill players on both the actual passing and estimation tasks, at each target distance and visual condition. In addition, kinematic data indicated that high-skill participants were more consistent and had different kinematic movement patterns than low-skill participants. Findings contribute to the understanding of the underlying mechanisms required for successful performance in a self-paced, discrete and closed motor task.
doi:10.3389/fpsyg.2015.00198
PMCID: PMC4345767  PMID: 25784886
action representation; vision; motor performance; error estimation; skill level
6.  Understanding Socio-cultural Influences on Smoking among Older Greek-Australian Smokers Aged 50 and over: Facilitators or Barriers? A Qualitative Study 
Smokers of all ages can benefit by quitting, but many smokers continue to smoke. Older Greek-Australian smokers, one of the largest ethnic groups in Australia, have higher rates of smoking than other groups of older Australians. This qualitative study aimed to explore older Greek-Australians’ views about socio-cultural influences on their smoking. A snowball sampling technique was used to identify twenty Greek–Australian smokers (12 males and eight females), aged ≥ 50 years. They were recruited through the Greek Orthodox Community Center of South Australia (GOCSA). Qualitative data were collected using semi-structured face-to-face interviews. The audio-taped interviews were translated and transcribed, and then analysed using content analysis. Results suggested that smoking was considered as the “norm” by older Greek-Australian smokers. There were four groups embedded in the participants’ social networks that were reported to be important in relation to either encouraging smoking or, smoking abstinence. These support groups included: family members, friends, the Greek community, and physicians. Smokers’ family members (brothers) and friends were identified as facilitators of smoking whereas non-smoker family members (children and spouses) were reported as providing barriers to smoking. Different approaches were used by supporter groups to assist smokers to quit smoking—both planned and unplanned. Knowledge, planning of social and cultural supports, and addressing barriers to smoking cessation are a important part of health planning for older Greek-Australians. Social norms, including those arising from social interactions, and predisposing traits can influence smoking behaviour. Addressing the specific barriers to smoking cessation of older Greek-Australians is critical to addressing the risk for chronic disease in this group.
doi:10.3390/ijerph120302718
PMCID: PMC4377928  PMID: 25739006
smoking cessation; Greek-Australians; older people; socio-cultural influences; facilitator; barriers
7.  Media actors’ perceptions of their roles in reporting food incidents 
BMC Public Health  2014;14:1305.
Background
Previous research has shown that the media can play a role in shaping consumer perceptions during a public health crisis. In order for public health professionals to communicate well-informed health information to the media, it is important that they understand how media view their role in transmitting public health information to consumers and decide what information to present. This paper reports the perceptions of media actors from three countries about their role in reporting information during a food incident. This information is used to present ideas and suggestions for public health professionals working with media during food incidents.
Methods
Thirty three semi-structured interviews with media actors from Australia, New Zealand and the United Kingdom were conducted and analysed thematically. Media actors were recruited via purposive sampling using a sampling strategy, from a variety of formats including newspaper, television, radio and online.
Results
Media actors said that during a food incident, they play two roles. First, they play a role in communicating information to consumers by acting as a conduit for information between the public and the relevant authorities. Second, they play a role as investigators by acting as a public watchdog.
Conclusion
Media actors are an important source of consumer information during food incidents. Public health professionals can work with media by actively approaching them with information about food incidents; promoting to media that as public health professionals, they are best placed to provide the facts about food incidents; and by providing angles for further investigation and directing media to relevant and correct information to inform such investigations. Public health professionals who adapt how they work with media are more likely to influence media to portray messages that fit what they would like the public to know and that are in line with public health recommendations and enable consumers to engage in safe and health promoting behaviours in response to food incidents.
doi:10.1186/1471-2458-14-1305
PMCID: PMC4301931  PMID: 25524217
Food; Food incident; Media; Public health; Public health professional
8.  Newcomers in a hazardous environment: a qualitative inquiry into sex worker vulnerability to HIV in Bali, Indonesia 
BMC Public Health  2014;14:832.
