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1.  Racism as a determinant of health: a protocol for conducting a systematic review and meta-analysis 
Systematic Reviews  2013;2:85.
Background
Racism is increasingly recognized as a key determinant of health. A growing body of epidemiological evidence shows strong associations between self-reported racism and poor health outcomes across diverse minority groups in developed countries. While the relationship between racism and health has received increasing attention over the last two decades, a comprehensive meta-analysis focused on the health effects of racism has yet to be conducted. The aim of this review protocol is to provide a structure from which to conduct a systematic review and meta-analysis of studies that assess the relationship between racism and health.
Methods
This research will consist of a systematic review and meta-analysis. Studies will be considered for review if they are empirical studies reporting quantitative data on the association between racism and health for adults and/or children of all ages from any racial/ethnic/cultural groups. Outcome measures will include general health and well-being, physical health, mental health, healthcare use and health behaviors. Scientific databases (for example, Medline) will be searched using a comprehensive search strategy and reference lists will be manually searched for relevant studies. In addition, use of online search engines (for example, Google Scholar), key websites, and personal contact with experts will also be undertaken. Screening of search results and extraction of data from included studies will be independently conducted by at least two authors, including assessment of inter-rater reliability. Studies included in the review will be appraised for quality using tools tailored to each study design. Summary statistics of study characteristics and findings will be compiled and findings synthesized in a narrative summary as well as a meta-analysis.
Discussion
This review aims to examine associations between reported racism and health outcomes. This comprehensive and systematic review and meta-analysis of empirical research will provide a rigorous and reliable evidence base for future research, policy and practice, including information on the extent of available evidence for a range of racial/ethnic minority groups
doi:10.1186/2046-4053-2-85
PMCID: PMC3850958  PMID: 24059279
Racism; Racial discrimination; Mental health; Physical health; Meta-analysis; Systematic review
2.  Mental health affects future employment as job loss affects mental health: findings from a longitudinal population study 
BMC Psychiatry  2013;13:144.
Background
Workforce participation is a key feature of public mental health and social inclusion policies across the globe, and often a therapeutic goal in treatment settings. Understanding the reciprocal relationship between participation and mental health has been limited by inadequate research methods. This is the first study to simultaneously examine and contrast the relative effects of unemployment on mental health and mental health on employment status in a single general population sample.
Method
Data were from working-age respondents (20 to 55 years at baseline) who completed nine waves of the Household, Income and Labour Dynamics in Australia (HILDA) Survey (N=7176). Cross-lagged path analyses were used to test the lagged and concurrent associations between unemployment and mental health over time, adjusting for sociodemographic characteristics.
Results
Mental health was shown to be both a consequence of and risk factor for unemployment. Thus, the poorer mental health observed amongst people who are not working is attributable to both the impact of unemployment and existing mental health problems. While the strength of these two effects was similar for women, the results for men suggested that the effect of unemployment on subsequent mental health was weaker than the effect of mental health on subsequent risk of unemployment.
Conclusion
Disentangling the reciprocal links between mental health and workforce participation is central to the development and success of clinical goals and health and social policies that aim to promote either aspect. This study demonstrates that both effects are important and supports concurrent responses to prevent a cycle of disadvantage and entrenched social exclusion.
doi:10.1186/1471-244X-13-144
PMCID: PMC3681556  PMID: 23705753
Mental health; Unemployment; Employment; Inclusion; Longitudinal; Social policy
3.  Access to eye health services among indigenous Australians: an area level analysis 
BMC Ophthalmology  2012;12:51.
Background
This project is a community-level study of equity of access to eye health services for Indigenous Australians.
Methods
The project used data on eye health services from multiple sources including Medicare Australia, inpatient and outpatient data and the National Indigenous Eye Health Survey.
The analysis focused on the extent to which access to eye health services varied at an area level according to the proportion of the population that was Indigenous (very low = 0-1.0%, low = 1.1-3.0%, low medium = 3.1-6.0%, high medium = 6.1-10.0%, high = 10.1-20.0%, very high = 20 + %). The analysis of health service utilisation also took into account age, remoteness and the Socioeconomic Indices for Areas (SEIFA).
Results
The rate of eye exams provided in areas with very high Indigenous populations was two-thirds of the rate of eye exams for areas with very low indigenous populations. The cataract surgery rates in areas with high medium to very high Indigenous populations were less than half that reference areas. In over a third of communities with very high Indigenous populations the cataract surgery rate fell below the World Health Organization (WHO) guidelines compared to a cataract surgery rate of 3% in areas with very low Indigenous populations.
