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Purpose: This paper aims to illustrate the complexity of understanding and managing violent behaviour in health care. The authors will show how different perceptions of the reasons for violent behaviour, and linkages between violent behaviour and illness have contributed to the creation of a wicked problem and added significant complexity to the management of violence towards staff within health-care settings. This paper will conclude with a call for strong multi-disciplinary action to address this ongoing issue. Design/methodology/approach: A narrative review was undertaken to explore the ways that violence has been perceived in health care and the ways in which the concept of violence has moved from being seen as a criminal issue to being within the realms of disease. This paper will show the importance of understanding who is perpetrating violence in health care, why and in what settings. It will expound on the idea that considering violence as a consequence of disease necessarily adds a layer of complexity to both individual and organisational responses to violence towards health-care staff. Findings: Understanding the complexity in preventing and managing violence against health-care staff can assist policymakers and managers to develop multi-faceted approaches to violence prevention, including better recognition and understanding of perpetrators of violence. Originality/value: This paper provides a unique perspective on thinking about violence in health care and the implications of its complexity.

People seeking treatment for substance use disorders (SUD) ultimately aspire to improve their quality of life (QOL) through reducing or ceasing their substance use, however the association between these treatment outcomes has received scant research attention. In a prospective, multi-site treatment outcome study ('Patient Pathways'), we recruited 796 clients within one month of intake from 21 publicly funded addiction treatment services in two Australian states, 555 (70%) of whom were followed-up 12 months later. We measured QOL at baseline and follow-up using the WHOQOL-BREF (physical, psychological, social and environmental domains) and determined rates of "SUD treatment success" (past-month abstinence or a statistically reliable reduction in substance use) at follow-up. Mixed effects linear regression analyses indicated that people who achieved SUD treatment success also achieved significantly greater improvements in QOL, relative to treatment non-responders (all four domains p < 0.001). Paired t-tests indicated that non-responders significantly improved their social (p = 0.007) and environmental (p = 0.033) QOL; however, their psychological (p = 0.088) and physical (p = 0.841) QOL did not significantly improve. The findings indicate that following treatment, QOL improved in at least some domains, but that reduced substance use was associated with both stronger and broader improvements in QOL. Addressing physical and psychological co-morbidities during treatment may facilitate reductions in substance use.

BACKGROUND: Children's positive socialisation to alcohol is associated with early initiation of drinking and alcohol-related harm in adult life. Internationally, there have been reports of adults' alcohol consumption at school events in the presence of children. The aim of this research was to identify the conditions under which Australian schools are required to apply for a liquor licence and the associated prevalence of liquor licences for these events where children were likely to be present. METHODS: A document review was conducted to examine temporary liquor licensing legislation. Quantitative analysis was used to examine relevant licensing data. Coding criteria was developed to determine school type, student year levels and the likely presence of children. RESULTS: Four jurisdictions provided data on 1817 relevant licences. The average annual licences/100 schools was highest amongst Independent schools followed by Catholic and public (government) schools. The rates were highest in Queensland and Victoria where children were present at 61% and 32% of events respectively. CONCLUSIONS: While there are legislative differences across jurisdictions, the prevalence of adults' alcohol use at school events in the presence of children may reflect the various education department policies and principals' and school communities' beliefs and attitudes. Licences are not required for all events where liquor is consumed so the prevalence of adults' use of alcohol at school events is likely to be higher than our analyses imply. Such practices may undermine teaching about alcohol use in the school curriculum and health promotion efforts to develop alcohol-free events when children are present.

BACKGROUND: Community misconception of what causes cancer is an important consideration when devising communication strategies around cancer prevention, while those initiating social marketing campaigns must decide whether to target the general population or to tailor messages for different audiences. This paper investigates the relationships between demographic characteristics, identification of selected cancer risk factors, and associated protective behaviours, to inform audience segmentation for cancer prevention social marketing. METHODS: Data for this cross-sectional study (n = 3301) are derived from Cancer Council New South Wales' 2013 Cancer Prevention Survey. Descriptive statistics and logistic regression models were used to investigate the relationship between respondent demographic characteristics and identification of each of seven cancer risk factors; demographic characteristics and practice of the seven 'protective' behaviours associated with the seven cancer risk factors; and identification of cancer risk factors and practising the associated protective behaviours, controlling for demographic characteristics. RESULTS: More than 90% of respondents across demographic groups identified sun exposure and smoking cigarettes as moderate or large cancer risk factors. Around 80% identified passive smoking as a moderate/large risk factor, and 40-60% identified being overweight or obese, drinking alcohol, not eating enough vegetables and not eating enough fruit. Women and older respondents were more likely to identify most cancer risk factors as moderate/large, and to practise associated protective behaviours. Education was correlated with identification of smoking as a moderate/large cancer risk factor, and with four of the seven protective behaviours. Location (metropolitan/regional) and country of birth (Australia/other) were weak predictors of identification and of protective behaviours. Identification of a cancer risk factor as moderate/large was a significa

