Search

Public policy plays a central role in creating and distributing resources and conditions of daily life that matter for health equity. Policy agendas have tended to focus on health care delivery and individualised interventions. Asking why there is a lack of policy action on structural drivers of health inequities raises questions about power inequities in policy systems that maintain the status quo. In this paper we investigate the power dynamics shaping public policy and implications for health equity. Using a Health Equity Power Framework (HEPF), we examined data from 158 qualitative interviews with government, industry and civil society actors across seven policy case studies covering areas of macroeconomics, employment, social protection, welfare reform, health care, infrastructure and land use planning. The influence of structures of capitalism, neoliberalism, sexism, colonisation, racism and biomedicalism were widely evident, manifested through the ideologies, behaviours and discourses of state, market, and civil actors and the institutional spaces they occupied. Structurally less powerful public interest actors made creative use of existing or new institutional spaces, and used network, discursive and moral power to influence policy, with some success in moderating inequities in structural and institutional forms of power. Our hope is that the methodological advancement and empirical data presented here helps to illuminate how public interest actors can navigate structural power inequities in the policy system in order to disrupt the status quo and advance a comprehensive policy agenda on the social determinants of health equity. However, this analysis highlights the unrealistic expectation of turning health inequities around in a short time given the long-term embedded power dynamics and inequities within policy systems under late capitalism. Achieving health equity is a power-saturated long game.

This paper reports findings from 55 stakeholder interviews undertaken in six Primary Health Networks (PHNs) in Australia as part of a study of the impact of population health planning in regional primary health organisations on service access and equity. Primary healthcare planning is currently undertaken by PHNs which were established in 2015 as commissioning organisations. This was a departure from the role of Medicare Locals, the previous regional primary health organisations which frequently provided services. This paper addresses perceptions of 23 senior staff, 11 board members and 21 members of clinical and community advisory councils or health priority groups from six case study PHNs on the impact of commissioning on equity. Participants view the collection of population health data as facilitating service access through redistributing services on the basis of need and through bringing objectivity to decision-making about services. Conversely, participants question the impact of the political and geographical context and population profile on capacity to improve service access and equity through service commissioning. Service delivery was seen as fragmented, the model is at odds with the manner in which Aboriginal Community Controlled Health Organisations (ACCHOs) operate and rural regions lack services to commission. As a consequence, reliance upon commissioning of services may not be appropriate for the Australian primary healthcare context.

SummaryIntroduction/Background Globally, health reforms continue to be high on the health policy agenda to respond to the increasing health care costs and managing the emerging complex health conditions. Many countries have emphasised PHC to prevent high cost of hospital care and improve population health and equity. The existing tension in PHC philosophies and complexity of PHC setting make the implementation and management of these changes more difficult. This paper presents an Australian case study of PHC restructuring and how these changes have been managed from the viewpoint of practitioners and middle managers. Methods As part of a 5-year project, we interviewed PHC practitioners and managers of services in 7 Australian PHC services. Findings Our findings revealed a policy shift away from the principles of comprehensive PHC including health promotion and action on social determinants of health to one-to-one disease management during the course of study. Analysis of the process of change shows that overall, rapid, and top-down radical reforms of policies and directions were the main characteristic of changes with minimal communication with practitioners and service managers. The study showed that services with community-controlled model of governance had more autonomy to use an emergent model of change and to maintain their comprehensive PHC services. Conclusions Change is an inevitable feature of PHC systems continually trying to respond to health care demand and cost pressures. The implementation of change in complex settings such as PHC requires appropriate change management strategies to ensure that the proposed reforms are understood, accepted, and implemented successfully.

Health system changes may increase primary health care workers’ dilemmatic space, created when reforms contravene professional values. Dilemmatic space may be a risk factor for burnout. This study partnered with six Australian primary health care services (in South Australia: four state government–managed services including one Aboriginal health team and one non-government organisation and in Northern Territory: one Aboriginal community–controlled service) during a period of change and examined workers’ dilemmatic space and incidence of burnout. Dilemmatic space and burnout were assessed in a survey of 130 staff across the six services (58% response rate). Additionally, 63 interviews were conducted with practitioners, managers, regional executives and health department staff. Dilemmatic space occurred across all services and was associated with higher rates of self-reported burnout. Three conditions associated with dilemmatic space were (1) conditions inherent in comprehensive primary health care, (2) stemming from service provision for Aboriginal and Torres Strait Islander peoples and (3) changes wrought by reorientation to selective primary health care in South Australia. Responses to dilemmatic space included ignoring directives or doing work ‘under the radar’, undertaking alternative work congruent with primary health care values outside of hours, or leaving the organisation. The findings show that comprehensive primary health care was contested and political. Future health reform processes would benefit from considering alignment of changes with staff values to reduce negative effects of the reform and safeguard worker wellbeing.

Background: There is an increasing emphasis on the importance of comprehensive primary healthcare (CPHC) in improving population health and health equity. There is, therefore, a need for a practical means to determine how comprehensive regional primary healthcare organisations (RPHCOs) are in their approach. This paper proposes a framework to provide such a means. The framework is then applied to assess the comprehensiveness of Australian RPHCOs. Methods: Drawing on a narrative review of the broader literature on CPHC versus selective primary healthcare (SPHC) and examples of international models of RPHCOs, we developed a framework consisting of the key criteria and a continuum from comprehensive to selective interventions. We applied this framework to Australian RPHCOs using data from the review of their planning documents, and survey and interviews with executive staff, managers, and board members. We used a spidergram as a means to visualise how comprehensive they are against each of these criteria, to provide a practical way of presenting the assessment and an easy way to compare progress over time. Results: Key criteria for comprehensiveness included (1) focus on population health; (2) focus on equity of access and outcomes; (3) community participation and control; (4) integration within the broader health system; (5) inter-sectoral collaboration; and (6) local responsiveness. An examination of Australian RPHCOs using the framework suggests their approach is far from comprehensive and has become more selective over time. Conclusion: The framework and spidergram offer a practical means of gauging and presenting the comprehensiveness of RPHCOs, and to identify gaps in comprehensiveness, and changes over time.