Background
Women new to sex work and those with a greater degree of mobility have higher risk of HIV infection. Using social capital as a theoretical framework, we argue that better understanding of the interactions of micro-level structural factors can be valuable in reshaping and restructuring health promotion programmes in Bali to be more responsive to the concerns and needs of newcomer and mobile female sex workers (FSWs).
Methods
We conducted interviews with 11 newcomer FSWs (worked < six months), 9 mobile FSWs (experienced but worked at the current brothel < six months), and 14 senior FSWs (experienced and worked at current brothel > six months). The interviews explored women’s experience of sex work including how and why they came to sex work, relationships with other FSWs and their HIV prevention practices.
Results
A thematic framework analysis revealed newcomer FSWs faced multiple levels of vulnerability that contributed to increased HIV risk. First, a lack of knowledge and self-efficacy about HIV prevention practices was related to their younger age and low exposure to sexual education. Second, on entering sex work, they experienced intensely competitive working environments fuelled by economic competition. This competition reduced opportunities for positive social networks and social learning about HIV prevention. Finally, the lack of social networks and social capital between FSWs undermined peer trust and solidarity, both of which are essential to promote consistent condom use. For example, newcomer FSWs did not trust that if they refused to have sex without a condom, their peers would also refuse; this increased their likelihood of accepting unprotected sex, thereby increasing HIV risk.
Conclusions
Public health and social welfare interventions and programmes need to build social networks, social support and solidarity within FSW communities, and provide health education and HIV prevention resources much earlier in women’s sex work careers.
doi:10.1186/1471-2458-14-832
PMCID: PMC4141952  PMID: 25113395
Sex work; Newcomers; Social network; Social support; HIV prevention knowledge; Trust
9.  The Effects of Housing on Health and Health Risks in an Aging Population: A Qualitative Study in Rural Thailand 
BioMed Research International  2014;2014:289731.
Background. Over the last decade, Thailand has experienced an aging population, especially in rural areas. Research finds a strong, positive relationship between good quality housing and health, and this paper assesses the impact and living experience of housing of older people in rural Thailand. Methods. This was a mixed-method study, using data from observations of the physical adequacy of housing, semistructured interviews with key informants, and archival information from health records for 13 households in rural Thailand. Results. There were four main themes, each of which led to health risks for the older people: “lighting and unsafe wires,” “house design and composition,” “maintenance of the house,” and “health care equipment.” The housing was not appropriately designed to accommodate health care equipment or to fully support individual daily activities of older people. Numerous accidents occurred as a direct result of inadequate housing and the majority of houses had insufficient and unsafe lighting, floor surfaces and furniture that created health risks, and toilets or beds that were at an unsuitable height for older people. Conclusion. This paper provides an improved and an important understanding of the housing situation among older people living in rural areas in Thailand.
doi:10.1155/2014/289731
PMCID: PMC4101953  PMID: 25101268
10.  Interpersonal Trust across Six Asia-Pacific Countries: Testing and Extending the ‘High Trust Society’ and ‘Low Trust Society’ Theory 
PLoS ONE  2014;9(4):e95555.
Background
Trust is regarded as a necessary component for the smooth running of society, although societal and political modernising processes have been linked to an increase in mistrust, potentially signalling social and economic problems. Fukuyama developed the notion of ‘high trust’ and ‘low trust’ societies, as a way of understanding trust within different societies. The purpose of this paper is to empirically test and extend Fukuyama’s theory utilising data on interpersonal trust in Taiwan, Hong Kong, South Korea, Japan, Australia and Thailand. This paper focuses on trust in family, neighbours, strangers, foreigners and people with a different religion.
Methods
Cross-sectional surveys were undertaken in 2009–10, with an overall sample of 6331. Analyses of differences in overall levels of trust between countries were undertaken using Chi square analyses. Multivariate binomial logistic regression analysis was undertaken to identify socio-demographic predictors of trust in each country.
