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Conference Reports

Showcasing PHCRED research from SA, NT and greater Green Triangle?

PHCRED Statewide Collaboration Annual Event
21 September 2006, Adelaide
Attended by Ellen McIntyre (presenter), Sarah Eckermann, Libby Kalucy, PHC RIS

Over 50 delegates coming from as far as Alice Springs, Warrnambool, Whyalla, Canberra and even Scotland were captured by the presentations from researchers funded through the PHCRED program.

Many stories from individual presenters were told throughout the day, putting a realistic context to the research that was presented. For example, Ricky Mentha, an Indigenous health worker, footballer and father of four, described how the "Responsible Alcohol Strategy" had been implemented at football games in Alice Springs . Alcohol restrictions enforced at these games have meant a more family friendly environment with fewer problem drinkers attending and less alcohol being sold. This has resulted in a decrease in the number of alcohol related incidents and improved crowd behaviour.

Robert Wells, Director of the Menzies Centre for Health Policy at ANU, provided useful insights into how the research can help policy in his presentation on "Making the evidence fit the policy". Policy moments, as he called them, are those opportunities where the right evidence is provided for the right problem at the right time to produce the right policy.

John Wakerman, Director of Centre for Rural and Remote Health, Alice Springs and current chair of the National Rural Health Alliance spoke on Linking policy and research - rural health in Australia .

National Rural health Alliance has 25 members, from a wide range of organisations, who hare united by a common goal of improving health status of Australians in rural areas. The Council communicates regularly by teleconference, has an annual priority setting meeting and a biannual conference. It promotes its existence widely in the public arena and has become a one stop shop for promoting the rural viewpoint. By being visible and credible, it collaborates with other NGOs on policy positions. NRHA now sets the agenda by producing policy papers, rather than just responding reactively. Their audience is wide, but the message always needs to make sense to people in the bush. NRHA members work through and nurture relationships with both public servants and politicians, transparently. NRHA communicates through many media - the Australian Journal of Rural Health, an electronic forum each fortnight, media releases, and most importantly, face to face with public servants and politicians on both sides of the house. Each year they hold a seminar in Canberra for public servants on key issues - this year will be on potential election issues.

John's messages for researchers are:

• Have a dissemination plan and budget:
• Use scholarly journals and trade journals, general media, and particularly face to face meetings, and amplify your messages through other groups.
• Anecdote based on fact is more powerful than the fact. 'Don't wipe away the tears', allow the message to have real impact.
• Research transfer is part of the design of a research project, and is more than printing a report.
• Credibility and visibility are important.
• Relationships take time and are not easy.
• Measure the impact of what you do.
• Be aware of the value set of those who hear and read your research, and take these into account.

Heather Petty, Principal Practice Officer (Research Policy & Funding) Department of Health, SA spoke from the decision makers' perspective. She agreed with John about the importance of relationships between researchers and decision makers, despite the difficulties presented by different time frames and incentives. Heather was very pleased to be able to tell participants that the executive of the Health Department had approved the State Health strategic health research program that day, and would be advertising soon to researchers to answer specific questions the Department has defined which relate to the SA Strategic Plan. The department is interested in co production of research to get more evidence into the system for decision makers, and bridge gaps between the health system and research community caused by lack of relationships and understanding. Heather recommended that researchers talk to the Department early about their research ideas, not just before submissions are due.

An important aspect of the day was the opportunity for researchers supported by PHCRED to present their work in progress.

Janet Kelly and Rose Daniel
Janet holds a PHC RED bursary from the Department of General Practice at Flinders University. Rose is an aboriginal woman working with Janet at a community health service in suburban Adelaide.

This joint presentation demonstrated that Janet is a knowledge broker in this community, having built up community trust over many years of working with these women. Rose identified that Janet brings knowledge about western ways of knowing, about health services and women's health to the aboriginal women in this community, and is an intermediary whom the women trust. They have a chance to say things, be heard and respected, to share their aboriginal women's knowledge. Janet 'has knowledge, she helps us to go there, to be better members of the world out there'. Rose said as a result the women are not frightened to go to the doctor to deal with the health things they have to deal with, that don't go away.

Claudia Smith, Spenser Gulf University Department of Rural Health.