© 2019 The Authors Objective: This paper provides a case study of the responses to alcohol of an Aboriginal Community Controlled Health Service (The Service), and investigates the implementation of comprehensive primary health care and how it challenges the logic of colonial approaches. Methods: Data were drawn from a larger comprehensive primary health care study. Data on actions on alcohol were collected from: a) six-monthly service reports of activities; b) 29 interviews with staff and board members; c) six interviews with advocacy partners; and d) community assessment workshops with 13 service users. Results: The Service engaged in rehabilitative, curative, preventive and promotive work targeting alcohol, including advocacy and collaborative action on social determinants of health. It challenged other government approaches by increasing Aboriginal people’s control, providing culturally safe services, addressing racism, and advocating to government and industry. Conclusions: This case study provides an example of implementation of the full continuum of comprehensive primary health care activities. It shows how community control can challenge colonialism and ongoing power imbalances to promote evidence-based policy and practice that support self-determination as a positive determinant for health. Implications for public health: Aboriginal Community Controlled Health Services are a good model for comprehensive primary health care approaches to alcohol control.

Objective: This paper examines whether Australian regional primary health care organisations – in this case, Medicare Locals (MLs) and Primary Health Networks (PHNs) – have engaged with migrant and refugee health, and what factors encourage work in this area. Methods: The study used mixed methods with surveys of ML (N=210) and PHN staff (N=66), interviews with ML (N=50) and PHN (N=55) staff, national consultations with migrant and refugee organisations (N=8 groups with 62 participants), and analysis of ML and PHN documents. Results: Needs assessment documents identified migrant and refugee health issues in 46% of MLs and 74% of PHNs. However, 48% of MLs and 55% of PHNs did not report any activities on migrant health, and 78% and 62% did not report any activities for refugees, respectively. Key factors identified by participants as associated with whether ML and PHN focus on migrant and refugee health were the determination of local priority areas, policy context and funding, collaboration with migrant and refugee organisations and communities, and mechanisms for engagement. Conclusions: Despite the importance of primary health care for migrants and refugees, there was relatively little attention paid to these population groups in MLs and PHNs, with a small number of notable exceptions. Implications for public health: The paper concludes with a range of recommendations for improving regional primary health care organisation engagement with migrant and refugee health.

This paper applies a critical analysis of the impact of neo-liberal driven management reform to examine changes in Australian primary health care (PHC) services over five years. The implementation of comprehensive approaches to primary health care (PHC) in seven services: five state-managed and two non-government organisations (NGOs) was tracked from 2009 to 2014. Two questions are addressed: 1) How did the ability of Australian PHC services to implement comprehensive PHC change over the period 2009–2014? 2) To what extent is the ability of the PHC services to implement comprehensive PHC shaped by neo-liberal health sector reform processes? The study reports on detailed tracking and observations of the changes and in-depth interviews with 63 health service managers and practitioners, and regional and central health executives. The documented changes were: in the state-managed services (although not the NGOs) less comprehensive service coverage and more focus on clinical services and integration with hospitals and much less development activity including community development, advocacy, intersectoral collaboration and attention to the social determinants. These changes were found to be associated with practices typical of neo-liberal health sector reform: considerable uncertainty, more directive managerial control, budget reductions and competitive tendering and an emphasis on outputs rather than health outcomes. We conclude that a focus on clinical service provision, while highly compatible with neo-liberal reforms, will not on its own produce the shifts in population disease patterns that would be required to reduce demand for health services and promote health. Comprehensive PHC is much better suited to that task.

Next generation telecommunications infrastructure is expanding and supporting rapid growth of broadband technologies and a digital economy. In this context, digital information and communications technologies (ICTs) are of increasing importance as a means for people to gain access to health or social services, employment opportunities, information and social networks. In this article we draw on our recent case study research to examine the policy (and politics) shaping implementation of Australia's National Broadband Network (NBN) and its likely effects on equity of access to high speed broadband (HSB) services. We monitored NBN policy and implementation from 2015 to 2018 through policy documents, reports, and media. To assess likely effects of NBN policy on implementation and subsequently on equity of access to HSB we: a) applied a framework defining four elements of equity of access; and b) analysed stakeholder views drawn from media articles and 22 interviews with experts on NBN policy including politicians, government staff, and industry representatives. We found that equity considerations competed with political and commercial imperatives during the rollout of the NBN. This resulted in positive and negative consequences for equity of access to HSB, with a change in policy and implementation in 2013 bringing greater risks to equity of access. The case study provides a framework for considering equity in the implementation of next generation telecommunications infrastructure and highlights the importance of considering equity in the evaluation of telecommunications infrastructure.

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Background Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected – they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. New research network In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. Conclusion Further research using this framework has considerable potential to advance effective policies to advance health and equity.

© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Background Worldwide, there are competing norms driving health system changes and reorganisation. One such norm is that of health systems’ responsibilities for population health as distinct from a focus on clinical services. In this paper we report on a case study of population health planning in Australian primary health care (PHC) organisations (Medicare Locals, 2011–2015). Drawing on institutional theory, we describe how institutional forces, ideas and actors shaped such planning. Methods We reviewed the planning documents of the 61 Medicare Locals and rated population health activities in each Medicare Local. We also conducted an online survey and 50 interviews with Medicare Local senior staff, and an interview and focus group with Federal Department of Health staff. Results Despite policy emphasis on population health, Medicare Locals reported higher levels of effort and capacity in providing clinical services. Health promotion and social determinants of health activities were undertaken on an ad hoc basis. Regulatory conditions imposed by the federal government including funding priorities and time schedules, were the predominant forces constraining population health planning. In some Medicare Locals, this was in conflict with the normative values and what Medicare Locals felt ought to be done. The alignment between the governmental and the cultural-cognitive forces of a narrow biomedical approach privileged clinical practice and ascribed less legitimacy to action on social determinants of health. Our study also shed light on the range of PHC actors and how their agency influenced Medicare Locals’ performance in population health. The presence of senior staff or community boards with a strong commitment to population health were important in directing action towards population health and equity. Conclusions There are numerous institutional, normative and cultural factors influencing population health planning. The experience of Australian Medicare Locals highlights the difficulties of planning in such a way that the impact of the social determinants on health and health equity are taken into account. The policy environment favours a focus on clinical services to the detriment of health promotion informed by a social determinants focus. Electronic supplementary material The online version of this article (10.1186/s12889-018-5273-4) contains supplementary material, which is available to authorized users.