Conclusions
There remain serious disparities in access to eye health service in areas with high Indigenous populations. Addressing disparities requires a co-ordinated approach to improving Indigenous people’s access to eye health services. More extensive take-up of existing Medicare provisions is an important step in this process. Along with improving access to health services, community education concerning the importance of eye health and the effectiveness of treatment might reduce reluctance to seek help.
doi:10.1186/1471-2415-12-51
PMCID: PMC3514169  PMID: 22998612
Aboriginal and Torres Strait Islander; Indigenous; Eye; Cataract; Equity
4.  Differences in primary health care delivery to Australia’s Indigenous population: a template for use in economic evaluations 
Background
Health economics is increasingly used to inform resource allocation decision-making, however, there is comparatively little evidence relevant to minority groups. In part, this is due to lack of cost and effectiveness data specific to these groups upon which economic evaluations can be based. Consequently, resource allocation decisions often rely on mainstream evidence which may not be representative, resulting in inequitable funding decisions. This paper describes a method to overcome this deficiency for Australia’s Indigenous population. A template has been developed which can adapt mainstream health intervention data to the Indigenous setting.
Methods
The ‘Indigenous Health Service Delivery Template’ has been constructed using mixed methods, which include literature review, stakeholder discussions and key informant interviews. The template quantifies the differences in intervention delivery between best practice primary health care for the Indigenous population via Aboriginal Community Controlled Health Services (ACCHSs), and mainstream general practitioner (GP) practices. Differences in costs and outcomes have been identified, measured and valued. This template can then be used to adapt mainstream health intervention data to allow its economic evaluation as if delivered from an ACCHS.
Results
The template indicates that more resources are required in the delivery of health interventions via ACCHSs, due to their comprehensive nature. As a result, the costs of such interventions are greater, however this is accompanied by greater benefits due to improved health service access. In the example case of the polypill intervention, 58% more costs were involved in delivery via ACCHSs, with 50% more benefits. Cost-effectiveness ratios were also altered accordingly.
Conclusions
The Indigenous Health Service Delivery Template reveals significant differences in the way health interventions are delivered from ACCHSs compared to mainstream GP practices. It is important that these differences are included in the conduct of economic evaluations to ensure results are relevant to Indigenous Australians. Similar techniques would be generalisable to other disadvantaged minority populations. This will allow resource allocation decision-makers access to economic evidence that more accurately represents the needs and context of disadvantaged groups, which is particularly important if addressing health inequities is a stated goal.
doi:10.1186/1472-6963-12-307
PMCID: PMC3468365  PMID: 22954136
Health economics; Resource allocation; Indigenous Australians; Primary health care services; Health service delivery; Health equity
6.  Child Health Partnerships: a review of program characteristics, outcomes and their relationship 
Background
Novel approaches are increasingly employed to address the social determinants of health of children world-wide. Such approaches have included complex social programs involving multiple stakeholders from different sectors jointly working together (hereafter Child Health Partnerships). Previous reviews have questioned whether these programs have led to significant improvements in child health and related outcomes. We aim to provide definitive answers to this question as well as identifying the characteristics of successful partnerships.
Methods
A comprehensive literature search identified 11 major Child Health Partnerships in four comparable developed countries. A critical review is focused on various aspects of these including their target groups, program mechanics and outcomes.
Results and Conclusions
There was evidence of success in several major areas from the formation of effective joint operations of partners in different partnership models to improvement in both child wellbeing and parenting. There is emerging evidence that Child Health Partnerships are cost-effective. Population characteristics and local contexts need to be taken into account in the introduction and implementation of these programs.
doi:10.1186/1472-6963-10-172
PMCID: PMC2908613  PMID: 20565798
7.  A cost-based equity weight for use in the economic evaluation of primary health care interventions: case study of the Australian Indigenous population 
Background
Efficiency and equity are both important policy objectives in resource allocation. The discipline of health economics has traditionally focused on maximising efficiency, however addressing inequities in health also requires consideration. Methods to incorporate equity within economic evaluation techniques range from qualitative judgements to quantitative outcomes-based equity weights. Yet, due to definitional uncertainties and other inherent limitations, no method has been universally adopted to date. This paper proposes an alternative cost-based equity weight for use in the economic evaluation of interventions delivered from primary health care services.
Methods
Equity is defined in terms of 'access' to health services, with the vertical equity objective to achieve 'equitable access for unequal need'. Using the Australian Indigenous population as an illustrative case study, the magnitude of the equity weight is constructed using the ratio of the costs of providing specific interventions via Indigenous primary health care services compared with the costs of the same interventions delivered via mainstream services. Applying this weight to the costs of subsequent interventions deflates the costs of provision via Indigenous health services, and thus makes comparisons with mainstream more equitable when applied during economic evaluation.