Results
Our data indicate a tripartite trust model: ‘high trust’ in Australia and Hong Kong; ‘medium trust’ in Japan and Taiwan; and ‘low trust’ in South Korea and Thailand. Trust in family and neighbours were very high across all countries, although trust in people with a different religion, trust in strangers and trust in foreigners varied considerably between countries. The regression models found a consistent group of subpopulations with low trust across the countries: people on low incomes, younger people and people with poor self-rated health. The results were conflicting for gender: females had lower trust in Thailand and Hong Kong, although in Australia, males had lower trust in strangers, whereas females had lower trust in foreigners.
Conclusion
This paper identifies high, medium and low trust societies, in addition to high and low trusting population subgroups. Our analyses extend the seminal work of Fukuyama, providing both corroboration and refutation for his theory.
doi:10.1371/journal.pone.0095555
PMCID: PMC3997396  PMID: 24760052
11.  A qualitative study of CVD management and dietary changes: problems of ‘too much’ and ‘contradictory’ information 
BMC Family Practice  2014;15:25.
Background
Nutrition education for cardiovascular disease (CVD) management is not effective for all population groups. There is little understanding of the factors that hinder patients from adhering to dietary recommendations.
Methods
37 interviews were conducted with people living with CVD in Adelaide, Australia. Recruitment occurred via General Practitioner (GP) clinics and hospital cardiac rehabilitation programs. Participants were either receiving preventive treatment or active treatment for established CVD.
Results
The volume and contradictory nature of dietary information were the most prominent barriers to making changes identified in interviews, especially by order participants.
Conclusion
Patients will seek out, or come into contact with information which contradicts advice from their GPs. The volume of information may lead them to resort to old and familiar habits. GPs play a valuable role in highlighting key take-home messages and reliable external sources of information. The findings have implications for GP practice given that lifestyle changes are a cost- and clinically-effective means of managing CVD.
doi:10.1186/1471-2296-15-25
PMCID: PMC3916316  PMID: 24495674
General practice; Cardiovascular disease; Lifestyle; Diet; Australia
12.  ‘Never testing for HIV’ among Men who have Sex with Men in Viet Nam: results from an internet-based cross-sectional survey 
BMC Public Health  2013;13:1236.
Background
Men who have sex with men in Viet Nam have been under-studied as a high-risk group for HIV infection, and this population’s percentage and determinants of HIV testing have not been comprehensively investigated.
Methods
A national Internet-based survey of self-reported sexual and health seeking behaviours was conducted between August and October 2011 with 2077 Vietnamese men who had sex with men in the last twelve months to identify the frequency of ‘never testing for HIV’ among Internet-using MSM living in Viet Nam, as well as the factors associated with this HIV-related high-rish behavior. Logistic regression analyses were conducted to assess the demographic characteristics and behaviours predicting never testing for HIV.
Results
A total of 76.5% of men who have sex with men who were surveyed reported never having been voluntarily tested for HIV. Predictors of never being tested included having a monthly income less than VND 5 Million, being a student, using the Internet less than 15 hour per week, and not participating in a behavioural HIV intervention.
Conclusions
Never testing for HIV is common among Internet-using men who have sex with men in Viet Nam. Given the dangerously high prevalence of this high-risk behaviour, our findings underscore the urgent need for segmented and targeted HIV prevention, care and treatment strategies, focusing on drastically reducing the number of men who have sex with men never testing for HIV in Viet Nam.
doi:10.1186/1471-2458-13-1236
PMCID: PMC3877867  PMID: 24373483
Men who have Sex with Men; High risk HIV behaviours; HIV testing; Viet Nam
13.  Identifying Vulnerable Populations Using a Social Determinants of Health Framework: Analysis of National Survey Data across Six Asia-Pacific Countries 
PLoS ONE  2013;8(12):e83000.