Claudia described the project she is just beginning on aboriginal breast cancer.

Sonia Champion and Les Taylor, Spenser Gulf University Department of Rural Health.

Sonia described in words and through her vivid and beautiful paintings what 'pass me around' sampling means in the Whyalla community. Her needs assessment about the Nunyara community wellbeing centre revealed some community characteristics such as the segregation between different indigenous groups which is both a strength and a weakness. Her colleague Les Taylor so far has been able to interview and test only 18 people about metabolic syndrome. He found it very hard to get through to the rest of the community, even being aboriginal. His work illustrated the segregation Sonia referred to, into Nunyara, CDEP and the rest of the indigenous community in Whyalla. The lower numbers he had achieved so far seemed to be the result both of being male and the nature of his work involving blood testing, as well as a more distant recruitment approach.

Deb Fernando, Ceduna - Desert Knowledge CRC, Plants for People SA.

Deb is a Koori woman who has worked in Ceduna for many years. She described a type of knowledge exchange where researchers must give knowledge back for the knowledge they gain from the community. Deb is working with people in small homelands and communities near Ceduna, the largest of which has about 120 people. The project helps people to grow vegetables and bush foods, revegetate cleared land, and set up local enterprises. In her presentation she made excellent use of quotes from the people she worked with.

• 'I did not realise I knew so much' from someone realising their own knowledge about local plants and foods.
• 'I've got something to do now - I'm 'up' every day now - I've got a vision, a common interest with someone.' This was from a man whom she said had been sitting depressed in his shed with nothing to do for three years.

The work has led to people being valued in the whole community, having status. Deb said she was blessed in working with really good people, and the project was open to what people really want to do. The researcher's role was to go out and find resources for specific people to meet their needs - not an abstract role. Although the government agencies were the hardest to work with, everyone else sees the value of what is being done.

In the final session at the end of a packed day, four researchers with staying power presented fascinating work in progress on important issues - Tania Pittman on sustainable interventions to address metabolic syndrome, Joanne Dollard and Jo Nolan on different aspects of falls prevention, and Miriam Keane on analysis of qualitative performance indicators. The interactions, questions and discussions generated even at this late stage demonstrated the value of the collaborative event to all those present.

The range of research presented at this Forum demonstrated how vibrant, exciting, relevant and useful research can be when it involves those who stand to benefit from it.

Presentations can be found at http://www.knowledgesouth.unisa.edu.au/phcred/

Tackling the determinants of health

37th Public Health Association of Australia Conference
25-27 September 2006, Sydney
Attended by Eleanor Jackson-Bowers, PHC RIS

Every so often it is good to be taken out of your usual social context and challenged with some alternative perspectives. The conference theme was tackling the determinants of health, and tackle them we did with motivating presentations on transport, housing design, town planning, climate change, food, social cohesion and more. There was a call for public health professionals to make better links with town planners and engineers and have input into the planning of services to better meet the health needs of the population for places to walk, environments that are conducive to social interaction and pleasant to live in.

One highlight of the conference, given the interest of PHCRED in networks and knowledge brokering, was a presentation by Professor Nancy Edwards about the Community Health Networks that have been established in Canada. CHNET-Works is an on-line discussion space for community health researchers, practitioners and policy makers. A feature is their 'fireside chats' which are simultaneous telephone and internet conferences on a set topic with invited speakers and discussion encouraged. Have a look at their website at www.chnet-works.ca.

Another highlight was a session on the use of social theory in qualitative research. While qualitative research is becoming an accepted methodology for health care research it is not always informed by social theory. This session advocated for more attention to this, arguing that social theory has been built up through the accumulated patterns found in many studies and that relating the findings of a project to the accumulated knowledge encapsulated in social theory enhances the validity of the findings and their generalisability. Social theory can be as scary for some as statistics is for others, but doing qualitative research without theory is like doing an RCT without using statistics.

This was a stimulating conference and well worth attending.

Evaluation in emerging areas

Australasian Evaluation Society 2006 International Conference
4-7 September 2006, Darwin
Attended by Peter Drake, PHC RIS

The conference theme Evaluation in Emerging Areas was explored in the following streams:

• International development contexts
• Indigenous contexts
• Innovative approaches to working in changing contexts
• New theoretical models and frameworks.

