Participatory Action Research-Dadirri-Ganma, using Yarning: methodology co-design with Aboriginal community members.

BACKGROUND: Appropriate choice of research design is essential to rightly understand the research problem and derive optimal solutions. The Comorbidity Action in the North project sought to better meet the needs of local people affected by drug, alcohol and mental health comorbidity. The aim of the study focused on the needs of Aboriginal peoples and on developing a truly representative research process. A methodology evolved that best suited working with members of a marginalised Aboriginal community. This paper discusses the process of co-design of a Western methodology (participatory action research) in conjunction with the Indigenous methodologies Dadirri and Ganma. This co-design enabled an international PhD student to work respectfully with Aboriginal community members and Elders, health professionals and consumers, and non-Indigenous service providers in a drug and alcohol and mental health comorbidity project in Adelaide, South Australia. METHODS: The PhD student, Aboriginal Elder mentor, Aboriginal Working Party, and supervisors (the research team) sought to co-design a methodology and applied it to address the following challenges: the PhD student was an international student with no existing relationship with local Aboriginal community members; many Aboriginal people deeply distrust Western research due to past poor practices and a lack of implementation of findings into practice; Aboriginal people often remain unheard, unacknowledged and unrecognised in research projects; drug and alcohol and mental health comorbidity experiences are often distressing for Aboriginal community members and their families; attempts to access comorbidity care often result in limited or no access; and Aboriginal community members experience acts of racism and discrimination as health professionals and consumers of health and support services. The research team considered deeply how knowledge is shared, interpreted, owned and controlled, by whom and how, within research, co-morbidity care and community settings. The PhD student was supported to co-design a methodology that was equitable, democratic, liberating and life-enhancing, with real potential to develop feasible solutions. RESULTS: The resulting combined Participatory Action Research (PAR)-Dadirri-Ganma methodology sought to create a bridge across Western and Aboriginal knowledges, understanding and experiences. Foundation pillars of this bridge were mentoring of the PhD student by senior Elders, who explained and demonstrated the critical importance of Yarning (consulting) and Indigenous methodologies of Dadirri (deep listening) and Ganma (two-way knowledge sharing), and discussions among all involved about the principles of Western PAR. CONCLUSIONS: Concepts within this paper are shared from the perspective of the PhD student with the permission and support of local Elders and Working Group members. The intention is to share what was learned for the benefit of other students, research projects and community members who are beginning a similar journey.

Perceived changes and perceived transferability for treating intoxicated women victims of violence among emergency clinicians after an alcohol and other drugs training program.

INTRODUCTION AND AIMS: Given the significant overlap between alcohol intoxication and violence against women, it is imperative that emergency clinicians are equipped to care for women presenting with both issues. This research aimed to explore emergency clinicians' perceived changes and ability to apply training, particularly to intoxicated women victims of violence. DESIGN AND METHODS: Using a pre-post questionnaire, 74 participants of the Emergency Mental Health Alcohol and Drug program were surveyed about their education/training, awareness and use of guidelines and tools, perceived changes in knowledge, skills and confidence and ability to apply the training. RESULTS: Low levels of previous education/training, awareness and use of best practice tools were reported. Although high rates of change in knowledge and confidence were reported after the program, a minority (38%) felt able to apply this to intoxicated women victims of violence. Working in an emergency department (P = 0.03) and having higher qualifications (P < 0.01) were the only significant factors affecting their ability to apply the training. DISCUSSION AND CONCLUSIONS: The lower rates of perceived ability to apply to intoxicated women victims of violence suggest a deficit in ability to translate knowledge into practice. Higher qualifications affected respondents' ability to apply the training to intoxicated women victims of violence, suggesting that general skills learned regarding translating knowledge into practice rather than specific content may have more impact. This research indicates that clinicians' knowledge and confidence can be positively impacted by targeted education/training, but any future education/training must include knowledge translation skills.

Emergency clinicians' perceived self-efficacy in the care of intoxicated women victims of violence.