OBJECTIVE To examine the strength and extent of collaborations between primary health care organisations and local government in population health planning. METHODS Methods included: a) online surveys with Medicare Locals (n=210) and Primary Health Networks (n=66), comparing the two using two-level mixed models; b) interviews with Medicare Local (n=50) and Primary Health Network (n=55) executives; c) interviews with members of local government associations and Primary Health Network board members with local government experience (n=7); and d) review of 54 Medicare Local and 31 Primary Health Network publicly available annual reports. RESULTS Despite partnership being a policy objective for Medicare Locals/ Primary Health Networks, they reported limited time and financial support for collaboration with local government. Organisational capacity and resources, supportive governance and public health legislation mandating a role for local governments were critical to collaborative planning. CONCLUSIONS Local government has the potential to tackle social factors affecting health; therefore, their inclusion in population health planning is valuable. Legislative mandates would help to achieve this, and PHNs require a stronger Federal Government mandate backed by sufficient resources and a governance structure that supports collaboration. Implications for public health: Improving primary health care and local government collaboration has great potential to improve the quality of health planning and action on social determinants, thus advancing population health and health equity.

Issue addressed: This paper examines recent Australian health reform policies and considers how the primary health care (PHC) workforce experiences subsequent change and perceives its impact on health promotion practice. Methods: Health policy documents were analysed to determine their intended impact on health promotion. Interviews were conducted with 39 respondents from four State-funded PHC services to gain their perceptions of the impact of policy change on health promotion. Results: There have been a plethora of policy and strategy documents over the last decade relevant to PHC, and these suggest an intention to strengthen health promotion. However, respondents report that changes to the role and focus of PHC services have led to fewer opportunities for health promotion. Services are struggling to engage in health promotion activity, while funding and policy directions are prioritised to targeted, individual behaviour change. Conclusion: The experience of PHC workforce respondents in South Australia suggests that, despite policy intentions, health promotion practice is much reduced. Our research suggests that rigorous evaluation of health sector reforms should be undertaken to assess both intended and unintended outcomes in terms of service quality and delivery. So what? Health promoters are experiencing a contradictory policy and practice environment, and this research should assist health promoters in advocating for more government accountability in the implementation of policies in order to advance comprehensive PHC.?

Community participation is a key principle of comprehensive primary health care (PHC). There is little literature on how community participation is implemented at Australian PHC services. As part of a wider study conducted in partnership with five South Australian PHC services, and one Aboriginal community controlled health service in the Northern Territory, 68 staff, manager, regional health executives, and departmental funders were interviewed about community participation, perceived benefits, and factors that influenced implementation. Additional data were collected through analysis of policy documents, service reports on activity, and a web-based survey completed by 130 staff. A variety of community participation strategies was reported, ranging from consultation and participation as a means to improve service quality and acceptability, to substantive and structural participation strategies with an emphasis on empowerment. The Aboriginal community controlled health service in our study reported the most comprehensive community participation. Respondents from all services were positive about the benefits of participation but reported that efforts to involve service users had to compete with a centrally directed model of care emphasising individual treatment services, particularly at state-managed services. More empowering substantive and structural participation strategies were less common than consultation or participation used to achieve prescribed goals. The most commonly reported barriers to community participation were budget and lack of flexibility in service delivery. The current central control of the state-managed services needs to be replaced with more local management decision making if empowering community participation is to be strengthened and embedded more effectively in the culture of services.

ObjectivesTo determine the feasibility of case-tracking methods in documenting client journeys at primary healthcare (PHC) services in order to investigate the comprehensiveness of service responses and the experiences of clients.DesignProspective pilot study. Quantitative and qualitative case management data were collected from staff via questionnaire or interview.SettingFive Australian multidisciplinary PHC services were involved including four South Australian state-managed and one Northern Territory Aboriginal community-controlled PHC service.ParticipantsClients using services for depression (95) or diabetes (185) at the PHC services were case tracked over a 12-month period to allow construction of client journeys for these two conditions. Clients being tracked were invited to participate in two semi-structured interviews (21) and complete a health log.ResultsThough a number of challenges were encountered, the case-tracking methods were useful in documenting the complex nature of client journeys for those with depression or diabetes accessing PHC services and the need to respond to the social determinants of health. A flexible research design was crucial to respond to the needs of staff and changing organisational environments.ConclusionsThe client journeys provided important information about the services’ responses to depression and diabetes, and about aspects unique to comprehensive PHC such as advocacy and work that takes into account the social determinants of health.

This paper reports on the health promotion and disease prevention conducted at Australian multi-disciplinary primary health care (PHC) services and considers the ways in which the organizational environment affects the extent and type of health promotion and disease prevention activity. The study involves five PHC services in Adelaide and one in Alice Springs. Four are managed by a state health department and two by boards of governance. The study is based on an audit of activities and on 68 interviews conducted with staff. All the sites undertake health promotion and recognize its importance but all report that this activity is under constant pressure resulting from the need to provide services to people who have health problems. We also found an increased focus on chronic disease management and prevention which prioritized individuals and behavioural change strategies rather than addressing social determinants affecting whole communities. There was little health promotion work that reflected a salutogenic approach to the creation of health. Most activity falls under three types: parenting and child development, chronic disease prevention and mental health. Only the non-government organizations reported advocacy on broader policy issues. Health reform and consequent reorganizations were seen to reduce the ability of some services to undertake health promotion. The paper concludes that PHC in Australia plays an important role in disease prevention, but that there is considerable scope to increase the amount of community-based health promotion which focuses on a salutogenic view of health and which engages in community partnerships., This work was supported by the National Health and Medical Research Council (grant number 535041), an Australian Research Council Federation Fellowship (to F.B.) and the Canada Research Chair program (to R.L.).

