Discrimination and health in an English study.

In this study we examine the relationship between education, racial discrimination and health among white (n=227), African Caribbean (n=213) and Indian and Pakistani (n=233) adults aged between 18 and 59 years living in Leeds, England, as measured in a stratified population survey. Measures of discrimination included any physical attack, verbal abuse and a combined variable, any discrimination due to race, colour, ethnicity or sex. Analyses were conducted examining the relationship between education and discrimination, discrimination and health, and discrimination and health controlling for education. People educated above secondary level were more likely than people educated to secondary level or below to report being physically attacked, verbally abused and exposed to discrimination. People from minority ethnic groups (African Caribbean and Indian Pakistani) were more likely to be verbally abused and exposed to discrimination than the white group. Ethnicity and education interacted for African Caribbeans, such that respondents with post-school qualifications were more likely to report verbal abuse or any discrimination. There was no association between having been exposed to any kind of discrimination and having fair or poor health. Physical attack and any discrimination were associated with anxiety, worry and depression. The results remained unchanged when ethnicity and education were included in the models. Education and ethnicity were associated with differences in exposure to discrimination. In turn, exposure to discrimination was associated with higher levels of anxiety, worry or depression although there was no association between discrimination and health. The results support the contention that racial discrimination may play an important role in modifying the relationship between ethnicity, socioeconomic position and health. The counter-intuitive relationship between education and levels of reported discrimination in non-minority ethnic groups highlights the value of explicitly modeling discrimination to gain a better understanding of the social determinants of health.

Health service utilisation among Filipino women in remote Queensland, Australia.

INTRODUCTION: This paper will discuss health issues among Filipinas (women born in the Philippines) living in remote and rural environments in Queensland in comparison to Filipinas living in other parts of the state. The sample was recruited as part of the University of Queensland component of the Australian Longitudinal Study of Women's Health. Access to health services will be discussed in terms of the framework outlined by McKinley et al: (i) Knowledge (Availability) is measured in terms of consumers' knowledge about the services and consumers' confidence in being able to use the medical care they require; (ii) Accessibility is considered in terms of their location to the consumers in relation to the services (distance) and being able to physically get to them (transport); (iii) Affordability is measured in terms of the extent to which cost is seen as a barrier to service use; (iv) Accommodation is measured in terms of the extent to which service delivery arrangements are able to accommodate consumers' needs and the extent to which doctors' attitudes are seen to be accommodating of those needs. It would be expected that cultural and linguistic issues would primarily affect Knowledge and Accommodation. Differences in Accessibility and Affordability would be expected to be affected by location. Access to services in rural areas may be more difficult and dependent on personal transport. METHODS: The sample, consisting of women born in the Philippines, was recruited though community organizations as part of the University of Queensland component of the Australian Longitudinal Study of Women's Health. Most of the women lived in urban or semi-urban areas (391) and 90 lived in areas designated as rural or remote areas by Queensland Health. The overall response rate was 87% and 83%. RESULTS: There were no differences between urban and rural and remote women in terms of knowledge. However women living in rural and remote areas had greater difficulty getting their information needs met. Consequently problems caused by structural limitations of health service delivery were often exacerbated by differences in expectations of health services and lack of understanding of methods to optimise access to care. CONCLUSION: Many of the barriers experienced by migrant women in rural/ remote areas mirror those of other Australian women. However the results suggest that better information about health services and self-management may improve the interface between service providers and their clients.

Health issues among Filipino women in remote Queensland.

This paper discusses health issues among Filipinas (women born in the Philippines) living in remote and rural environments in Queensland. The sample was recruited as part of the University of Queensland component of the Australian Longitudinal Study of Women's Health (ALSWH). Most of the women lived in an urban or semi-urban area (391), whereas 90 lived in rural or remote areas. Community perceptions had a much greater impact on health service utilisation in rural and remote areas than in urban areas. The transition between newcomer and old-timer is more difficult for Filipinas than for other rural women because they are visibly different from other members of the community and suffer from stigmatisation associated with perceptions of Filipinas as mail order brides. For these women, concerns about confidentiality and a reluctance to ask for support are major barriers to health service utilisation. The area of greatest concern is mental health, particularly in relation to parenting issues. Improving access may involve providing a greater awareness of what services are available and allowing women to access services in a way that does not require them to label themselves or be labelled by others.