Background
In order to improve the health of the most vulnerable groups in society, the WHO called for research on the multiple and inter-linking factors shaping the social determinants of health (SDH). This paper analyses four key SDH (social cohesion, social inclusion, social empowerment and socioeconomic security) across six Asia-Pacific countries: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand.
Methods
Population surveys were undertaken using a validated instrument in 2009-10, with sample sizes around 1000 in each country. The four SDH were analysed using multivariate binomial logistic regression to identify socio-demographic predictors in each country.
Results
Low socio-economic security was associated with low income in all six study countries and with poor subjective health in Japan, South Korea and Thailand and with being married or cohabiting in Australia and Hong Kong. Low social cohesion was associated with low income in all countries and with undertaking household duties in South Korea, Thailand and Taiwan. Low social inclusion was associated with low income in Australia, South Korea and Taiwan and with poor subjective health in Australia, Japan and South Korea. Older people had lower social inclusion in Taiwan (50-59 years) and Hong Kong (retired), younger people in Japan and South Korea (20-29 years in both countries) and younger and middle-aged people in Australia. Low social empowerment was associated with low income in Australia, Thailand and Taiwan, with being aged 60 years or over in Australia, Hong Kong and South Korea, and over 50 years in Thailand.
Conclusions
This paper provides baseline measures for identifying where and how policy should be altered to improve the SDH. Furthermore, these data can be used for future policy evaluation to identify whether changes in policy have indeed improved the SDH, particularly for marginalised and vulnerable populations.
doi:10.1371/journal.pone.0083000
PMCID: PMC3857316  PMID: 24349417
14.  Inequities in access to healthcare: analysis of national survey data across six Asia-Pacific countries 
Background
Evidence suggests that there is a link between inequitable access to healthcare and inequitable distribution of illness. A recent World Health Organization report stated that there is a need for research and policy to address the critical role of health services in reducing inequities and preventing future inequities. The aim of this manuscript is to highlight disparities and differences in terms of the factors that distinguish between poor and good access to healthcare across six Asia-Pacific countries: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand.
Methods
A population survey was undertaken in each country. This paper is a secondary analysis of these existing data. Data were collected in each country between 2009 and 2010. Four variables related to difficulties in access to healthcare (distance, appointment, waiting time, and cost) were analysed using binomial logistic regression to identify socio- and demographic predictors of inequity.
Results
Consistent across the findings, poor health and low income were identified as difficulties in access. Country specific indicators were also identified. For Thailand, the poorest level of access appears to be for respondents who work within the household whereas in Taiwan, part-time work is associated with difficulties in access. Within Hong Kong, results suggest that older (above 60) and retired individuals have the poorest access and within Australia, females and married individuals are the worst off.
Conclusion
Recognition of these inequities, from a policy perspective, is essential for health sector policy decision-making. Despite the differences in political and economic climate in the countries under analysis, our findings highlight patterns of inequity which require policy responses. Our data should be used as a means of deciding the most appropriate policy response for each country which includes, rather than excludes, socially marginalised population groups. These findings should be of interest to those involved in health policy, but also in policy more generally because as we have identified, access to health care is influenced by determinants outside of the health system.
doi:10.1186/1472-6963-13-238
PMCID: PMC3734194  PMID: 23816181
Equity; Access; Healthcare; Asia; Pacific; Social determinants; Policy
15.  Evaluating the use of citizens’ juries in food policy: a case study of food regulation 
BMC Public Health  2013;13:596.
Background
Deliberative engagement techniques and citizens’ juries are touted as means of incorporating the public into policy decision-making, managing community expectations and increasing commitment to public health policy. This paper reports a study to examine the feasibility of citizens’ juries as a means of collecting data to inform public health policy related to food regulation through evaluation of the conduct of a citizens’ jury.
Methods
A citizens’ jury was conducted with a representative sample of 17 South Australians to explore their willingness to consider the proposition that food and drink advertising and/or sponsorship should be banned at children’s sporting events.