This article draws on data from a 5-year project that examined the effectiveness of Comprehensive primary healthcare (CPHC) in local communities. A hallmark of CPHC services is interprofessional teamwork. Drawing from this study, our article presents factors that enabled, or hindered, healthcare teams working interprofessionally in Australian primary healthcare (PHC) services. The article reports on the experiences of teams working in six Australian PHC services (four managed by state governments, one non-government sexual health organisation, and one Aboriginal community-controlled health service) during a time of significant health sector restructure. Findings are drawn from two key methods: an online survey of practitioners and managers (n = 154), and interviews with managers and practitioners (n = 60) from the six study sites. The majority of survey respondents worked with other health professionals in their service to provide interprofessional care to clients. Processes included formal team meetings, case conferencing, referring clients to other health professionals if needed, informal communication with other health professionals about clients, and team-based delivery of care. A range of interrelated factors affected interprofessional work at the services, from contextual, organisational, processual, and relational domains. Funding cuts and policy changes that saw a reorientation and re-medicalisation of South Australian services undermined interprofessional work, while a shared CPHC culture and commitment among some staff was helpful in resisting some of these effects. The co-location of services was a factor in PHC teams working interprofessionally and not only enabled some PHC teams to work more interprofessionally but also created barriers to interprofessional teamwork through disruption resulting from restructuring of services. Our study indicates the importance of decision makers taking into account the potential effects of policy and structural changes on interprofessional teamwork. Decision makers should strive to minimise unintended negative effects of changes on the functioning of interprofessional teams.

Objectives: The present study examined Australian ED nurses' practices in asking patients about alcohol and assisting them to manage their alcohol consumption. It also investigated strategies to support ED nurses in these interventions. Methods: A two‐stage survey was administered to ED nurses. The first questionnaire measured theoretical and organizational predictors of behaviour, and underlying beliefs, and the subsequent questionnaire explored rates of asking and assisting patients. Results: A total of 125 nurses returned the first questionnaire. Participants held generally positive attitudes, perceived norms, feelings of legitimacy and perceived ability to ask about and intervene for alcohol, but lower role adequacy. The 71 ED nurses who completed the second questionnaire had intervened with almost 500 patients concerning alcohol in the previous week. Participants asked approximately one in four patients about alcohol (median = 26.3% of patients, 1095/4279 total patients asked). The Theory of Planned Behaviour did not predict rates of asking or assisting patients. Several strategies were identified that might increase rates: identify environmental factors that prevent nurses acting on their intentions to ask and intervene, raise confidence and skills, make asking about alcohol part of routine assessment, make supports such as drug and alcohol units or nurses available, and implement organizational policies on alcohol. Conclusions: Nurses appear positively disposed to engage with patients in regard to alcohol. However, greater support is needed to achieve the considerable significant public health benefits from this engagement. The findings point to several practical strategies that could be pursued to provide this support.

This is the peer reviewed version of the following article: [Freeman, T., White, V., & Roche, A.M. (2011) Which Australian secondary school students are at risk of illicit drug use? : A nationwide survey. Drug and Alcohol Review, 30, 589-596], which has been published in final form at [DOI: 10.1111/j.1465-3362.2010.00246.x]. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving.

Background There have been increasing national and international calls for the introduction of drug testing as a policy measure to address harmful drug use. Such strategies have been applied in workplaces, sporting arenas, prisons and more latterly school settings. They are predicated on a belief in their efficacy in reducing drug-related harm, a need to ‘send the right' message to potential users and to reassure the community at large that ‘something is being done.' Rigorous examination is required of purported benefits of drug testing in schools. Methods A comprehensive examination was made of testing efficacy and accuracy. Australian legal and ethical issues, encompassing duty of care, rights of the child and privacy determinations, were juxtaposed with that of the United States of America. Results Evidence examined indicates no compelling case for the application of drug testing and that caution should be applied when considering drug testing as a drug detection and prevention strategy in the school setting. Conclusion While this review did not support school drug testing, there are alternative evidence-based strategies that schools can implement to prevent drug-related problems among student populations.

Issues. The traditional approach to increasing the capacity of health and human service professionals to deliver alcohol, tobacco and other drug interventions has been to build relevant knowledge, skills and attitudes through the provision of education and training. However, as a stand alone strategy, education and training is likely to have limited impact. Approach. This paper examines not only the features and characteristics of successful training programs and approaches, but also the wider array of systems and structural factors that might act as impediments to the implementation of new knowledge, skills and clinical behaviours. Key Findings. There is a constellation of factors that extend beyond traditional notions of ‘training’ that fall under the rubric of ‘workforce development’. Implications and Conclusions. A workforce development approach requires three levels of action—system-wide, capacity building and professional development to ensure effective responses. [Roche AM, Pidd K, Freeman T. Achieving professional practice change: From training to workforce development. Drug Alcohol Rev 2009;28:550–557]

To conduct a systematic review of hospital alcohol screening studies to identify effective and efficient evidence-based strategies.Sixty-five studies (N=100,980) of alcohol problem prevalence amongst hospital patients were reviewed.Prevalence of positive alcohol screens varied according to hospital location, screening tool and patient characteristics. BAC measures (26%) were nearly twice as likely (OR=1.92, p.001) to reveal positive screens in the ED than self-reports (16%). No difference was found in prevalence of self-report positive screens between ED (16%) and ward settings (17%). Males were two to four times more likely than females to screen positive (BAC: OR=2.37, p.001, ED self-report: OR=3.07, p.001, ward self-report: OR=4.30, p.001). ED patients aged 20-40 years and ward patients aged 30-50 years had the highest prevalence of positive screens.Prevalence of risky or problematic drinking among hospital patients is high and warrants systematic screening and intervention. Many hospitals lack sufficient resources to undertake widespread screening programs. For optimum return on resources, it is recommended to screen males in the ED using BAC measures. Established protocols applying priority criteria and staff training can increase screening accuracy and effectiveness.