Developing qualitative databases for multiple users.

Conventionally, anthropological data are collected and analyzed by individuals, and although researchers may use data managers to organize their information, there is little need to classify and code systems to be accessible to others. Recently, however, qualitative and quantitative data have been collected in projects with multiple researchers. Difficulties with the establishment, verification, and management of databases for multiple users, particularly in longitudinal studies, are considerable if the rules underlying coding schemes are difficult to identify or if the documentation is cumbersome. Drawing on the authors' experiences in Australia, the use of computer packages for data management is discussed, and the importance of preserving the integrity of data and maintaining context while facilitating its continued and varied use is emphasized.

Migration and mainstreaming: matching health services to immigrants' needs in Australia.

The provision of special services for people of non-English speaking background in Australia emerged in the context of the development of policies of multiculturalism. This article documents the trends in state and federal policy development and service provision in the 1990s, as influenced by the sometimes-competing forces of political will, financial resources and community demand. The sustainability of various programmes is examined in the context of the continuing need to provide for people whose access to mainstream health services remains problematic.

The impact of medicare funding on the use of mammography among older women: implications for improving access to screening.

BACKGROUND: In 1991, a policy change extended finan cial coverage for biennial mammography to holders of Medicare part B. The impact of this decision on mammography use was examined by comparing mammography use among Medicare-eligible and ineligible women in the years before (1990) and after (1993) the policy change, using National Health Interview Survey (NHIS) data, controlling for socioeconomic indicators and for having a usual source of medical care. METHODS: The Medicare-eligible group consists of 2,419 women ages 65-69 years and women ages 60-64 years who are Medicare-eligible. The Medicare-ineligible group consists of 1,872 women ages 60-64 years. The analysis used logistic regressions and compared women who had undergone mammography in the prior 2 years and controlled for race, ethnicity, socioeconomic status, insurance status, and usual source of care. RESULTS: Medicare reimbursement of mammography appears to have increased the number of Medicare-eligible women who had had a mammogram in the 2 years prior to the survey. However, the analyses suggested that disparities in mammography use due to access to primary care and socioeconomic status persisted after the change in Medicare coverage. Analyses indicated that having additional insurance was the only significant predictor of having a usual source of care among the Medicare population. CONCLUSIONS: This analysis suggests that simply removing financial barriers to mammography for older women (such as the 1998 elimination of a deductible payment for mammograms provided under Medicare) may have limited effectiveness. The strong relationship between having a usual source of care and mammography suggests that disparities in mammography use may reflect inequalities in access to health care in general.

The Transtheoretical Model and cervical screening: its application among culturally diverse communities in Queensland, Australia.

