Preparing interdisciplinary leadership for a sustainable future.

Urgent sustainability challenges require effective leadership for inter- and trans-disciplinary (ITD) institutions. Based on the diverse experiences of 20 ITD institutional leaders and specific case studies, this article distills key lessons learned from multiple pathways to building successful programs. The lessons reflect both the successes and failures our group has experienced, to suggest how to cultivate appropriate and effective leadership, and generate the resources necessary for leading ITD programs. We present two contrasting pathways toward ITD organizations: one is to establish a new organization and the other is to merge existing organizations. We illustrate how both benefit from a real-world focus, with multiple examples of trajectories of ITD organizations. Our diverse international experiences demonstrate ways to cultivate appropriate leadership qualities and skills, especially the ability to create and foster vision beyond the status quo; collaborative leadership and partnerships; shared culture; communications to multiple audiences; appropriate monitoring and evaluation; and perseverance. We identified five kinds of resources for success: (1) intellectual resources; (2) institutional policies; (3) financial resources; (4) physical infrastructure; and (5) governing boards. We provide illustrations based on our extensive experience in supporting success and learning from failure, and provide a framework that articulates the major facets of leadership in inter- and trans-disciplinary organizations: learning, supporting, sharing, and training.

SimAmph: an agent-based simulation model for exploring the use of psychostimulants and related harm amongst young Australians.

BACKGROUND: Computer simulations provide a useful tool for bringing together diverse sources of information in order to increase understanding of the complex aetiology of drug use and related harm, and to inform the development of effective policies. In this paper, we describe SimAmph, an agent-based simulation model for exploring how individual perceptions, peer influences and subcultural settings shape the use of psychostimulants and related harm amongst young Australians. METHODS: We present the conceptual architecture underpinning SimAmph, the assumptions we made in building it, the outcomes of sensitivity analysis of key model parameters and the results obtained when we modelled a baseline scenario. RESULTS: SimAmph's core behavioural algorithm is able to produce social patterns of partying and recreational drug use that approximate those found in an Australian national population survey. We also discuss the limitations involved in running closed-system simulations and how the model could be refined to include the social, as well as health, consequences of drug use. CONCLUSION: SimAmph provides a useful tool for integrating diverse data and exploring drug policy scenarios. Its integrated approach goes some way towards overcoming the compartmentalisation that characterises existing data, and its structure, parameters and values can be modified as new data and understandings emerge. In a companion paper (Dray et al., 2011), we use the model outlined here to explore the possible consequences of two policy scenarios.

Are drug detection dogs and mass-media campaigns likely to be effective policy responses to psychostimulant use and related harm? Results from an agent-based simulation model.

BACKGROUND: Agent-based simulation models can be used to explore the impact of policy and practice on drug use and related consequences. In a linked paper (Perez et al., 2011), we described SimAmph, an agent-based simulation model for exploring the use of psychostimulants and related harm amongst young Australians. METHODS: In this paper, we use the model to simulate the impact of two policy scenarios on engagement in drug use and experience of drug-related harm: (i) the use of passive-alert detection (PAD) dogs by police at public venues and (ii) the introduction of a mass-media drug prevention campaign. RESULTS: The findings of the first simulation suggest that only very high rates of detection by PAD dogs reduce the intensity of drug use, and that this decrease is driven mainly by a four-fold increase in negative health consequences as detection rates rise. In the second simulation, our modelling showed that the mass-media prevention campaign had little effect on the behaviour and experience of heavier drug users. However, it led to reductions in the prevalence of health-related conditions amongst moderate drug users and prevented them from becoming heavier users. CONCLUSION: Agent-based modelling has great potential as a tool for exploring the reciprocal relationships between environments and individuals, and for highlighting how intended changes in one domain of a system may produce unintended consequences in other domains. The exploration of these linkages is important in an environment as complex as the drug policy and intervention arena.

Models of policy-making and their relevance for drug research.