A substantial body of research evidence has accumulated in support of the efficacy of brief interventions for a number of alcohol and drug-related problem areas, most notably alcohol and tobacco. This evidence has been used to exhort a range of professional groups such as general practitioners (GPs), and more recently emergency department hospital staff to engage in brief interventions. Internationally, however, these secondary prevention efforts have largely failed. Why have these proven interventions not been embraced by frontline workers? This is a little-asked question as efforts to press-gang unwilling professionals to take up the cudgel continue. This paper examines the characteristics of brief interventions and their principal delivery agents and explores reasons for the failure to move from efficacy to effectiveness. Given the prevention potential that rests with brief intervention, these are crucial questions to address. A key feature of brief intervention delivery also examined is the role of GPs versus the less well-explored option of the practice nurse. It will be proposed that perhaps we have the right vehicle but the wrong driver and that until closer scrutiny is made of this issue efforts in this key prevention area will continue to fail to achieve optimum results.

Background Since the WHO’s Alma Ata Declaration on Primary Health Care (PHC) there has been debate about the advisability of adopting comprehensive or selective PHC. Proponents of the latter argue that a more selective approach will enable interim gains while proponents of a comprehensive approach argue that it is needed to address the underlying causes of ill health and improve health outcomes sustainably. Methods This research is based on four case studies of government-funded and run PHC services in Adelaide, South Australia. Program logic models were constructed from interviews and workshops. The initial model represented relatively comprehensive service provision in 2010. Subsequent interviews in 2013 permitted the construction of a selective PHC program logic model following a series of restructuring service changes. Results Comparison of the PHC service program logic models before and after restructuring illustrates the changes to the operating context, underlying mechanisms, service qualities, activities, activity outcomes and anticipated community health outcomes. The PHC services moved from focusing on a range of community, group and individual clinical activities to a focus on the management of people with chronic disease. Under the more comprehensive model, activities were along a continuum of promotive, preventive, rehabilitative and curative. Under the selective model, the focus moved to rehabilitative and curative with very little other activities. Conclusion The study demonstrates the difference between selective and comprehensive approaches to PHC in a rich country setting and is useful in informing debates on PHC especially in the context of the Sustainable Development Goals.

To examine the partnerships in population health planning between Medicare Locals (MLs) and Local Health Networks (LHNs) in South Australia, and the factors that facilitated or constrained collaborations, to offer lessons for LHNs and Primary Health Networks.We conducted a qualitative study using individual interviews with key informants (executive or program leader staff) from the five South Australian MLs and the five South Australian LHNs. A total of 34 interviews were conducted between March and July 2014.Significant work was undertaken by MLs in the process of population health planning and needs assessment. Participants from both MLs and LHNs described examples of collaborative work, including data sharing and synthesis, program implementation and community consultation. The focus of LHNs on acute and intermediate care, the lack of system-level strategies to support collaboration, and constant policy and structural changes leading to uncertainty in the primary health care landscape were perceived as key barriers to collaboration.The experience of MLs and their achievements in building relationships and trust with stakeholders in their regions, including LHNs, provide valuable lessons for the new Primary Health Networks in Australia.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated, Background: This paper describes the development of a model of Comprehensive Primary Health Care (CPHC) applicable to the Australian context. CPHC holds promise as an effective model of health system organization able to improve population health and increase health equity. However, there is little literature that describes and evaluates CPHC as a whole, with most evaluation focusing on specific programs. The lack of a consensus on what constitutes CPHC, and the complex and context-sensitive nature of CPHC are all barriers to evaluation. Methods: The research was undertaken in partnership with six Australian primary health care services: four state government funded and managed services, one sexual health non-government organization, and one Aboriginal community controlled health service. A draft model was crafted combining program logic and theory-based approaches, drawing on relevant literature, 68 interview s with primary health care se rvice staff, and researcher experience. The model was then refined through an iterative process involving two to three workshops at each of the six participating primary health care services, engaging health service staff, regional health executives and central health department staff. Results: The resultant Southgate Model of CPHC in Australia model articulates the theory of change of how and why CPHC service components and activities, based on t he theory, evidence and values which underpin a CPHC approach, are likely to lead to indivi dual and population health outcome s and increased health equity. The model captures the importance of context, the mechanisms of CPHC, and the space for action services have to work within. The process of development engendered and supported collaborati ve relationships between researchers and stakeholders and the product provide d a description of CPHC as a whole and a framework for evaluation. The model was endorsed at a research symposium involving inv estigators, service staff, and key stakeholders. Conclusions: The development of a theory-based program logi c model provided a framework for evaluation that allows the tracking of progress towards desired outcomes and exploration of the particular aspects of context and mechanisms that produce outcomes. This is important because there are no existing models which enable the evaluation of CPHC services in their entirety.

Objective: To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Methods: Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. Results: The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. Conclusions: While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Implications: Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action.

Objective This study addressed the potential role of pharmacists in helping their patients to quit smoking by providing a summary of their self-reported levels of current activities, confidence, and readiness to change around the provision of brief advice and support for patients who smoke. In addition to investigating which barriers are perceived to be most important, this study also examined the relative importance of confidence, barriers and practice factors in relation to pharmacists' smoking cessation practices. Method A 58-item questionnaire was mailed to 720 pharmacists. The questionnaire measured demographic and background variables, level of smoking cessation activity (asking, advising, assessing, assisting and arranging including follow-up), confidence in undertaking smoking-cessation activities, readiness to change, perceived importance of barriers to providing smoking-cessation services, and further education or training in relation to smoking cessation. Setting Community pharmacists in South Australia. Key findings Respondents indicated high rates of activity in relation to assessing and assisting patients to quit smoking, with lower rates of advising and arranging including following up. Recording of smoking status was very low. Confidence emerged as the most important predictor of smoking-cessation activities, with pharmacist barriers including fear of alienating patients approaching significance. Reported levels of smoking-specific education and training were low. Conclusions South Australian pharmacists are contributing to the prevention of tobacco-related harms. With additional support there is a greater scope for involvement. Results indicate a need for a team-based, systematic and multifaceted approach to address barriers and enhance pharmacists' confidence. Further implementation research is required to assess the effectiveness of multifaceted pharmacy support programmes on the uptake and sustainability of smoking-cessation services.