Results
The results showed that, in relation to the central proposition and evaluation data from the jury, opinion on the proposition remained comparatively stable. Most jurors indicated that they thought that food and drink sponsorship and/or advertising at children’s sporting events would have little or no effect on altering children’s diet and eating habits, with the proportion increasing during the jury process. Jurors were given evaluation sheets about the content of the jury and the process of the citizens’ jury to complete at the end of the session. The evaluation of the citizens’ jury process revealed positive perceptions. The majority of jurors agreed that their knowledge of the issues of food and drink sponsorship in children’s sport had increased as a result of participation in the citizens’ jury. The majority also viewed the decision-making process as fair and felt that their views were listened to. One important response in the evaluation was that all jurors indicated that, if given the opportunity, they would participate in another citizens’ jury.
Conclusions
The findings suggest that the citizens’ jury increased participant knowledge of the issue and facilitated reflective discussion of the proposition. Citizens’ juries are an effective means of gaining insight into public views of policy and the circumstances under which the public will consider food regulation; however a number of issues need to be considered to ensure the successful conduct of a citizens’ jury.
doi:10.1186/1471-2458-13-596
PMCID: PMC3733832  PMID: 23782688
Citizens’ juries; Deliberative democracy; Food regulation; Food sponsorship; Children sporting events
16.  The impact of education programs on smoking prevention: a randomized controlled trial among 11 to 14 year olds in Aceh, Indonesia 
BMC Public Health  2013;13:367.
Background
School-based smoking prevention programs have been shown to increase knowledge of the negative effects of smoking and prevent tobacco smoking. The majority of evidence on effectiveness comes from Western countries. This study investigated the impact of school-based smoking prevention programs on adolescents’ smoking knowledge, attitude, intentions and behaviors (KAIB) in Aceh, Indonesia.
Methods
We conducted a 2 × 2 factorial randomized controlled trial among 7th and 8th grade students aged 11 to 14 years. Eight schools were randomly assigned to a control group or one of three school-based programs: health-based, Islamic-based, or a combined program. Students in the intervention groups received eight classroom sessions on smoking prevention education over two months. The KAIB impact of the program was measured by questionnaires administered one week before and one week after the intervention.
Results
A total of 477 students participated (58% female, 51% eighth graders). Following the intervention, there was a significant main effect of the Health based intervention for health knowledge scores (β = 3.9 ± 0.6, p < 0.001). There were significant main effects of the Islamic-based intervention in both health knowledge (β = 3.8 ± 0.6, p < 0.001) and Islamic knowledge (β = 3.5 ± 0.5, p < 0.001); an improvement in smoking attitude (β = −7.1 ± 1.5, p < 0.001). The effects of Health and Islam were less than additive for the health and Islamic factors for health knowledge (β = −3.5 ± 0.9, p < 0.01 for interaction) and Islamic knowledge (β = −2.0 ± 0.8, p = 0.02 for interaction). There were no significant effects on the odds of intention to smoke or smoking behaviors.
Conclusions
Both Health and Islamic school-based smoking prevention programs provided positive effects on health and Islamic related knowledge respectively among adolescents in Indonesia. Tailoring program interventions with participants’ religion background information may provide additional benefits to health only focused interventions.
Trial registration
Australia and New Zealand Clinical Trials Register, ACTRN12612001070820
doi:10.1186/1471-2458-13-367
PMCID: PMC3640933  PMID: 23596980
Smoking prevention; Indonesia; Schools; Health knowledge; Attitude; Behavior; Intention
17.  Trust makers, breakers and brokers: building trust in the Australian food system 
BMC Public Health  2013;13:229.
Background
The importance of consumer trust in the food supply has previously been identified, and dimensions of consumer trust in food—who they trust and the type of trust that they exhibit—has been explored. However, there is a lack of research about the mechanisms through which consumer trust in the food supply is developed, maintained, broken and repaired. This study seeks to address this gap by exploring if, and how, consumer trust in the food supply is considered by the media, food industry and governments when responding to food scares. The aim of the research is to develop models of trust building that can be implemented following food scares.