The conference bought together many cultures at different points in their journey in developing evaluation practices. It provided the environment to consider the question "Where to from here?" which underpinned much discussion.

Key messages from the conference were:

• Evaluation needs to move towards a knowledge management model that results in 'just in time' evaluation results. Features include:
• A model closer to delivery of results in 'real time'.
• Monitoring and evaluation merge more.
• Less individual studies and more streams of evaluation
• Evaluation adapted to use the internet, geographic information systems (GIS) and instant access.
• Evaluation used as a tool for program development and enhancement, both concurrently and retrospectively.
• Combining capacity building and empowerment evaluation in developing countries has benefits for stakeholders.
• Minimise or eliminate funder restrictions that inhibit capacity building and sustainability.
• Form evaluation partnerships between key stakeholders.
• Program design and evaluations need to consider both environmental and cultural context to understand what has occurred and why.
• Program design needs to be aware of cultural context to ensure delivery is consistent with local values, customs, language and thought processes.
• Evaluation that is not contextually informed is unlikely to give meaningful results.
• A clear well defined evaluation process in organisations with large power differentials can result in 'gaming' of the process, a potential weakness that needs consideration.
• A productive way to examine a program is to ask "What would have happened if the program had not been implemented?" (The counterfactual approach.)

Enhancing performance: Breaking down the barriers

IPAC Conference 2006
6-8 October 2006, New Zealand
Attended by Ann-Louise Hordacre, PHC RIS

The Independent Practitioners Association Council (IPAC) Conference looked to the future of New Zealand healthcare by considering local and international experiences and challenges. The conference was opened by the Governor-General of NZ, The Honourable Anand Satyanand, and addressed by the NZ Minister of Health, The Hon Pete Hodgson who discussed the importance of the NZ Primary Health Care Strategy. This strategy, which is still being operationalised was designed to have a team based approach, focused on reducing inequalities, population health, community involvement, and value for money.

A number of informal and highly interesting discussion panels were used to draw out the experiences of international speakers, Sir Donald Irvine, Richard Smith and Judith Smith. These sessions briefly explored the safety and quality issues raised by two high profile cases in England, the Bristol Royal Infirmatory Inquiry and the Shipman Inquiry. These challenging cases had a major impact on the English health care system. Today in many English practices, patients can choose their GP, get same-day appointments - and book ahead. Additionally, access to hospitals has increased without long waiting times. These changes go some way toward addressing patient wishes for fast reliable access to care, and effective treatment by trusted professionals.

The New Zealand health care system, like many other health care systems around the world, is in transition. The need for unity and forward momentum was clearly demonstrated by the experiences of a local company representing the cooperative interests of 11,600 NZ dairy farmers. They see progress as constant and proactive change, building rather than fixing. Together they have the power to represent the interests of their membership - alone they are weak. By detailing the similar experiences of a non-health care organisation, it is easier to recognise 'collective blindspots' in health care and the health system, and to more clearly see the path forward.

View conference abstracts and presentations: www.ipac.org.nz/conference2006/

International Society for Equity in Health

4th International Conference
11-13 September 2006, Adelaide
Attended by Peter Drake, Anne Magarey & Libby Kalucy, PHC RIS

The two themes of the conference Creating Healthy Societies through Inclusion and Equity were represented with presentations and discussions that considered their multiple facets in a complex environment. The arts were strongly represented as a device for facilitating social inclusion.

Professor Shane Huston delivered the first key note presentation focussed on equity in Australian Aboriginal communities.

He delivered two important messages:

• Do not trade culture (indigenous context) for western trappings such as a house, high income.
• Equity must be about values - based on culture. Improvement and sustainability must be about what the indigenous communities believe.

David Vadivelu delivered the second key note address based on his experience with developing community authored multimedia presentations in an Australian Aboriginal community. (See www.usmob.com.au)

The productions actively engage the community who author and participate directly in the recordings.

The key messages delivered included:

• Respect culture
• Don't be ashamed of your culture
• Don't envy other cultures
• Embrace your culture
• The process enhances social inclusion.