BACKGROUND: Previous research has identified perceived self-efficacy to be a vital component of clinicians' positive attitudes towards caring for intoxicated patients and women who have been assaulted. To date, little is known about the perceived self-efficacy and influences among emergency clinicians towards intoxicated women victims of violence. METHOD: Using mixed methods, 179 emergency clinicians were surveyed and 22 emergency clinicians were interviewed in South Australia about their education/training, their awareness and use of best practice guidelines and tools, and their perceived self-efficacy toward treating intoxicated women victims of violence. FINDINGS: There were statistically significant relationships between use of best practice tools (n = 32) and knowledge (χ2 = 6.52; p = .02) and confidence (χ2 = 6.52; p = .02) treating women victims of violence. There were also statistically significant relationships between previous alcohol and other drug education/training and knowledge (n = 43), skills and confidence treating both intoxicated patients (χ2 = 7.85; p = .01) and women victims of violence (χ2 = 11.63; p < .01). The interviews identified four themes about confidence, knowledge and use of research evidence, education and training, and resources. CONCLUSION: Emergency clinicians reported low levels of perceived self-efficacy, and infrequent use of guidelines and tools to support the care of intoxicated women victims of violence. Participants wanted more knowledge and education/training in caring for intoxicated women who have been assaulted, as they felt lacking in these skills.

Improving the provision of services to young people from refugee backgrounds with comorbid mental health and substance use problems: addressing the barriers.

BACKGROUND: South Australia (SA) has resettled 151,134 refugees in the last ten years (Department of Immigration and Border Protection, Settlement reporting facility, 2014). Northern metropolitan Adelaide, an area which experiences significant social disadvantage, has received a significant number of (predominantly young) refugees. Research indicates that refugee youth are at elevated risk of mental health (MH) and alcohol and other drug (AOD) problems. These factors, along with the low socio-economic status of northern Adelaide, the number of refugee youth residing there, and the added complexity of treating comorbid MH and AOD problems (comorbidity) prompted this research. We investigated the barriers and facilitators to culturally responsive comorbidity care for these youth and whether the MH and AOD services were equipped to provide such support. METHODS: This mixed-methods study employed semi-structured interviews with refugee youth and service providers and an online survey with managers of services. Thirty participants (15 refugee youth, 15 service providers) took part in the semi-structured interviews and 56 (40 complete, 16 partially-complete) in the survey. RESULTS: Thematic analysis of the interview data revealed the most commonly reported barriers related to four broad areas: (1) organisational and structural, (2) access and engagement, (3) treatment and service delivery, and (4) training and resources. Survey data supported the barriers identified in the qualitative findings. CONCLUSIONS: This research highlights significant gaps in the response of MH and AOD services to refugee youth with comorbidity. Based on the findings, ways of overcoming the barriers are discussed, and are of particular relevance to policy makers, organisations and clinicians.

"The Chicken or the Egg": Barriers and Facilitators to Collaborative Care for People With Comorbidity in a Metropolitan Region of South Australia.

Mental health disorder and alcohol and other drug comorbidity is prevalent in Australia. This qualitative study used semistructured interviews (N = 20) to elicit clinicians' and workers' knowledge, experiences, and opinions regarding issues pertaining to service needs of people with comorbidity in a metropolitan region of South Australia. The study revealed barriers to effective access and delivery of comorbidity care by MH and AOD services. Participants reported difficulties with identification, access, suitability, policy, funding, and collaboration between sectors and services responding to comorbidity. Results suggest that these models of practice were inadequate influencing the delivery, consistency, and reliability of comorbidity care.

Comorbidity Action in the North: a study of services for people with comorbid mental health and drug and alcohol disorders in the northern suburbs of Adelaide.