Background: Children's positive socialisation to alcohol is associated with early initiation of drinking and alcohol-related harm in adult life. Internationally, there have been reports of adults' alcohol consumption at school events in the presence of children. The aim of this research was to identify the conditions under which Australian schools are required to apply for a liquor licence and the associated prevalence of liquor licences for these events where children were likely to be present. Methods: A document review was conducted to examine temporary liquor licensing legislation. Quantitative analysis was used to examine relevant licensing data. Coding criteria was developed to determine school type, student year levels and the likely presence of children. Results: Four jurisdictions provided data on 1817 relevant licences. The average annual licences/100 schools was highest amongst Independent schools followed by Catholic and public (government) schools. The rates were highest in Queensland and Victoria where children were present at 61% and 32% of events respectively. Conclusions: While there are legislative differences across jurisdictions, the prevalence of adults' alcohol use at school events in the presence of children may reflect the various education department policies and principals' and school communities' beliefs and attitudes. Licences are not required for all events where liquor is consumed so the prevalence of adults' use of alcohol at school events is likely to be higher than our analyses imply. Such practices may undermine teaching about alcohol use in the school curriculum and health promotion efforts to develop alcohol-free events when children are present.

Background and Aims: Our understanding of patient pathways through specialist Alcohol and Other Drug treatment and broader health/welfare systems in Australia remains limited. This study examines how treatment outcomes are influenced by continuity in specialist Alcohol and Other Drug treatment, engagement with community services and mutual aid, and explores differences between clients who present with a primary alcohol problem relative to those presenting with a primary drug issue. Method: In a prospective, multi-site treatment outcome study, 796 clients from 21 Alcohol and Other Drug services in Victoria and Western Australia completed a baseline interview between January 2012 and January 2013. A total of 555 (70%) completed a follow-up assessment of subsequent service use and Alcohol and Other Drug use outcomes 12-months later. Results: Just over half of the participants (52.0%) showed reliable reductions in use of, or abstinence from, their primary drug of concern. This was highest among clients with meth/amphetamine (66%) as their primary drug of concern and lowest among clients with alcohol as their primary drug of concern (47%), with 31% achieving abstinence from all drugs of concern. Continuity of specialist Alcohol and Other Drug care was associated with higher rates of abstinence than fragmented Alcohol and Other Drug care. Different predictors of treatment success emerged for clients with a primary drug problem as compared to those with a primary alcohol problem; mutual aid attendance (odds ratio = 2.5) and community service engagement (odds ratio = 2.0) for clients with alcohol as the primary drug of concern, and completion of the index treatment (odds ratio = 2.8) and continuity in Alcohol and Other Drug care (odds ratio = 1.8) when drugs were the primary drugs of concern. Conclusion: This is the first multi-site Australian study to include treatment outcomes for alcohol and cannabis users, who represent 70% of treatment seekers in Alcohol and Other Drug

BACKGROUND: People seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC. METHODS: Seven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann-Whitney U tests. RESULTS: Rates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC. CONCLUSIONS: While those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances th

BACKGROUND: Schools provide opportunities for parents and the wider community to connect and support the physical and emotional wellbeing of their children. Schools therefore have the potential to play a role in the socialisation of alcohol use through school policies and practices regarding consumption of alcohol by adults at school events in the presence of children. METHODS: This survey was undertaken to a) compare the extent to which alcohol is used at secondary school events, when children are present, in the states of New South Wales (NSW) and Victoria (VIC), Australia; b) describe principals' level of agreement with these practices; c) their awareness of state policies on this issue; and d) the predictors of such events. A random sample of secondary schools, stratified to represent metropolitan and non-metropolitan schools were invited to participate. Bivariate and multivariate analysis were conducted with p values < 0.05 considered significant. RESULTS: A total of 241 (43%) schools consented to participate in the study. Fifteen percent of participating NSW schools and 57% of VIC schools held at least one event in which alcohol was consumed by adults in the presence of children in the year before the survey. Of the 100 reported events, 78% were Year 12 graduation dinners, and 18% were debutante balls. Compared to NSW principals, VIC principals were significantly more likely to agree with the use of alcohol at these events; significantly less likely to be aware of their state education department policy on this issue; have a policy at their own school or support policy that prohibits alcohol use at such events; and less likely to report having enough information to make decisions about this. CONCLUSIONS: There is a growing focus on adults' use of alcohol at school events when children are present. Schools can play an important role in educating and socialising children about alcohol via both the curriculum and policies regarding adults' alcohol use at school e