INTRODUCTION AND AIMS: Researchers are often frustrated by their inability to influence policy. We describe models of policy-making to provide new insights and a more realistic assessment of research impacts on policy. DESIGN AND METHODS: We describe five prominent models of policy-making and illustrate them with examples from the alcohol and drugs field, before drawing lessons for researchers. RESULTS: Policy-making is a complex and messy process, with different models describing different elements. We start with the incrementalist model, which highlights small amendments to policy, as occurs in school-based drug education. A technical/rational approach then outlines the key steps in a policy process from identification of problems and their causes, through to examination and choice of response options, and subsequent implementation and evaluation. There is a clear role for research, as we illustrate with the introduction of new medications, but this model largely ignores the dominant political aspects of policy-making. Such political aspects include the influence of interest groups, and we describe models about power and pressure groups, as well as advocacy coalitions, and the challenges they pose for researchers. These are illustrated with reference to the alcohol industry, and interest group conflicts in establishing a Medically Supervised Injecting Centre. Finally, we describe the multiple streams framework, which alerts researchers to 'windows of opportunity', and we show how these were effectively exploited in policy for cannabis law reform in Western Australia. DISCUSSION AND CONCLUSIONS: Understanding models of policy-making can help researchers maximise the uptake of their work and advance evidence-informed policy.

A research routine to assess bias introduced by low response rates in postal surveys.

Low response rates to postal surveys potentially bias study results. We used three approaches to determine why 46 per cent of a sample were non-responders, and to analyse any potential bias. Labour force data, telephone interviews with a number of non-responders and trend examination showed that our study sample was no different to the known nursing population, that there were few differences between responders and non-responders and that there were no trends in differences between early and late responders respectively. Results suggest 'intenders', or potential responders who do not complete and return the survey, are a key factor in non-response in surveys of nurses. Analysis for response bias increases confidence in the interpretations and conclusions of any study and should therefore become standard survey practice.

Extending drug ethno-epidemiology using agent-based modelling.

AIMS: To show how the inclusion of agent-based modelling improved the integration of ethno-epidemiological data in a study of psychostimulant use and related harms among young Australians. METHODS: Agent-based modelling, ethnographic fieldwork, in-depth interviews and epidemiological surveys. SETTING: Melbourne, Perth and Sydney, Australia. PARTICIPANTS: Club drug users in Melbourne, recreational drug users in Perth and street-based injecting drug users in Sydney. Participants were aged 18-30 years and reported monthly or more frequent psychostimulant use. FINDINGS: Agent-based modelling provided a specific focus for structured discussion about integrating ethnographic and epidemiological methods and data. The modelling process was underpinned by collective and incremental design principles, and produced 'SimAmph', a data-driven model of social and environmental agents and the relationships between them. Using SimAmph, we were able to test the probable impact of ecstasy pill-testing on the prevalence of harms--a potentially important tool for policy development. The study also navigated a range of challenges, including the need to manage epistemological differences, changes in the collective design process and modelling focus, the differences between injecting and non-injecting samples and concerns over the dissemination of modelling outcomes. CONCLUSIONS: Agent-based modelling was used to integrate ethno-epidemiological data on psychostimulant use, and to test the probable impact of a specific intervention on the prevalence of drug-related harms. It also established a framework for collaboration between research disciplines that emphasizes the synthesis of diverse data types in order to generate new knowledge relevant to the reduction of drug-related harms.

Improving nurses' therapeutic attitude to patients who use illicit drugs: workplace drug and alcohol education is not enough.

This study examines the impact of workplace drug and alcohol education on nurses' therapeutic attitude to patients who use illicit drugs. It builds on a study of the generalist nursing workforce in the Australian Capital Territory in 2003, which showed that the interaction of role support with workplace drug and alcohol education facilitated nurses' therapeutic attitude. This paper explores this interaction in detail, showing that workplace education has no independent association with therapeutic attitude and that an effect from education only occurs when nurses have at least a moderate level of role support. Nursing workforce development needs to focus on strategies that provide role support for nurses as they work with this clinically challenging patient group. Without the ready availability of someone in the nurse's clinical field to advise and assist them, efforts to increase nurses' knowledge and skills are wasted.

Fast-tracking implementation through trial design: the case of buprenorphine treatment in Victoria.