OBJECTIVE: This study identified barriers to and facilitators of mental health (MH) and alcohol and drug (AOD) comorbidity services, in order to drive service improvement. METHOD: Participatory action research enabled strong engagement with community services, including Aboriginal and refugee groups. Surveys, interviews and consultations were undertaken with clinicians and managers of MH, AOD and support services, consumers, families, community advocates and key service providers. Community participation occurred through consultation, advisory and working party meetings, focus groups and workshops. RESULTS: Barriers included inadequate staff training and poor community and workforce knowledge about where to find help. Services for Aboriginal people, refugees, the elderly and youth were inadequate. Service fragmentation ('siloes') occurred through competitive short-term funding and frequent re-structuring. Reliance on the local hospital emergency department was concerning. Consumer trust, an important element in engagement, was often lacking. CONCLUSIONS: Comorbidity should be core business of both MH and AOD services by providing consistent 'no wrong door' care. Non-governmental organisations (NGOs) need longer funding cycles to promote stability and retain skilled workers. Comorbidity workforce training for government and NGO staff is required. Culturally appropriate comorbidity services are urgently needed. Despite the barriers, collaboration between clinicians/workers was valued.

Merging perspectives: obstacles to recovery for youth from refugee backgrounds with comorbidity.

OBJECTIVE: This research aimed to identify challenges encountered by young people from refugee backgrounds with co-existing mental health (MH) and alcohol and other drug (AOD) problems (comorbidity) and sought to compare the perspectives of refugee youth and service providers in a metropolitan region of Adelaide, South Australia. METHODS: Semi-structured interviews were conducted with two groups of participants: young people from refugee backgrounds (African, Afghan, Bhutanese) and workers from MH, AOD and refugee support services. RESULTS: The refugee youth reported that the biggest difficulty they face once they develop MH and AOD problems is social disconnectedness. They lacked awareness that services are available to support them. In contrast, clinicians rated difficulty accessing and receiving culturally competent comorbidity care as the greatest challenge. Other reported challenges were relatively consistent across both groups. CONCLUSIONS: This study has implications for how we engage these young people in services, prioritise areas of care and effectively treat and support refugee youth experiencing comorbidity. These findings emphasise the need for a combined therapeutic casework approach, addressing needs such as social connectedness, housing, education and employment.

Stopping the run-around? A study of services for people with comorbid mental health and substance use disorders in northern Adelaide.

OBJECTIVE: Comorbidity between mental health and alcohol and other drug (AOD) disorders is common. This study aimed to identify and describe all of the local government and non-government (NGO) mental health and AOD services in a socially disadvantaged urban region in Adelaide, South Australia. METHOD: Services were identified using telephone directories and the internet, and via information from workers employed by a wide range of mental health and AOD services. RESULTS: Local mental health and AOD services were difficult to locate, but eventually we identified a total of 70 services. Soon after this, reorganisation of the mental health services and a new NGO funding round changed the service configuration, with a decrease in the number of services. The available services were fragmented, and rarely addressed comorbidity specifically. CONCLUSION: Our real-world study demonstrates the lack of a clear pathway for people to access existing services. Further, changes occur frequently as government funded services generally reorganise every couple of years, and NGO services come and go according to funding. There is a need for a central, widely available database for mental health and AOD services. More services addressing comorbid mental health and AOD disorders are required.

Beliefs about the use of nonprescribed antibiotics among people in Yogyakarta City, Indonesia: a qualitative study based on the theory of planned behavior.

Although antibiotics are prescription-only medicine in Indonesia, they can be purchased without prescription. This qualitative study elicited beliefs about nonprescribed antibiotics use informed by the theory of planned behavior to develop a questionnaire for an expanded theory of planned behavior survey. Twenty-five (N = 25) adults with experience of using nonprescribed antibiotics were interviewed. Content analysis was applied. Participants reported that the use of nonprescribed antibiotics was advantageous in term of saving time and money and of reducing the number of medicines that need to be purchased, in contrast to a perception of what occurs with medical prescriptions. Potential adverse effects, poor health outcomes, and antimicrobial resistance were the perceived disadvantages. Facilitators of such use were the availability of over-the-counter antibiotics and successful experience in using antibiotics. Medication for children was the perceived barrier to such use. Family members and friends, especially those with health education background, approved of such use.