OBJECTIVES: To apply the Transtheoretical Model of Behaviour Change (TTM) to cervical cancer screening to determine and report on the level of support required by different language and cultural groups in Queensland to enhance participation. The model consists of six stages: Pre-contemplation (no intention to be screened, no past action), Contemplation (intention to be screened, no past action), Action (intention to be screened, initial screening), Maintenance (intention to be screened, regular screening), Relapse (no intention to be screened, initial screening) and Relapse Risk (no intention to be screened, regular screening). DESIGN: Focus groups and structured interviews were used to classify women in terms of the model and collect information regarding knowledge, health service contact barriers and enhancing factors and sources of information in relation to cervical cancer screening. The sample was recruited by bi-cultural workers for each community using snowball techniques. RESULTS: The interview sample consisted of Australian South Sea Islanders, Chinese, German, Greek and Moslem women. There was no evidence of significant differences in TTM stage according to ethnicity. Women who intended to be screened in the future were more likely to have positive decisional balance scores and higher knowledge scores than women who did not. Women who had had Pap tests were significantly more likely to have received information from their general practitioner (GP) than women who had not had Pap tests. Women in Action and Maintenance were also more likely to have had their last Pap test by a female GP compared to women in relapse categories. Women in Pre-contemplation were more likely than women who had Pap tests to agree that they would travel a long way to see a practitioner who spoke their own language. CONCLUSION: Classification based on the model was supported both by the decisional balance scale and measures of knowledge. Women in earlier stages of the model were more likely to express preferences for the provision of services in their own language and by a female. Cervical cancer screening among women in Action and Maintenance appeared to be better supported by GPs. Cervical cancer screening promotion for women of diverse cultures and ethnicities has tended to focus on Pre-contemplation and Contemplation stages, however, as most women in this sample were in Action or Maintenance, as are most Australian-born women, structuring cervical cancer screening promotion in terms of the TTM may significantly improve the effectiveness of interventions for women of diverse cultures and ethnicities.

Towards evidence-based health promotion and service provision for new migrants to Australia.

OBJECTIVES: To examine patterns of health utilization and health information dissemination among immigrants to Australia in the first 6 months of immigration using data from the Longitudinal Study of Immigrants to Australia (LSIA). METHODS: The population for the LSIA consists of 5178 principal applicants making their first arrival to Australia on a migrant visa between 1 September 1993 and 31 August 1995, inclusive, and who are aged 15 years or over at the time (96% of all principal applicants). The influence of immigration category, country of birth, health status and age on the likelihood of receiving information about health, sources of health information and use of general practitioners were explored using separate logistic regressions for men and women. RESULTS: Women who received health information were older and less likely to have a chronic illness than women who did not. Men who received health information were older and more likely to be in the Business visa category. Younger women, those in Preferential Family visa categories and bilingual women were more likely than other women to have received health information from an NGO. For men, the only significant predictor of source of health information was being in the Independent visa category. Women who used health services were younger, more likely to have a chronic illness, be proficient in English and less likely to be in the Independent visa category than women who did not. Men who used health services were older, more likely to have a chronic condition and have limited English than men who did not. Men who used health services were more likely to be in the Humanitarian visa class and less likely to be in the Concessional Family or Business visa categories than men who did not use health services. They were also more likely to have been born in Oceania, Middle East and North Africa and Africa. CONCLUSIONS: The results of this study indicate that there are important differentials in knowledge of and use of the health system and these differences are unlikely to be captured by using measures based on ethnicity or country of origin alone. Predictors of health service utilization were different for men and women. In particular, age and lack of English proficiency appeared to be barriers to health service use for women. Visa category and country of birth were more important determinants of health service use for men.

Power and the politics of abuse: rethinking violence in Filipina-Australian marriages.

In this paper we take as a starting point the perceived high prevalence of domestic violence in marriages between Filipino women and Australian men. In in-depth interviews and structured questionnaires with service providers and with Filipinas married to Anglo-Australian and Filipino men the issue of underreporting physical and emotional violence was a recurring theme. We explore the relationships of power that characterize these marriages, the changes in balance of power that result from the externalization of anger, physical and verbal violence, and stigmatization of domestic violence experienced by Filipinas individually and in the community. We suggest that social disapproval and stereotypical representations of Filipina-Australian marriages in Australian society, and the consequent shame experienced by Filipinas, has led to underreporting of emotional and physical abuse.

Community perceptions of health, illness and care: identifying issues for indigenous communities.

Community meetings, interviews with key informants, and focus groups were used to document major health concerns and problems among Indigenous women in Queensland, as part of the Australian Longitudinal Study on Women's Health. In this article, we analyze understandings of "community" as used in Australian health research and among Indigenous women. We then examine health issues as identified and experienced by women and explore the gaps that exist between community concerns, individual health status, and service delivery.

Security and safe havens: health issues among women in mobile homes.