Methods
Semi-structured interviews will be undertaken with media, public relations officials and policy makers in Australia, New Zealand and the United Kingdom. Participants will be recruited through purposive sampling and will be asked to discuss a hypothetical case study outlining a food incident, and any experiences of specific food scares. Models of trust development, maintenance and repair will be developed from interview data. Comment on these models will be sought from experts in food-related organizations through a Delphi study, where participants will be asked to consider the usefulness of the models. Participants’ comments will be used to revise the models until consensus is reached on the suitability and usability of the models.
Discussion
This study will contribute to the literature about systems-based trust, and explore trust as a social and regulatory process. The protocol and results will be of interest and use to the food industry, food regulators, consumer advocate groups, media seeking to report food-related issues and policy makers concerned with public health and consumer health and well-being. This research represents an important contribution to the translation of the theoretical conceptualizations of trust into practical use in the context of food.
doi:10.1186/1471-2458-13-229
PMCID: PMC3729665  PMID: 23496819
Food; Trust; Food scare; Food safety; Australia; United Kingdom
18.  Food Stress in Adelaide: The Relationship between Low Income and the Affordability of Healthy Food 
Healthy food is becoming increasingly expensive, and families on low incomes face a difficult financial struggle to afford healthy food. When food costs are considered, families on low incomes often face circumstances of poverty. Housing, utilities, health care, and transport are somewhat fixed in cost; however food is more flexible in cost and therefore is often compromised with less healthy, cheaper food, presenting an opportunity for families on low incomes to cut costs. Using a “Healthy Food Basket” methodology, this study costed a week's supply of healthy food for a range of family types. It found that low-income families would have to spend approximately 30% of household income on eating healthily, whereas high-income households needed to spend about 10%. The differential is explained by the cost of the food basket relative to household income (i.e., affordability). It is argued that families that spend more than 30% of household income on food could be experiencing “food stress.” Moreover the high cost of healthy foods leaves low-income households vulnerable to diet-related health problems because they often have to rely on cheaper foods which are high in fat, sugar, and salt.
doi:10.1155/2013/968078
PMCID: PMC3569900  PMID: 23431321
19.  HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention 
Systematic Reviews  2012;1:56.
Background
Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention.
Methods
We undertook a realist review to answer the research question: ‘How are HIV prevention interventions in high-income countries adapted to suit immigrants’ needs?’ A key goal was to uncover underlying theories or mechanisms operating in behavioural HIV prevention interventions with immigrants, to uncover explanations as how and why they work (or not) for particular groups in particular contexts, and thus to refine the underlying theories. The realist review mapped seven initial mechanisms underlying culturally appropriate HIV prevention with immigrants. Evidence from intervention studies and qualitative studies found in systematic searches was then used to test and refine these seven mechanisms.
Results
Thirty-four intervention studies and 40 qualitative studies contributed to the analysis and synthesis of evidence. The strongest evidence supported the role of ‘consonance’ mechanisms, indicating the pivotal need to incorporate cultural values into the intervention content. Moderate evidence was found to support the role of three other mechanisms – ‘understanding’, ‘specificity’ and ‘embeddedness’ – which indicated that using the language of immigrants, usually the ‘mother tongue’, targeting (in terms of ethnicity) and the use of settings were also critical elements in culturally appropriate HIV prevention. There was mixed evidence for the roles of ‘authenticity’ and ‘framing’ mechanisms and only partial evidence to support role of ‘endorsement’ mechanisms.
Conclusions
This realist review contributes to the explanatory framework of behavioural HIV prevention among immigrants living in high-income countries and, in particular, builds a greater understanding of the suite of mechanisms that underpin adaptations of interventions by the cultural context and population being targeted.
doi:10.1186/2046-4053-1-56
PMCID: PMC3534573  PMID: 23168134
HIV prevention; Immigrants; Realist review; Culturally appropriate; Behavioural interventions
20.  Does prognosis and socioeconomic status impact on trust in physicians? Interviews with patients with coronary disease in South Australia 
BMJ Open  2012;2(5):e001389.