Equity in Health was a constant theme. It was matched with many divergent views on how it should/could be measured and, indeed, who should decide what it means.

The application of the arts to promote social inclusion and from there - promote improved health - was delivered/discussed in a number of forums.

Programs that appear to have succeeded and were sustained had many of the following characteristics:

• Community ownership
• Cultural respect and integration
• Skill development to sustain practices.

Some of the barriers to effective programs included:

• Time limited projects
• Heavy workloads of managers
• Failure to engage the community
• Gaps in involvement
• Centralisation of activities
• Inappropriate focus on service provision.

One provocative view presented was that talking about the social determinants of health can paralyse action.

Several presentations were made about reforms made in developing countries based on a free or modified market approach with requirements for health insurance. The results of these presentations did not, generally, show the applied models to be successful.

Further information can be found at: www.iseqh.org

Multi-disciplinary approaches to health inequities research

Australian Health Inequities Conference
14 September 2006, Adelaide
Attended by Eleanor Jackson-Bowers, PHC RIS

An imperative is emerging for research to be policy relevant and a strong message from this conference was that multidisciplinary research, which incorporates a number of different perspectives on an issue is much better for informing policy than research with a single viewpoint. The analogy was made several times that each discipline can illuminate a small area but bringing multiple perspectives can 'broaden the beam' and bring insights which would otherwise be unavailable.

The conference specified the difference between interdisciplinary research, that is, working in the gaps between disciplines, and multidisciplinary research which combines multiple perspectives. Some projects are more suitable for some disciplines than others. Specialist methodologies and in depth knowledge is absolutely necessary in many cases, but bringing these multiple methodologies to a problem will also yield valuable insights. The audience heard an example of multidisciplinary teamwork in the Mitsubishi Project, which is looking at the effects of job loss on a cohort of workers made redundant from the Mitsubishi plant in southern Adelaide. This project has a research team from the Departments of Social Work, Social Administration, Geography and Public Health at Flinders University as well as an Advisory Committee which includes policy makers.

The conference discussed the epistemological and methodological challenges in working with multiple perspectives. A key theme was the need to have respect for the methodologies and specialist skills of other disciplines when working in multidisciplinary teams. Social Science methods, in particular, were perceived by many as under valued and 'practicing Social Science without a licence' was frowned upon. On the other hand, there was a call to move out of our 'cloistered orders' and to change the way research is done. Researchers need to know their discipline but also need to be able to be 'interlockers' and work competently across disciplines.

Be the future

RACGP Annual Scientific Convention
5-8 October 2006, Brisbane
Attended by Ellen McIntyre (presenter), PHC RIS

The 600+ delegates at the RACGP Annual Scientific Convention were treated to such an extensive range of presentations that each delegate would be forgiven if they thought they had attended a different conference from any of their colleagues. So it was particularly notable that the opening plenary presentation The epidemiology of knowledge and ignorance by Professor Paul Glasziou was often referred to throughout the conference even though this session competed with four other equally interesting sessions at the time.

Professor Glasziou covered three key issues:

The gap between research and practice. In this section, he outlined the steps that needed to be taken from doing the research to utilizing it in practice - awareness, acceptance, targeting, do-ability, recall, agreement by patient, and implementation. He indicated that there were many "leaks" with each of these steps such that even if there was an 80% achievement rate at each step, the overall achievement would only be 21% (more detail about this can be found at www.acpjc.org/Content/142/2/issue/ACPJC-2005-142-2-A08.htm).

The cause of this gap he stressed was overload not competence. For example there is an ever widening gap between the number of original research papers being published and the synthesis of this information through systematic reviews.

Coping with the overload was what generated most interest. Professor Glasziou suggested strategies such as:

• filtering your journal reading. How much of what you read is both valid and relevant? Reading an evidence-based abstraction journal (such as www.evidence-basedmedicine.com) can reduce the amount of reading.
• forming a case discussion journal club with colleagues. This involves regular meetings with your colleagues wherein you can appraise and discuss the literature pertinent to a selected case.
• getting someone else to search the literature for you eg the UK based National Library Health Primary Care Question Answering Service (www.library.nhs.uk) answers questions posed by health professionals in a clinically relevant timeframe.

Presentations from the conference can be found at www.racgp.org.au