This paper is based on a small study of women resident in caravan parks. The study, undertaken in the context of the Australian Longitudinal Study on Women's Health, explored the health status and the health seeking behavior of women living in mobile homes in two townships in north coast New South Wales, Australia. Older women had moved to park accommodation, some with husbands, to escape the financial strains of maintaining larger homes on fixed incomes. Younger women, in contrast, typically moved to the parks alone or with children but without an adult partner, and were motivated to move from more permanent housing as a result of financial hardship, domestic violence, and their own or partners' drug and alcohol abuse. We had hypothesized some differences in women's health status and health related behavior according to place of residence, because of the differences in the two townships with respect to infrastructure and social characteristics. However, women's health status varied primarily according to age. Women believed they were physically healthy, although with some dental, sexual and particularly mental health problems.

HIV prevalence and risk behaviour in needle exchange attenders: a national study. The Collaboration of Australian Needle Exchanges.

OBJECTIVE: To determine whether needle and syringe exchange programs represent feasible sites to describe the prevalence of HIV and related risk behaviour among injecting drug users. DESIGN: Cross-sectional survey. SETTING: 21 needle and syringe exchange programs in all Australian jurisdictions. PARTICIPANTS: All persons attending the needle and syringe exchange programs over one week in March 1995 were eligible to participate in the study once. INTERVENTION: Needle and syringe exchange attenders were asked to complete a brief, self-administered questionnaire and provide a finger-prick blood sample. MAIN OUTCOME MEASURES: Prevalence of HIV antibody, drug injecting and sexual behaviour, and survey cost. RESULTS: Completed questionnaires with blood samples suitable for testing were provided by 1005 (42%) of 2373 individuals who attended the needle and syringe exchange programs during the survey week. Women were more likely than men to participate in the survey but there was no difference in the response rate by age group. The HIV prevalence was 2.1% and was significantly higher in men who described themselves as homosexual, compared to men who described themselves as heterosexual (22.5% v. 0.7%; P < 0.001). Thirty-one per cent of respondents reported using a syringe after someone else in the preceding month. CONCLUSION: Cross-sectional surveys of needle exchange clients offer a practical method for monitoring risk behaviour and seroprevalence of bloodborne viral infections.

Characteristics of admissions to residential drug treatment agencies in New South Wales, 1988-92: I. Illicit drug problems.

The Clients at Residential Agencies (CARA) database of the New South Wales Drug and Alcohol Directorate was analysed for trends in admissions of clients with illicit drug problems over the years 1988-92. The mean age of admissions rose from 26.8 years to 27.9 years over the study period. There was a small increase in the proportion of male admissions to agencies (66.5% in 1988 to 69.9% in 1992). The proportion of admissions reporting opiates as their primary drug problem declined from 81% to 65%, while the proportion of admissions for stimulant problems doubled in that period (8% to 16%), as did those for cannabis (3.6% to 8.7%). There was a significant increase in the proportions of admissions who had drug problems of 10 or more years' standing (34.9-41.3%). The proportion of admissions that had never been in treatment decreased from 51% to 15% over the study period. Admissions with prior methadone experience rose from 37% to 69% between 1988 and 1992.

Characteristics of admissions to residential drug treatment agencies in New South Wales, 1988-92: II. Alcohol problems.

The Clients at Residential Agencies (CARA) database of the New South Wales Drug and Alcohol Directorate was analysed for trends in admissions of clients with alcohol problems over the years 1988-92. There were no changes in the mean age and sex ratio of admissions, with the treatment population in all years predominantly males in their mid-thirties. There was a decrease in the proportion of clients who were employed full-time (25.1-16.4%), and an increase in admissions with criminal histories (45.7-59.3%). More than half of admissions in all years had alcohol problems of greater then 10 years' standing. The percentage of people who had never been in treatment before decreased from 44.4% in 1988 to 18.7% in 1992.

Longitudinal predictors of burnout in HIV/AIDS health professionals.