Objectives
There is concern across a range of healthcare settings worldwide that trust in physicians is declining. Decreased trust may lead to lesser tolerance of prognosis uncertainty and an increased demand for tests, referrals and second opinions. Literature suggests that there has been a recent cultural shift towards decreased trust in, and increased questioning of, medical advice. We investigated the impact of varying prognosis and socioeconomic status (SES) on trust in physicians, and patient questioning of medical advice.
Design
Semistructured, audio-recorded transcribed interviews were conducted. The interview schedule was developed with reference to the Health Belief Model. Interviews were conducted between October 2008 and September 2009.
Setting
Participants were recruited via general practitioner clinics and hospital cardiac rehabilitation programmes.
Participants
Participants consisted of patients either receiving preventive treatment or active treatment for established cardiovascular disease.
Outcome measures
A coding structure was developed based on the aim of the research, to investigate the impact of varying prognosis and SES on trust in physicians.
Results
Older participants are more likely than their younger counterparts to be unquestioning of medical advice. Higher SES participants are more likely to question medical advice than lower SES participants. Also, unlike primary prevention participants, established pathology increased participants’ trust, or decreased questioning behaviour. Participants who perceived themselves at risk of a poor or uncertain outcome were unlikely to doubt medical advice.
Conclusions
Blind trust in physicians remains strong in older participants, participants who perceive their prognosis to be uncertain and a proportion of lower SES participants. This is important for practitioners in terms of patient agency and points to the importance of moral and ethical practice. However, physicians also need to be aware that there are a growing proportion of patients for whom trust needs to be developed, and cannot be assumed.
doi:10.1136/bmjopen-2012-001389
PMCID: PMC3488703  PMID: 23035015
Preventive Medicine; Medical Education & Training
21.  Elevated HIV prevalence and risk behaviours among men who have sex with men (MSM) in Vietnam: a systematic review 
BMJ Open  2012;2(5):e001511.
Objectives
To review and analyse original studies on HIV prevalence and risk behaviours among men who have sex with men (MSM) in Vietnam.
Design
Systematic literature review. Comprehensive identification of material was conducted by systematic electronic searches of selected databases. Inclusion criteria included studies conducted from 2002 onwards, following a systematic review concluding in 2001 conducted by Colby, Nghia Huu and Doussantousse. Data analysis was undertaken through the application of both the Cochrane Collaboration and ePPI Centre approaches to the synthesis of qualitative and quantitative studies.
Setting
Vietnam.
Results
Sixteen studies, undertaken during 2005–2011, were identified that met the inclusion criteria. The analysis showed that HIV prevalence among MSM in Vietnam has increased significantly (eg, from 9.4% in 2006 to 20% in 2010 in Hanoi) and that protective behaviours, such as condom use and HIV testing and counselling, continue at inadequately low levels.
Conclusions
Increasing HIV prevalence and the lack of effective protective behaviours such as consistent condom use during anal sex among MSM in Vietnam indicate a potential for a more severe HIV epidemic in the future unless targeted and segmented comprehensive HIV prevention strategies for MSM in Vietnam are designed and programmes implemented.
doi:10.1136/bmjopen-2012-001511
PMCID: PMC3467604  PMID: 23015604
HIV; AIDS; Homosexuality; Gay men; Sexual behaviour
22.  Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study 
BMJ Open  2012;2(3):e000939.
Objectives
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Design
Qualitative study involving focus groups with members of the public.
Setting
The West of Scotland.
Participants
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Results
Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be ‘high risk’. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence.
Conclusion
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be ‘high risk’, unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
Article summary
Article focus
Why do the public access GPs for services, which are also available in community pharmacies?
What sort of services do the public trust community pharmacists to deliver?
What factors underpin greater public trust in GP services relative to community pharmacy services?