Results
Based on achieving 'equitable access', existing measures of health inequity are suitable for establishing 'need', however the magnitude of health inequity is not necessarily proportional to the magnitude of resources required to redress it. Rather, equitable access may be better measured using appropriate methods of health service delivery for the target group. 'Equity of access' also suggests a focus on the processes of providing equitable health care rather than on outcomes, and therefore supports application of equity weights to the cost side rather than the outcomes side of the economic equation.
Conclusion
Cost-based weights have the potential to provide a pragmatic method of equity weight construction which is both understandable to policy makers and sensitive to the needs of target groups. It could improve the evidence base for resource allocation decisions, and be generalised to other disadvantaged groups who share similar concepts of equity. Development of this decision-making tool represents a potentially important avenue for further health economics research.
doi:10.1186/1475-9276-8-34
PMCID: PMC2768712  PMID: 19807930
8.  The effects of an area-based intervention on the uptake of maternal and child health assessments in Australia: A community trial 
Background
Recognition of the importance of the early years in determining health and educational attainment and promotion of the World Health Organization Health for All (HFA) principles has led to an international trend towards community-based initiatives to improve developmental outcomes among socio-economically disadvantaged children. In this study we examine whether, Best Start, an Australian area-based initiative to improve child health was effective in improving access to Maternal and Child Health (MCH) services.
Methods
The study compares access to information, parental confidence and annual 3.5 year Ages and Stages visiting rates before (2001/02) and after (2004/05) the introduction of Best Start. Access to information and parental confidence were measured in surveys of parents with 3 year old children. There were 1666 surveys in the first wave and 1838 surveys in the second wave. The analysis of visiting rates for the 3.5 year Ages and Stages visit included all eligible Victorian children. Best Start sites included 1,739 eligible children in 2001/02 and 1437 eligible children in 2004/05. The comparable figures in the rest of the state were and 45, 497 and 45, 953 respectively.
Results
There was a significant increase in attendance at the 3.5 year Ages and Stages visit in 2004/05 compared to 2001/02 in all areas. However the increase in attendance was significantly greater at Best Start sites than the rest of the state. Access to information and parental confidence improved over the course of the intervention in Best Start sites with MCH projects compared to other Best Start sites.
Conclusion
These results suggest that community-based initiatives in disadvantaged areas may improve parents' access to child health information, improve their confidence and increase MCH service use. These outcomes suggest such programmes could potentially contribute to strategies to reduce child health inequalities.
doi:10.1186/1472-6963-9-53
PMCID: PMC2674040  PMID: 19320980
9.  The applicability of measures of socioeconomic position to different ethnic groups within the UK 
Background
In this paper we seek to tease out differences in socioeconomic position between ethnic groups. There are 3 main reasons why conventional socioeconomic indicators and asset based measures may not be equally applicable to all ethnic groups:
1) Differences in response rate to conventional socioeconomic indicators
2) Cultural and social differences in economic priorities/opportunities
3) Differences in housing quality, assets and debt within socioeconomic strata
Methods
The sample consisted of White (n = 227), African-Caribbean (n = 213) and Indian and Pakistani (n = 233) adults aged between 18 and 59 years living in Leeds as measured in a stratified population survey. Measures included income, education, employment, car ownership, home ownership, housing quality, household assets, investments, debt, perceived ability to obtain various sums and perceived level of financial support given and received.
Results
Response rates to education and income questions were similar for the different ethnic groups. Overall response rates for income were much lower than those for education and biased towards wealthier people. There were differences between ethnic groups in economic priorities/opportunities particularly in relation to car ownership, home ownership, investment and debt. Differences in living conditions, household assets and debt between ethnic groups were dependent on differences in education; however differences in car ownership, home ownership, ability to obtain £10 000, and loaning money to family/friends and income from employment/self employment persisted after adjustment for education.
Conclusion
In the UK, education appears to be an effective variable for measuring variation in SEP across ethnic groups but the ability to account for SEP differences may be improved by the addition of car and home ownership, ability to obtain £10 000, loaning money to family/friends and income from employment/self employment. Further research is required to establish the degree to which results of this study are generalisable.
doi:10.1186/1475-9276-8-4
PMCID: PMC2657895  PMID: 19250528
10.  Impact of telephone triage on emergency after hours GP Medicare usage: a time-series analysis 
Background
The Australian government sponsored trials aimed at addressing problems in after hours primary medical care service use in five different parts of the country with different after hours care problems. The study's objective was to determine in four of the five trials where telephone triage was the sole innovation, if there was a reduction in emergency GP after hours service utilization (GP first call-out) as measured in Medicare Benefits Schedule claim data. Monthly MBS claim data in both the pre-trial and trial periods was monitored over a 3-year period in each trial area as well as in a national sample outside the trial areas (National comparator). Poisson regression analysis was used in analysis.