This study examined causes of burnout in doctors, nurses and social workers caring for patients in HIV/AIDS units. There were 84 participants at Time 1 (1990) and 134 at Time 2 (1991). The results focus on the longitudinal subsample of 32 who participated in the study at both times. Path analysis was used to explore relationships between burnout at Time 2 and age, hours per week in HIV/AIDS work, and external coping style at Time 1. Older age was related to lower levels of burnout at Time 2. Hours per week in HIV/AIDS work was related to levels of burnout. Participants using an external coping style were more likely to score highly on burnout at Time 2. Where possible, management should avoid recruiting young, inexperienced staff without addressing burnout issues. Workshops to teach staff internal coping skills are recommended. Units might promote the psychosocial achievements of staff, shifting away from the traditional cure-based achievement measures.

Dominant situational determinants of sexual risk behaviour in gay men.

OBJECTIVE: To examine the interplay between situational, social and psychological factors in gay men's decisions about HIV risk behaviour, using multiple hypothetical situations. METHOD: The sample included 79 gay men from Sydney recruited through flyers, press advertisements or personal contact at gay venues. Subjects were presented with 20 hypothetical situations graphically on a computer, which included different levels of attraction to partner, intoxication, attractiveness to partner, condom availability, desire for anal sex by subject, insistence of partner on using a condom and time constraints in each situation. Subjects used a computerized graphic rating scale to indicate the likelihood of unprotected anal sex in each situation, the frequency with which they had experienced the hypothetical situation in real life and satisfaction with their response. The probability of having unsafe anal sex in any given situation was the dependent variable. All other variables were predictors. RESULTS: A vector of predictors accounted for 30% of the variance (r = 0.54). Ratings of the probability of anal sex increased with the frequency that subjects had experienced hypothetical situations in real life, attraction to partner, attractiveness to partner and time elapsed since real life experience similar to the hypothetical one. Ratings of the probability of anal sex decreased with condom availability. CONCLUSIONS: Our results suggest that interventions must address the way that individuals interact with their partner and their environment in order to be successful.

Predictors of intoxicated sex in injecting drug users.

Transmission of HIV by sexual contact as well as through sharing of contaminated injection equipment is a source of viral spread from injecting drug users (IDUs). We report on an analysis of data from 1,245 IDUs interviewed in Sydney, Australia in which half of the respondents reported being intoxicated during sex for more than half of their sexual encounters. The most common drugs on which people were intoxicated during sex were heroin, cannabis and alcohol. Predictors of having sex when intoxicated were a lower likelihood of having been in treatment, higher number of sexual partners, sharing injection equipment with more people and more recently, being intoxicated when injecting, and not being a sex worker. The data indicate that having sex while intoxicated is common in these IDUs and that sex under the influence of drugs is part of a more general lifestyle of spending a greater time intoxicated. Targeting of those IDUs who spend a significant amount of time intoxicated and their recruitment into treatment may thus reduce both risky sexual behaviour and risky injecting behaviour.

Quality of life in health care professionals: Burnout and its associated factors in hiv/aids related care.

Health care professionals working in HIV/AIDS are dedicated to providing quality care for their clients. They also need to care for themselves. This study examines why burnout occurs and how it may be prevented in the care of clients with HIV/AIDS. The sample of Australian HIV/AIDS health care professionals (n = 84). consisted of 54 nurses, 16 doctors and 14 social workers. Respondents were divided into groups on the basis of their burnout scores. Members of the High Burnout group had higher levels of Anxiety, Stress and Stigma, were more likely to use External Coping Strategies and higher amounts of Tangible Support than members of the Low Burnout group. Subjects in the Low Burnout group were more likely to use Internal Coping Strategies, had greater Affiliation with the Gay Community, experienced greater Support Belonging and Relationship Satisfaction and Social Recognition and Reward than their counterparts in the High Burnout group. Support and job-related rewards may buffer and prevent experiences of burnout. Programmes to prevent burnout should include the teaching of coping skills and relaxation skills and should foster staff support and recognition.