OBJECTIVES: We investigated how a randomised controlled trial (RCT) could be designed to incorporate features known or thought likely to enhance the uptake of the new treatment into clinical practice post-trial. METHOD AND RESULTS: Between 1999 and 2001, we trialled buprenorphine treatment for heroin dependence in community settings throughout Victoria, using 28 experienced methadone prescribers and 34 pharmacists across 19 sites. In this case study, we describe how we incorporated seven features considered important in treatment uptake: skilled and experienced practitioners, government and policy support, incentives to prescribe the new treatment, specialist support services, clinical guidelines, training programs and patient involvement and information. We also present information showing that uptake of buprenorphine treatment was substantially boosted in Victoria compared with other Australian jurisdictions immediately after the trial in 2001 and that this increase was sustained until at least 2006. CONCLUSION: While we cannot prove that our trial design was responsible for the increased uptake of buprenorphine treatment in Victoria, we do show that design has been a neglected aspect of clinical trials in terms of enhancing post-trial uptake of the treatment being tested. IMPLICATIONS: Those interested in closing the 'know-do' gap between research and practice may wish to further explore this very promising lead. Imaginative linking of features known to enhance treatment uptake to pressing research questions may lead to new information on efficacy, as well as getting valuable drugs into the treatment system more rapidly.

The determinants of nurses' therapeutic attitude to patients who use illicit drugs and implications for workforce development.

AIM: To examine the determinants of generalist nurses' therapeutic attitude to patients who use illicit drugs, and to model workforce development initiatives. BACKGROUND: Individuals who use illicit drugs rely heavily on healthcare in emergency departments and inpatient hospital wards. Little is known about the determinants of generalist nurses' therapeutic attitude to provide care, therefore limiting our understanding of the important issues for workforce development. DESIGN: The study was a cross-sectional survey of registrants on the Australian Capital Territory Nurses Registration Roll 2002 (N = 3241, 50% response rate). The associations between variables and nurses' therapeutic attitude were examined by multi-variable linear regression analysis. METHOD: Nurses' therapeutic attitude was assessed using a modified version of the Alcohol and Alcohol Problems Perception Questionnaire. Personal characteristics, attitudes to illicit drugs and professional practice variables such as drug and alcohol education, experience with the patient group and role support were examined using a mix of standardised and new questions. RESULTS: Professional practice variables explained 53% of the variation of nurses' therapeutic attitude, the most important being role support. Although a negative attitude to illicit drugs had a statistically significant association with therapeutic attitude, it added less than 1% to the variation explained. Personal characteristics showed no association. CONCLUSIONS: Generalist nurses struggle to provide care to this patient group. Role support was found to be the strongest driver of nurses' therapeutic attitude, and workplace illicit drug education was only useful in combination with high role support. RELEVANCE TO CLINICAL PRACTICE: Nurses' caring role with patients who use illicit drugs is complex and demanding. Nursing workforce development must focus on increasing nurses' role support, in terms of appropriately skilled staff readily available for consultation and advice. Support for nurses, in the form of evidence-based practice standards and appropriate time allocation, is also important.

Effective drug policy: a new approach demonstrated in the Drug Policy Modelling Program.

The aim of this paper is to describe a new comprehensive approach to studying illicit drug policy - one that integrates evidence, disciplinary approaches, drug use behaviours and policy making processes. The methods described here include systematic reviews of the evidence, studies of the ways in which policy decision-making actually occurs, and the use of modelling approaches that can explicate the multi-dimensional nature of drug policy responses and their dynamic interactions. The approach described has the potential to facilitate new drug policy that would not have been possible or apparent through the sole study of one aspect of drug policy, such as the evidence-base or the political context or the economics of drug markets. We believe this approach may be more likely to produce strategic drug policy because it reflects the richness and complexity of the real world of drug use, and drug policy. The purpose of employing an integrative methodology is to create the potential for new drug policy insights, ideas and interventions - not restricted to one body of evidence, nor to accidental or fortuitous policy-making processes.

When is a little knowledge dangerous? Circumstances of recent heroin overdose and links to knowledge of overdose risk factors.