Over-the-counter analgesic use by urban Aboriginal people in South Australia.

Despite recent health gains for Australian Aboriginal people their significantly poorer health status compared with that of non-Aboriginal Australians remains significant. Within the context of high levels of mortality and morbidity, research highlights significant barriers to timely health-care, access and safe use of prescribed and over-the-counter medicines. The risks to Aboriginal people's health due to unsafe medication use are preventable. The purpose of this article is to present the findings from qualitative research focused on Aboriginal people's knowledge, use and experience of over-the-counter analgesics. The study was conducted in the north-western metropolitan area of Adelaide, which has the largest urban Aboriginal population in South Australia. The employment of an Aboriginal Elder as Cultural Advisor enabled engagement with Aboriginal participants. Purposive 'snow ball' sampling was used to recruit participants for four focus groups [n = 30] and one participant opting for a personal semi-structured interview. Participants worked with the researchers to develop the findings and formulate recommendations. The 25 women and 6 men, aged 20-80 years reported various chronic medical conditions. Focus groups/interview elicited accounts of critical issues concerning safe selection and use of over-the-counter analgesics. Serious health risks were evident due to limited knowledge about safe analgesic use and over-reliance on information from family, friends and advertising. Extremely poor access was reported by participants to culturally and linguistically appropriate information, education and advice from a range of doctors and other health professionals including Aboriginal health workers.

Drinking contexts and the legitimacy of alcohol use: findings from a focus group study on alcohol use in Denmark.

AIM: To examine the perceptions and meanings of alcohol use in Denmark with specific focus on drinking contexts. METHODS: A qualitative study using focus group interviews. The sample consisted of five focus groups of adults with one group for each of the following age groups: 16-20; 21-34; 35-44; 45-64; and 65-82 years. The groups consisted of both men and women with five to six participants in each group (27 in total). RESULTS: Alcohol use is perceived as legitimate in many social contexts with few being defined as inappropriate. Drinking alone is mostly associated with having alcohol-related problems, but considered legitimate if it is characterized by activity. Drinking socially plays an important role in people's considerations of legitimate use and seems to overrule the actual alcohol amount consumed. Different contexts influence different meanings of drinking with context and purpose changing with age and life stages. CONCLUSIONS: The social drinking context is pivotal in people's perception of the legitimacy of their alcohol use, leaving the alcohol amount less important. This calls for the need to focus on and incorporate the drinking context within public health initiatives aimed at reducing high risk drinking, just as the focus on the actual amount of alcohol people consume or their frequency of use.

Knowledge and beliefs about antibiotics among people in Yogyakarta City Indonesia: a cross sectional population-based survey.

BACKGROUND: Misconceptions about antibiotic use among community members potentially lead to inappropriate use of antibiotics in the community. This population-based study was aimed at examining common knowledge and beliefs about antibiotic use of people in an urban area of Indonesia. METHODS: The population of the study was adults (over 18 years old) in Yogyakarta City. A cluster random sampling technique was applied (N = 640). Data were collected using a pre-tested questionnaire and analyzed using descriptive statistics and correlation. RESULTS: A total of 625 respondents was approached and 559 respondents completed the questionnaire (90% response rate). Out of 559 respondents, 283 (51%) are familiar with antibiotics. Out of 283 respondents who are familiar with antibiotics, more than half have appropriate knowledge regarding antibiotic resistance (85%), allergic reactions (70%), and their effectiveness for bacterial infections (76%). Half these respondents know that antibiotics ought not to be used immediately for fever (50%). More than half have incorrect knowledge regarding antibiotics for viral infections (71%). More than half believe that antibiotics can prevent illnesses from becoming worse (74%). Fewer than half believe that antibiotics have no side effects (24%), that antibiotics can cure any disease (40%), and that antibiotic powders poured onto the skin can quickly cure injuries (37%). Those who are uncertain with these beliefs ranged from 25% to 40%. Generally, these respondents have moderate knowledge; where the median is 3 with a range of 0 to 5 (out of a potential maximum of 5). Median of scores of beliefs is 13 (4 to 19; potential range: 4 to 20). The results of correlation analysis show that those with appropriate knowledge regarding antibiotics would also quite likely have more appropriate beliefs regarding antibiotics. The correlation is highest for those who are male, young participants, with higher education levels, and have a higher income level. CONCLUSIONS: Misconceptions regarding antibiotic use exist among people in this study. Therefore, improving appropriate knowledge regarding antibiotic use is required.