Results
There was significant reduction in first call out MBS claims in three of the four study areas where stand-alone call centre services existed. These were the Statewide Call Centre in both its Metropolitan and Non-metropolitan areas in which it operated – Relative Risk (RR) = 0.87 (95% Confidence interval: 0.86 – 0.88) and 0.60 (95% CI: 0.54 – 0.68) respectively. There was also a reduction in the Regional Call Centre in the non-Metropolitan area in which it operated (RR = 0.46 (95% CI: 0.35 – 0.61) though a small increase in its Metropolitan area (RR = 1.11 (95% CI: 1.06 – 1.17). For the two telephone triage services embedded in existing organisations, there was also a significant reduction for the Deputising Service – RR = 0.62 (95% CI: 0.61 – 0.64) but no change in the Local Triage centre area.
Conclusion
The four telephone triage services were associated with reduced GP MBS claims for first callout after hours care in most study areas. It is possible that other factors could be responsible for some of this reduction, for example, MBS submitted claims for after hours GP services being reclassified from 'after hours' to 'in hours'. The goals of stand-alone call centres which are aimed principally at meeting population needs rather than managing demand may be being met only in part.
doi:10.1186/1743-8462-4-21
PMCID: PMC2151763  PMID: 17927836
11.  Impact of standalone and embedded telephone triage systems on after hours primary medical care service utilisation and mix in Australia 
Background
The Australian government sponsored five local trials aimed at addressing problems in after hours (AH) primary medical care (PMC). The study's objective was to determine if the four trials, where telephone triage was the sole innovation, led to a reduction in AH service utilisation and change in service mix towards AH GP clinics. Changes in utilisation and mix of AH GP clinic and home visits, ED and ambulance use were monitored in the trial areas, and in a national sample to adjust for the effects of secular trend. Pre- and post-trial telephone surveys of two separate random samples of approximately 350 AH PMC user households in each area were conducted.
Results
Some types of AH PMC use became more frequent in both of the standalone services using nurse-administered proprietary call centre software, which were aimed at better addressing population need (Statewide call centre; Regional call centre). Service use overall (95%CI: 1.03–1.83) and GP clinic use (95%CI: 1.07–2.00) increased in the metro area of the Statewide call centre and in GP clinic (95%CI: 1.04–2.14) and home visits (95%CI: 1.03–3.91) in the non-metro area of the Regional call centre. Service mix only changed in the non-metro area of the Regional call centre with increased contact in GP home visits (95%CI: 1.02–4.38). Levels of use remained unchanged in both embedded services using other than proprietary software, which were established to support the GP workforce (Deputising service; Local triage centre). Service mix only changed in the Deputising service with a change away from AH GP clinics in both contact (95%CI: 0.39–0.97) and frequency (95% CI: -2.12 – -0.7).
Conclusion
Bearing in mind limitations in estimating AH PMC utilisation levels and mix, it is concluded that the impacts of telephone triage were generally smaller in Australia than reported elsewhere. There were different impacts on levels of service utilisation and service mix in standalone call centres and embedded services. Impacts of telephone triage on service utilisation and mix are influenced by the type of telephone triage offered, the goals of the agency providing the service, as well as local factors. (345 words)
doi:10.1186/1743-8462-2-30
PMCID: PMC1334205  PMID: 16343354
12.  Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander people and other Australians: Implications for policy 
Background
Health Assessment (HA) items were introduced in 1999 for Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years. In 2004 a new item was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15–54 years. The new item has been applauded as a major policy innovation however this enthusiasm has been tempered with concern about potential barriers to its uptake. In this study we aim to determine whether there are disparities in uptake of HA items for Aboriginal and Torres Strait Islander people compared to other Australians.
Method
The analysis was based on Health Insurance Commission data. Indigenous status was ascertained based on the item number used. Logistic regression was used to compare uptake of HA items for older people among Aboriginal and Torres Strait Islander people compared to other Australians. Adjustments were made for dual eligibility. Uptake of the HA items for older people was compared to the uptake of the new item for Aboriginal and Torres Strait Islander people aged 15–44 years.
Results
Our analyses suggest a significant and persistent disparity in the uptake of items for older patients among Aboriginal and Torres Strait Islander people compared to other Australians. A similar disparity appears to exist in the uptake of the new adult Aboriginal and Torres Strait Islander HA item.
Conclusion
Further engagement of primary care providers and the community around the uptake of the new HA items may be required to ensure that the anticipated health benefits eventuate.
doi:10.1186/1743-8462-2-21
PMCID: PMC1239906  PMID: 16150154

Results 1-12 (12)