OBJECTIVES: To describe the circumstances surrounding recent heroin overdose among a sample of heroin overdose survivors and the links to their knowledge of overdose risk. METHODS: A cross-sectional survey of 257 recent non-fatal heroin overdose survivors was undertaken to examine self-reported knowledge of overdose risk reduction strategies, behaviour in the 12 h prior to overdose and attributions of overdose causation. RESULTS: Most of the overdoses occurred in public spaces as a result of heroin use within 5 min of purchasing the drug. A substantial number of overdoses occurred with no one else present and/or involved the concomitant use of other drugs. While knowledge of at least one overdose prevention strategy was reported by 90% of the sample, less then half of the sample knew any single strategy. Furthermore knowledge of the dangers of mixing benzodiazepines and/or alcohol with heroin was associated with an increased likelihood of such mixing being reported prior to overdose. CONCLUSIONS: While heroin users can articulate knowledge of key overdose risk reduction strategies, this knowledge was not generally associated with a reduction in risk behaviours but was in some cases associated with increased reports of overdose risk behaviours. Further research is required in order to better understand this paradoxical effect, focussing on risk reduction education amenable to the social contexts in which heroin use takes place.

Australian lesbian and bisexual women's health and social experiences of living with hepatitis C.

We recruited women in two Australian locations to complete a questionnaire on their health and social experiences of living with the hepatitis C virus (HCV). Among 462 respondents 9% identified themselves as lesbian and 14% as bisexual. Bisexuals were more disadvantaged than lesbians or heterosexuals on income, work status, home ownership, and level of education. Lesbians and bisexuals were less likely to be referred for HCV treatment and were more likely to report being treated negatively by any health professional. Lesbians and bisexuals experience HCV differently from one another and from heterosexuals. Their needs are not being met by women's health and HCV-specific services.

Transient changes in behaviour lead to heroin overdose: results from a case-crossover study of non-fatal overdose.

BACKGROUND AND AIMS: Heroin overdose is a serious consequence of heroin use and one of the leading causes of premature death and illness in Australia. Despite considerable research effort little is known about the effects of transient changes in heroin user behaviour and the links to overdose. This research is the first to use a suitable methodology to allow such ephemeral changes and their effects on non-fatal heroin overdose to be examined. METHODS: A case-crossover design was used in which non-fatal heroin overdose survivors' recall of risk behaviours in the 12 hours prior to overdose (hazard period) was compared to their recall of risk behaviours in the 12 hours prior to a selected non-overdose heroin injection (control period). RESULTS: A total of 155 participants were able to provide valid details of hazard and control periods. A dose-response relationship was observed between the self-reported amount of heroin used and likelihood of overdose (e.g. > AUD50, OR 12.97, 95% CI 2.54-66.31). The use of benzodiazepines (OR 28, 95% CI 3.81-205.79) or alcohol (OR 2.88, 95% CI 1.29-6.43), during the hazard period was related to overdose risk, but the effect of alcohol was attenuated by the effect of benzodiazepines. Shifting from private to public locations between control and hazard periods was also related to increased risk of overdose (OR 3.63, 95% CI 1.66-7.93). CONCLUSIONS: We demonstrate the value of a new methodology to explore heroin overdose, as well as discussing its limitations and ways to overcome them in future. In terms of our findings, overdose prevention messages need to highlight the impact of these transient changes in behaviour and to emphasize the risks of using higher doses of heroin as well as continuing to emphasize the risks of combining heroin with other central nervous system (CNS) depressants. Safer environments for heroin use, such as injecting rooms, may also reduce the chances of overdose.

Implementing buprenorphine treatment in community settings in Australia: experiences from the Buprenorphine Implementation Trial.

Buprenorphine was registered in Australia as a maintenance and detoxification agent for the management of opioid dependence in November, 2000, and became widely available in August, 2001. This paper provides an overview of key developments in the introduction of buprenorphine treatment in Australia, with an emphasis upon the delivery of services in community-based (primary care) settings. A central study in this work was the Buprenorphine Implementation Trial (BIT), a randomized, controlled trial comparing buprenorphine and methadone maintenance treatment delivered under naturalistic conditions by specialist and community-based service providers (general practitioners and community pharmacists) in 139 subjects across nineteen treatment sites. In addition to conventional patient outcome measures (treatment retention, drug use, psychosocial functioning, and cost effectiveness), the BIT study also involved the development and evaluation of clinical guidelines, training programs for clinicians, and client literature, which are described here. Integration of treatment systems (methadone with buprenorphine, specialist and primary-care programs) and factors thought to be important in the uptake of buprenorphine treatment in Australia since registration are discussed.