This paper examines recent Australian health reform policies and considers how the primary health care (PHC) workforce experiences subsequent change and perceives its impact on health promotion practice.Health policy documents were analysed to determine their intended impact on health promotion. Interviews were conducted with 39 respondents from four State-funded PHC services to gain their perceptions of the impact of policy change on health promotion.There have been a plethora of policy and strategy documents over the last decade relevant to PHC, and these suggest an intention to strengthen health promotion. However, respondents report that changes to the role and focus of PHC services have led to fewer opportunities for health promotion. Services are struggling to engage in health promotion activity, while funding and policy directions are prioritised to targeted, individual behaviour change.The experience of PHC workforce respondents in South Australia suggests that, despite policy intentions, health promotion practice is much reduced. Our research suggests that rigorous evaluation of health sector reforms should be undertaken to assess both intended and unintended outcomes in terms of service quality and delivery. SO WHAT? Health promoters are experiencing a contradictory policy and practice environment, and this research should assist health promoters in advocating for more government accountability in the implementation of policies in order to advance comprehensive PHC.

This is the accepted version of the following article: [Freeman, T., Edwards, T., Baum, F., Lawless, A., Jolley, G., Javanparast, S. and Francis, T. (2014), Cultural respect strategies in Australian Aboriginal primary health care services: beyond education and training of practitioners. Australian and New Zealand Journal of Public Health, 38: 355–361. ], which has been published in final form at doi: 10.1111/1753-6405.12231. This item was under embargo for a period of 12 months from the date of publication, in accordance with the publisher's policy., Objective. There is little literature on health service level strategies for culturally respectful care to Aboriginal and Torres Strait Islander Australians. We conducted two case studies: , one Aboriginal community controlled, and one state government managed primary health care service to examine cultural respect strategies, client experiences, and barriers to cultural respect. Methods. Data were drawn from 22 interviews with staff from both services, and four community assessment workshops, with a total of 21 clients. Results. Staff and clients at both services reported positive appraisals of the achievement of cultural respects. Strategies included being grounded in a social view of health, including advocacy and addressing social determinants, employing Aboriginal staff, creating a welcoming service, supporting access through transport, outreach, and walk-in centres, and integrating cultural protocol. Barriers included communication difficulties, racism and discrimination, and externally developed programs. Conclusions. Service level strategies were necessary to achieving cultural respect. These strategies have the potential to improve Aboriginal and Torres Strait Islander health and wellbeing. Implications. Primary health care’s social determinants of health mandate, the community controlled model, and the development of the Aboriginal and Torres Strait Islander health workforce need to be supported to ensure a culturally respectful health system.

Community participation is a key principle of comprehensive primary health care (PHC). There is little literature on how community participation is implemented at Australian PHC services. As part of a wider study conducted in partnership with five South Australian PHC services, and one Aboriginal community controlled health service in the Northern Territory, 68 staff, manager, regional health executives, and departmental funders were interviewed about community participation, perceived benefits, and factors that influenced implementation. Additional data were collected through analysis of policy documents, service reports on activity, and a web-based survey completed by 130 staff. A variety of community participation strategies was reported, ranging from consultation and participation as a means to improve service quality and acceptability, to substantive and structural participation strategies with an emphasis on empowerment. The Aboriginal community controlled health service in our study reported the most comprehensive community participation. Respondents from all services were positive about the benefits of participation but reported that efforts to involve service users had to compete with a centrally directed model of care emphasising individual treatment services, particularly at state-managed services. More empowering substantive and structural participation strategies were less common than consultation or participation used to achieve prescribed goals. The most commonly reported barriers to community participation were budget and lack of flexibility in service delivery. The current central control of the state-managed services needs to be replaced with more local management decision making if empowering community participation is to be strengthened and embedded more effectively in the culture of services.

Background. Indigenous alcohol and other drug (AOD) workers’ roles are often exhausting, poorly paid and underrecognised. There has been relatively little examination of work-related stressors on their health and well-being. This national study identified Indigenous AOD workers’ experiences and perspectives on well-being, stress and burnout along with strategies to improve worker well-being. Methods. Focus groups were conducted with 121 participants (70 Indigenous, 20 nonIndigenous, 31 unspecified) from metropolitan, rural and remote locations around Australia, selected via a purposive sampling strategy. Audio files and interview notes were analysed to identify key themes. Results. Main themes identified included excessive workloads, extensive demands and expectations, workers’ proximity to communities, loss and grief issues, lack of recognition, inadequate rewards, stigma and racism, and Indigenous ways of working. Stressors were compounded by workers’ complex personal circumstances, profound levels of loss and grief, and lack of culturally safe working environments. Discussion and Conclusion. Indigenous workers’ stress was exacerbated by close links and responsibilities to their communities and a ‘dual accountability’, being constantly on call, playing multiple roles, complex personal and professional lives, and needing to interact with multiple agencies. Many Indigenous AOD workers had developed mechanisms to deal with work-related pressures and received valued support from their communities. The study identified the importance of workforce strategies to improve Indigenous workers’ well-being and reduce stress, including: mutual support networks, training in assertiveness and boundary setting, workloads that take account of Indigenous ways of working, adequate remuneration, supervision and mentorship, and cultural sensitivity training for non-Indigenous workers. [Roche AM, Duraisingam V, Trifonoff A, Battams S, Freeman T, Tovell A, Weetra D, Bates N. Sharing stories: Indigenous alcohol and other drug workers’ well-being, stress and burnout. Drug Alcohol Rev 2013]

Community assessment workshops were developed to gather client experiences of primary health care services in Australia. Primary health care services are particularly concerned with working with disadvantaged populations, for whom traditional client survey methods such as written surveys may not be inclusive and accessible. Service staff at six Australian primary health care services, including two Aboriginal-specific services, invited participants to attend workshops in 2011–2012. Participants were offered transport, childcare and an interpreter, and provided with reimbursement for their time. Ten workshops were run with a total of 65 participants who accessed a variety of services and programmes. A mix of age and gender was achieved. The workshops yielded detailed qualitative data and quantitative rankings for nine service qualities: holistic, effective, efficient, culturally respectful, used by those most in need, responsive to the local community, increasing individual control, supports and empowers the community, and mix of treatment, prevention and promotion. Discussions were audio recorded and transcribed for qualitative analysis. The workshop approach succeeded in being (i) inclusive, reaching users from disadvantaged sections of the community; (ii) comprehensive, providing ratings and discussion that took account of the whole service; (iii) richly descriptive, with researchers able to generate detailed feedback; and (iv) more empowering than traditional client survey methods, by allowing more control to participants and greater benefits than surveys of individuals. The community assessment workshops are a method that could be widely applied to health service evaluation research where the goal is to reach disadvantaged communities and provide ratings and detailed analysis of the experience of users. The participants and the research benefited from the group approach, and the workshops provided valuable, actionable information to the health services. Recruitment of users, particularly those from culturally diverse backgrounds, remains one of the key challenges facing evaluators.