Self medication with antibiotics in Yogyakarta City Indonesia: a cross sectional population-based survey.

BACKGROUND: Self medication with antibiotics has become an important factor driving antibiotic resistance. This study investigated the period prevalence, patterns of use, and socio-demographic factors associated with self medication with antibiotics in Yogyakarta City Indonesia. This cross-sectional population-based survey used a pre-tested questionnaire which was self-administered to randomly selected respondents (over 18 years old) in Yogyakarta City Indonesia in 2010 (N = 625). Descriptive statistics, chi-square and logistic regression were applied. RESULTS: A total of 559 questionnaires were analyzed (response rate = 90%). The period prevalence of self medication with antibiotics during the month prior to the study was 7.3%. Amoxicillin was the most popular (77%) antibiotic for self medication besides ampicilline, fradiomisin-gramisidin, tetracycline, and ciprofloxacin to treat the following symptoms: the common-cold including cough and sore throat, headache, and other minor symptoms; with the length of use was mostly less than five days. Doctors or pharmacists were the most common source of information about antibiotics for self medication (52%). Antibiotics were usually purchased without prescription in pharmacies (64%) and the cost of the purchases was commonly less than US $1 (30%). Previous experience was reported to be the main reason for using non-prescribed antibiotics (54%). There were no socio-demographic variables significantly associated with the actual practice of using non-prescribed antibiotics. However, gender, health insurance, and marital status were significantly associated with the intent to self medicate with antibiotics (P < 0.05). Being male (Odds Ratio = 1.7 (1.2 - 2.6)) and having no health insurance (Odds Ratio = 1.5 (1.0 -2.3)) is associated with the intent to self medicate with antibiotics. CONCLUSIONS: This study is the first population-based study of self-medication with antibiotics among the Indonesian population. Usage of non-prescribed antibiotics as well as intent of doing so is common across socio-demographic categories. Given the findings, factors influencing people's intentions to self medicate with antibiotics are required to be investigated to better understand such behavior. Impact of health insurance coverage on self medication with antibiotics should also be further investigated.

The developing role of transition to practice programs for newly graduated mental health nurses.

A number of significant challenges face graduate mental health nurses entering the workforce. In response, Transition to Practice programs have been promoted as a potential strategy for improving recruitment and retention within the mental health system. This review explores the experience of transition for mental health nurse graduates and identifies key aspects of Transition to Practice programs that facilitate the transition to practising professional. A comprehensive review of qualitative research, which sought to provide insight into the experience of transition for graduate mental health nurses, was conducted. Nine studies were identified through a search of MEDLINE, CINAHL, PsychINFO, PsychArticles, Psychology, AMED, EMBASE and Health Source: Nursing/academic edition. Findings showed a disparity between undergraduate perceptions of the mental health nurse role and what is actually observed during placement, highlighting the need for the positive contribution of preceptors and mentors within a transitional support model for newly graduated mental health nurses.

Heatwaves and their impact on people with alcohol, drug and mental health conditions: a discussion paper on clinical practice considerations.