Women, work and musculoskeletal health.

Why are employed women at increased risk for upper limb musculoskeletal disorders and what can this tell us about the way work and family life shape health? Despite increases in women's labour force participation, gender differences in work-related health conditions have received little research attention. This appears be the first study to examine why employed women are much more likely than men to experience upper body musculoskeletal disorders. A mailed self-report survey gathered data from 737 Australian Public Service employees (73% women). The majority of respondents were clerical workers (73%). Eighty one per cent reported some upper body symptoms; of these, 20% reported severe and continuous upper body pain. Upper body musculoskeletal symptoms were more prevalent and more severe among women. The gender difference in symptom severity was explained by risk factors at work (repetitive work, poor ergonomic equipment), and at home (having less opportunity to relax and exercise outside of work). Parenthood exacerbated this gender difference, with mothers reporting the least time to relax or exercise. There was no suggestion that women were more vulnerable than men to pain, nor was there evidence of systematic confounding between perceptions of work conditions and reported health status. Changes in the nature of work mean that more and more employees, especially women, use computers for significant parts of their workday. The sex-segregation of women into sedentary, repetitive and routine work, and the persisting gender imbalance in domestic work are interlinking factors that explain gender differences in musculoskeletal disorders.

Aged care services for indigenous people in the Australian Capital Territory and surrounds: analysing needs and implementing change.

OBJECTIVE: To ascertain and meet current and anticipated needs for residential care and other services by older Indigenous people in the Australian Capital Territory (ACT) and region. METHODS: With advice from a reference group, qualitative and quantitative data were gathered from 98 older (45 years and over) Indigenous people in the ACT and region during 1999/2000. Indigenous and non-Indigenous researchers worked closely throughout all phases of the research. We helped participants with immediate problems identified during the interviews and worked directly with the Government funding body to implement the findings. RESULTS: No one expressed a current need for residential services. In terms of future needs, 50% of respondents favoured an arrangement where an existing mainstream provider of aged care accommodated a cluster of Indigenous people in the same facility as non-Indigenous people. Thirty-two per cent preferred an Indigenous-run organisation. Our study also revealed a broad range of health problems and needs. Assessment using the Resident Classification Scale showed that 70% required a low level of care and 4% needed a high level of care. CONCLUSION: The research identified the needs and provided a health profile of older Indigenous people in the ACT and region. This then provided policymakers with evidence on which they acted to provide appropriate aged care services. IMPLICATIONS: Collaboration between Indigenous and non-Indigenous researchers can access high-quality information, and partnership between researchers and policymakers can improve Indigenous services.

The injection of methadone syrup in New South Wales: patterns of use and increased harm after partial banning of injecting equipment.

OBJECTIVE: To describe methadone injectors and the risk practices associated with injecting methadone in New South Wales, Australia. To assess the impact on injecting drug use and risk behaviour of the withdrawal of methadone injecting equipment from government-funded needle and syringe programs. METHOD: Cross-sectional survey, conducted in 1999, of 206 people who had injected methadone at least once in the previous month. Participants were from Central Sydney, West Sydney and rural New South Wales. RESULTS: Of participants who had injected both methadone and other drugs in the previous month (n=162), significantly more reused their methadone injecting equipment compared with those who reused their other drug injecting equipment (60% vs. 28%, p<0.01). There was no significant difference in terms of sharing injecting equipment, with 19% reporting sharing methadone injecting equipment and 14% sharing other drug injecting equipment. However, women were more likely than men to share methadone injecting equipment. Over half of the participants had accessed diverted methadone and a substantial minority reported the use of public spaces for injecting methadone. CONCLUSIONS: Our results suggest that the current policy has led to increased reuse of equipment for injecting methadone. IMPLICATIONS: A range of other possible policy options, such as closer monitoring and dilution of take-home doses, increasing oral doses and implementing trials of injected methadone, may assist to reduce the prevalence of methadone syrup injection and related harms.