Indigenous alcohol and other drug (AOD) workers' roles are often exhausting, poorly paid and under-recognised. There has been relatively little examination of work-related stressors on their health and well-being. This national study identified Indigenous AOD workers' experiences and perspectives on well-being, stress and burnout along with strategies to improve worker well-being.Focus groups were conducted with 121 participants (70 Indigenous, 20 non-Indigenous, 31 unspecified) from metropolitan, rural and remote locations around Australia, selected via a purposive sampling strategy. Audio files and interview notes were analysed to identify key themes.Main themes identified included excessive workloads, extensive demands and expectations, workers' proximity to communities, loss and grief issues, lack of recognition, inadequate rewards, stigma and racism, and Indigenous ways of working. Stressors were compounded by workers' complex personal circumstances, profound levels of loss and grief, and lack of culturally safe working environments.Indigenous workers' stress was exacerbated by close links and responsibilities to their communities and a 'dual accountability', being constantly on call, playing multiple roles, complex personal and professional lives, and needing to interact with multiple agencies. Many Indigenous AOD workers had developed mechanisms to deal with work-related pressures and received valued support from their communities. The study identified the importance of workforce strategies to improve Indigenous workers' well-being and reduce stress, including: mutual support networks, training in assertiveness and boundary setting, workloads that take account of Indigenous ways of working, adequate remuneration, supervision and mentorship, and cultural sensitivity training for non-Indigenous workers.

Community development plays an important role in increasing the access of disadvantaged groups to resources and services. We examined how community development in primary healthcare services may improve patient safety by involving people in activities that lead to their enhanced use of services.Audits of service activity and 68 in-depth interviews at six primary healthcare services in South Australia and the Northern Territory. Managers, practitioners and administration staff, plus regional health service executives and departmental funders participated in the interviews.Each of the services undertook some community development. Reported benefits included engaging people in health promoting activity, providing people with social contacts and, crucially, encouraging people to use health services.Community development is a means of engaging people who, for a range of reasons, are reluctant to use services and therefore can increase patient safety.

Dental hygienists are well placed to assist their patients to quit smoking. Smoking affects oral health and dental treatments, and hygienists report greater time with patients than dentists with more focus on prevention. However, there has been little research into the extent to which hygienists assist patients to quit smoking and strategies to support them in this role.A 2-stage survey of Australian dental hygienists was conducted. The first survey measured potential predictors of asking patients about smoking and assisting patients to quit smoking using the Theory of Planned Behavior as a framework. The second survey measured these behaviors in the past week. Structural equation modeling was used to examine predictors of the two behaviors.A total of 362 hygienists returned the first questionnaire. Intentions to ask and assist patients were high. The 273 hygienists who returned the second questionnaire assisted an estimated total of 1,394 patients to quit smoking in 1 week. Predictors within the Theory of Planned Behavior framework explained significant variance in asking (11%) and assisting (29%) behaviors, with self-efficacy the most critical predictor in both cases (β = .27 and .32, respectively).Dental hygienists may be a viable and willing avenue for addressing smoking. Hygienists may be best supported in this role through increasing skills and confidence around asking sensitively about smoking, building rapport, and assisting patients to quit smoking. Incorporation of smoking status into general history taking and adoption of organizational policies on assisting patients to quit smoking could also be encouraged.

The present study examined Australian ED nurses' practices in asking patients about alcohol and assisting them to manage their alcohol consumption. It also investigated strategies to support ED nurses in these interventions.A two-stage survey was administered to ED nurses. The first questionnaire measured theoretical and organizational predictors of behaviour, and underlying beliefs, and the subsequent questionnaire explored rates of asking and assisting patients.A total of 125 nurses returned the first questionnaire. Participants held generally positive attitudes, perceived norms, feelings of legitimacy and perceived ability to ask about and intervene for alcohol, but lower role adequacy. The 71 ED nurses who completed the second questionnaire had intervened with almost 500 patients concerning alcohol in the previous week. Participants asked approximately one in four patients about alcohol (median = 26.3% of patients, 1095/4279 total patients asked). The Theory of Planned Behaviour did not predict rates of asking or assisting patients. Several strategies were identified that might increase rates: identify environmental factors that prevent nurses acting on their intentions to ask and intervene, raise confidence and skills, make asking about alcohol part of routine assessment, make supports such as drug and alcohol units or nurses available, and implement organizational policies on alcohol.Nurses appear positively disposed to engage with patients in regard to alcohol. However, greater support is needed to achieve the considerable significant public health benefits from this engagement. The findings point to several practical strategies that could be pursued to provide this support.

Equity of access to services and in health outcomes are key goals of primary health care. This study considers understandings of equity and perceptions of current performance in relation to equity among primary health care service staff, health service executives and funders. Semi-structured interviews were conducted with managers, practitioners and administration staff at five primary health care services in Adelaide and one in Alice Springs, as well as with South Australian funders and regional health service executives (n = 68). Services were responding to health inequity by taking actions to improve equitable access to their service, facilitating equitable access to health care more generally, and advocating and taking action on the social determinants of health inequities. As well as availability, affordability and acceptability, our analysis indicated a fourth dimension of equity of access we named ‘engagement’. Our respondents were less able to point to examples of advocacy or action on the social determinants of health inequities than they were to examples of actions to improve equity of access. These findings indicate current strengths and also scope to encourage a broader and more comprehensive role for primary health care in addressing health inequities.