AIM: This article discusses the clinical implications of adverse health outcomes derived during heatwaves for people with mental health disorders, substance misuse and those taking prescribed medications such as lithium, various neuroleptic and anticholinergic drugs. BACKGROUND: With climate change it is predicted that the incidence of prolonged periods of extreme heat will increase. Specific adverse health outcomes associated with high environmental temperatures include heat stroke and heat exhaustion. Those at increased risk for heat-related mortality are those with chronic health conditions, including those with mental health disorders and substance misuse. DATA SOURCES: Sources of evidence included and 'grey' literature published between 1985 and 2010, such as key texts, empirical research, public policies, training manuals and community information sheets on heat waves. DISCUSSION: Current clinical practice and clinical impact of heatwaves on those people with comorbidity is explored. This includes the physiological components of heat stress, heat regulation, and the impact of alcohol and other drugs; and, ramifications and professional practice issues for those with mental health conditions and those requiring mental health medications. IMPLICATIONS FOR NURSING: Client education covering modification of the environment and the use of client heat safety action plans. Secure, accessible stores of prescribed medication are recommended and emergency substance withdrawal kits could be made available. CONCLUSION: All nurses have a responsibility to increase the capability and resilience of their clients to manage their chronic health needs during a heatwave. At these times nurses need to give extra monitoring and assistance when clients lack the capacity or resources to protect themselves.

Better medication management for Aboriginal people with mental health disorders: a survey of providers.

OBJECTIVE: To explore the experiences and training needs of service providers in relation to medication management for Aboriginal people with mental health disorders. DESIGN: Survey. SETTING: Aboriginal and mainstream health and human service organisations in metropolitan, rural and remote South Australia. SUBJECTS: Aboriginal health workers, nurses, mental health workers, substance misuse workers, managers, liaison officers, social workers, police, pharmacists, general practitioners, community workers, counsellors, paramedics, educators, family support workers and others. RESULTS: The major health service issues for Aboriginal people with mental health disorders and their carers are related to access to, and availability and appropriateness of services. Quality use of medications by Aboriginal clients is influenced by drug and alcohol misuse, cost, compliance, feelings about the value of medicines, sharing of medications and unwanted side-effects. Many workers providing services to Aboriginal people with mental health disorders lack adequate training and/or resources on mental health and safe medication management; yet, are required to provide advice or assistance on these matters. CONCLUSIONS: The survey provides new, reliable evidence relevant to mental health services and medication management for South Australian Aboriginal people. It highlights the major issues impacting on quality of care and service provision, demonstrates the wide range of health and allied workers providing medication advice and assistance to Aboriginal people, and reveals workforce development needs.

Mental health and alcohol and other drug training for emergency department workers: one solution to help manage increasing demand.

OBJECTIVE: To evaluate a training course for ED staff aiming to improve knowledge and skills in working with mental health and drug/alcohol patients attending EDs. METHODS: Pre- and postcourse questionnaires assessed attitudes and self-ratings of confidence, knowledge and skills in working with these patients. Follow-up interviews assessed if new skills or approaches to patient management had been integrated into daily ED practice. RESULTS: Little change was observed in the course participants' attitudes, although reported attitudes were generally appropriate. Self-ratings of confidence in skills and knowledge showed a significant improvement on all questions following the course. Responses to the follow-up interviews suggest course information has been retained and integrated into practice, especially in conducting triage and other assessments and taking more time to talk to patients. CONCLUSION: The course has led to staff feeling more confident and competent to help mental health or drug/alcohol patients who attend the ED.

Our interest is swelling: a collaborative venture to establish the world's first free public screening for lymphoedema.

This article describes the collaborative processes involved in the implementation of a free public health screening program for people at risk of lymphoedema following the removal of lymph nodes during surgery to control breast, prostate and other cancers, or injury. The planning phase of the program is described with emphasis on the need to secure a well situated venue, the commitment of a cohort of key health professionals, service club and lay volunteers, and the need to carefully target and publicise the event widely. The implementation phase requires careful consideration of the physical layout of the event, the direction and management of the flow of human traffic, information and equipment requirements, and recognition that screening programs place people in vulnerable positions. Effective communication skills are essential, as is a knowledge of where people can be referred should the need arise. A budget is provided together with discussion regarding the success of the program and recommendations for future consideration such as the need to target men to attend screening and for long term follow up of the outcomes.