Key messages
Public trust in GPs was greater than that in pharmacists; many were reluctant to trust pharmacists to deliver unfamiliar ‘high-risk’ services.
Numerous system-based factors reinforce public trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments.
This study suggests that increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services could build public trust.
Strengths and limitations of this study
This is the first study to apply sociological perspectives of trust to understand public perspectives of community pharmacy.
The qualitative approach has allowed us to gather in-depth information in an under-researched area.
The study methodology limits generalisation, although theme saturation was achieved and the context of the study is explicitly defined.
doi:10.1136/bmjopen-2012-000939
PMCID: PMC3358628  PMID: 22586286
23.  Complex problems require complex solutions: the utility of social quality theory for addressing the Social Determinants of Health 
BMC Public Health  2011;11:630.
Background
In order to improve the health of the most vulnerable groups in society, the WHO Commission on Social Determinants of Health (CSDH) called for multi-sectoral action, which requires research and policy on the multiple and inter-linking factors shaping health outcomes. Most conceptual tools available to researchers tend to focus on singular and specific social determinants of health (SDH) (e.g. social capital, empowerment, social inclusion). However, a new and innovative conceptual framework, known as social quality theory, facilitates a more complex and complete understanding of the SDH, with its focus on four domains: social cohesion, social inclusion, social empowerment and socioeconomic security, all within the same conceptual framework. This paper provides both an overview of social quality theory in addition to findings from a national survey of social quality in Australia, as a means of demonstrating the operationalisation of the theory.
Methods
Data were collected using a national random postal survey of 1044 respondents in September, 2009. Multivariate logistic regression analysis was conducted.
Results
Statistical analysis revealed that people on lower incomes (less than $45000) experience worse social quality across all of the four domains: lower socio-economic security, lower levels of membership of organisations (lower social cohesion), higher levels of discrimination and less political action (lower social inclusion) and lower social empowerment. The findings were mixed in terms of age, with people over 65 years experiencing lower socio-economic security, but having higher levels of social cohesion, experiencing lower levels of discrimination (higher social inclusion) and engaging in more political action (higher social empowerment). In terms of gender, women had higher social cohesion than men, although also experienced more discrimination (lower social inclusion).
Conclusions
Applying social quality theory allows researchers and policy makers to measure and respond to the multiple sources of oppression and advantage experienced by certain population groups, and to monitor the effectiveness of interventions over time.
doi:10.1186/1471-2458-11-630
PMCID: PMC3167771  PMID: 21819576
24.  The Karyotype of the Yellow Dung Fly, Scathophaga stercoraria, a Model Organism in Studies of Sexual Selection 
Knowledge of karyotypical characteristics of a species is essential for understanding how sexually selected and sexually antagonistic traits evolve. The yellow dung fly Scathophaga stercoraria L. (Diptera: Scathophagidae) is an established model system for studies of sexual selection and sexual conflict, but karyotypical data are lacking to date. Here, the karyotype of S. stercoraria was characterized using conventional Giemsa-staining and C-banding techniques. The diploid chromosome set consists of 6 pairs of bi-armed meta- or submetacentric chromosomes. The sex chromosomes are the largest chromosomes and constitute 30% of the total length of the diploid set in females and about 25% in males. Males are the heterogametic sex, and the length of the Y chromosome is about three-quarters of that of the X chromosome. C-banding revealed that both sex chromosomes are largely heterochromatic. In contrast, in the five autosome pairs, heterochromatin is limited to narrow bands in the centromeric regions. This karyotypic information will help provide a more profound understanding of the inheritance of phenotypic variation in reproductive traits and the chromosomal locations of underlying genes.
doi:10.1673/031.010.11801
PMCID: PMC3016996  PMID: 20874599
antagonistic; dimorphism; Diptera; heterochromatin; Scatophaga; sex chromosome; sexual conflict
25.  Health and happiness in a materially deprived, ethnically mixed locality 
PMCID: PMC2465540  PMID: 16361461
happiness; health; social exclusion; social model of health; trust

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