Over recent years, numerous school-based preventive strategies have been explored as possible options to address illicit drug use by young people. However, there is scope to extend current knowledge of which school students are most at risk of illicit drug-related harm. To investigate potential differential risk, the prevalence and patterns of illicit drug use of Australian secondary school students were examined according to demographic, school, economic and licit drug use factors.Analyses were conducted on the 2005 Australian Secondary Students' Alcohol and Drug survey. A total of 21 805 secondary school students aged 12-17 years from 376 schools completed the pencil and paper classroom questionnaire.The greatest risk factors for students using illicit drugs were tobacco and alcohol use. Students with self-rated below average academic achievement, with more than $20 a week of disposable income, and who were Indigenous were more likely to report illicit drug use.While causal pathways could not be examined in the current data, and these relationships are likely to be complex and multi-directional, the findings indicate potentially at-risk populations who warrant extra support to address illicit drug-related harm.

The traditional approach to increasing the capacity of health and human service professionals to deliver alcohol, tobacco and other drug interventions has been to build relevant knowledge, skills and attitudes through the provision of education and training. However, as a stand alone strategy, education and training is likely to have limited impact.This paper examines not only the features and characteristics of successful training programs and approaches, but also the wider array of systems and structural factors that might act as impediments to the implementation of new knowledge, skills and clinical behaviours.There is a constellation of factors that extend beyond traditional notions of 'training' that fall under the rubric of 'workforce development'.A workforce development approach requires three levels of action-system-wide, capacity building and professional development to ensure effective responses.

Little attention has been directed to the use of methamphetamine among Australian workers. To address this, a study was conducted that examined drug consumption patterns of the Australian work-force.A secondary analysis of the 2004 National Drug Strategy Household Survey (NDSHS) data was undertaken that focused on methamphetamine use among those in paid employment.Methamphetamine use in the past 12 months was reported by 4.0% of workers compared to 2.2% of respondents not in the paid work-force. A larger proportion of male (4.8%) than female workers (3.0%) used methamphetamine. The highest prevalence occurred among 18-29-year-old workers (11.2%; males: 12.6%; females: 9.4%), and among workers in hospitality (9.5%), construction (5.4%) and transport (5.4%) industries and among tradespeople (6.5%). Significantly more methamphetamine users reported absenteeism compared to users of other illicit drugs and non-drug users. Among respondents reporting methamphetamine use, 13.4% reported absenteeism due to illicit drug use, while 56.8% reported absenteeism due to any illness or injury. Significantly more methamphetamine users (32.9%) reported going to work under the influence than users of other illicit drugs. Compared to users of other illicit drugs, methamphetamine users were also significantly more likely to drive a car, operate heavy machinery or abuse someone while under the influence.The specific details of the profile of workers using methamphetamine and the impact it has on work performance allows for the development of targeted interventions and tailored prevention strategies previously not possible.

Equity of access and reducing health inequities are key objectives of comprehensive primary health care. However, the supports required to target equity are fragile and vulnerable to changes in the fiscal and political environment. Six Australian primary healthcare services, five in South Australia and one in the Northern Territory, were followed over 5 years (2009–2013) of considerable change. Fifty-five interviews were conducted with service managers, staff, regional health executives and health department representatives in 2013 to examine how the changes had affected their practice regarding equity of access and responding to health inequity. At the four state government services, seven of 10 previously identified strategies for equity of access and services’ scope to facilitate access to other health services and to act on the social determinants of health inequity were now compromised or reduced in some way as a result of the changing policy environment. There was a mix of positive and negative changes at the non-government organisation. The community-controlled service increased their breadth of strategies used to address health equity. These different trajectories suggest the value of community governance, and highlight the need to monitor equity performance and advocate for the importance of health equity.

Aims: This study examined the antecedents of health professionals’ motivation and satisfaction in responding to alcohol and other drug (AOD) issues. Building on Shaw and colleagues’ seminal work, the study examined the influence of education, support, AOD experience, and perceptions of role adequacy and role legitimacy.Method: This study involved a national survey of Australian health professionals (N = 351) from two occupations: nurses (N = 223) and mental health professionals (N = 128).Findings: The strongest predictors of role legitimacy and role adequacy were support and the perceived usefulness of education. Satisfaction was predicted by perceived role legitimacy in both samples, and by perceived role adequacy for mental health professionals. Motivation was predicted by perceived role adequacy and role legitimacy in both samples.Conclusion: Identification of support as a key predictor of role adequacy and legitimacy reinforces the importance of workforce development interventions at an organizational...

GP smoking cessation interventions have been found to be highly efficacious. However, reported uptake is low, and little is known about barriers or comparisons with other health professionals. The objectives of this study were to examine GPs' provision of smoking cessation activities, confidence and perceived barriers, and compare the results to other health professions (dentists, dental hygienists and pharmacists). A random sample of South Australian GPs (n = 269) were surveyed. Comparisons were made with dentists, dental hygienists and pharmacists for whom similar data had been obtained. Participants were surveyed on their confidence, perceived barriers, level of smoking cessation activity and practice and demographic factors. GPs reported greater provision of and greater confidence in a range of brief smoking cessation interventions than other professions and perceived fewer barriers to the provision of smoking cessation activities. Confidence and system barriers were reported as the most common factors that impeded greater provision of smoking cessation activities. It was concluded that confidence and system barriers need to be addressed to increase rates of smoking cessation interventions provided by these professional groups. Skills-based training that develops confidence would be beneficial for all health professional groups and would increase the number of smokers receiving advice and assistance to quit smoking.

This study examined the role of values, affect, and deservingness judgments in health professionals' views of patients with stigmatized conditions (e.g., drug dependence). Participants were 277 nurses who responded to a survey containing 2 scenarios of a nurse providing high- or low-quality care to a patient with a condition related to prolonged use of alcohol or heroin. Affective responses to the patient were more positive for nurses with higher self-transcendence values, and more negative for nurses with higher conservation values. Deservingness judgments were predicted by positive and negative affect toward the patient, but not by attributions of responsibility for drug use. Deservingness judgments emerged as strong predictors of nurses' satisfaction with the provision of high- or low-quality care. The findings imply that the deservingness judgments made by nurses reflected strong entitlement norms concerning the provision of proper care for patients that were independent of patients' perceived responsibility for their condition.