© 2016 The Author(s). Background: People seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC. Methods: Seven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann-Whitney U tests. Results: Rates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC. Conclusions: While those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use

Background - Schools provide opportunities for parents and the wider community to connect and support the physical and emotional wellbeing of their children. Schools therefore have the potential to play a role in the socialisation of alcohol use through school policies and practices regarding consumption of alcohol by adults at school events in the presence of children. Methods - This survey was undertaken to a) compare the extent to which alcohol is used at secondary school events, when children are present, in the states of New South Wales (NSW) and Victoria (VIC), Australia; b) describe principals’ level of agreement with these practices; c) their awareness of state policies on this issue; and d) the predictors of such events. A random sample of secondary schools, stratified to represent metropolitan and non-metropolitan schools were invited to participate. Bivariate and multivariate analysis were conducted with p values < 0.05 considered significant. Results - A total of 241 (43 %) schools consented to participate in the study. Fifteen percent of participating NSW schools and 57 % of VIC schools held at least one event in which alcohol was consumed by adults in the presence of children in the year before the survey. Of the 100 reported events, 78 % were Year 12 graduation dinners, and 18 % were debutante balls. Compared to NSW principals, VIC principals were significantly more likely to agree with the use of alcohol at these events; significantly less likely to be aware of their state education department policy on this issue; have a policy at their own school or support policy that prohibits alcohol use at such events; and less likely to report having enough Information to make decisions about this. Conclusions - There is a growing focus on adults’ use of alcohol at school events when children are present. Schools can play an important role in educating and socialising children about alcohol via both the curriculum and policies regarding adults’ alcohol use at

BACKGROUND: Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary health care has been identified as essential to improving the delivery of mental health care. Consultation liaison is a model of mental health care where the primary care provider maintains the central role in the delivery of mental health care with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental health care in the primary care setting and in turn improve outcomes for people with a mental disorder. OBJECTIVES: To identify whether consultation liaison can have beneficial effects for people with a mental disorder by improving the ability of primary care providers to provide mental health care. SEARCH METHODS: We searched the EPOC Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases: MEDLINE, EMBASE, CINAHL and PsycINFO, in March 2014. We also searched reference lists of relevant studies and reviews to identify any potentially relevant studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) which compared consultation liaison to standard care or other service models of mental health care in the primary setting. Included participants were people attending primary care practices who required mental health care or had a mental disorder, and primary care providers who had direct contact with people in need of mental health care. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the titles and abstracts of identified studies against the inclusion criteria and extracted details including the study design, participants and setting, intervention, outcomes and any risk of bias. We resolved any disagreements by discussion or referral to a third au

© 2015 Elsevier B.V. Background: This study aimed to explore the association between substance use, social disadvantage and past year alcohol and other drug (AOD) treatment among clients entering publically funded AOD services in Victoria and Western Australia, to inform system development. Methods: Participants (n = 781) completed a structured interview on substance use, social circumstances, and past year service use. Results: Most participants were severely AOD dependent and a high proportion were recently homeless, receiving welfare benefits, and with criminal justice issues. Previous AOD treatment was common. Logistic regression analysis showed that past year AOD treatment was more frequent among those receiving welfare benefits, with opioids as their primary drug of concern, and using multiple substances. Conclusion: While AOD dependence characterised this treatment group, social disadvantage independently predicted higher rates of prior AOD service use. Specialist AOD treatment systems need capacity to provide or at least work alongside services designed to address social disadvantage.

BACKGROUND: The ability to sustain comprehensive primary health care (PHC) services in the face of change is crucial to the health of rural communities. This paper illustrates how one service has proactively managed change to remain sustainable. METHODS: A 6-year longitudinal evaluation of the Elmore Primary Health Service (EPHS) located in rural Victoria, Australia, is currently underway, examining the performance, quality and sustainability of the service. Threats to, and enablers of, sustainability have been identified from evaluation data (audit of service indicators, community surveys, key stakeholder interviews and focus groups) and our own observations. These are mapped against an overarching framework of service sustainability requirements: workforce organisation and supply; funding; governance, management and leadership; service linkages; and infrastructure. RESULTS: Four years into the evaluation, the evidence indicates EPHS has responded effectively to external and internal changes to ensure viability. The specific steps taken by the service to address risks and capitalise on opportunities are identified. CONCLUSIONS: This evaluation highlights lessons for health service providers, policymakers, consumers and researchers about the importance of ongoing monitoring of sentinel service indicators; being attentive to changes that have an impact on sustainability; maintaining community involvement; and succession planning.

BACKGROUND: Rural communities throughout Australia are experiencing demographic ageing, increasing burden of chronic diseases, and de-population. Many are struggling to maintain viable health care services due to lack of infrastructure and workforce shortages. Hence, they face significant health disadvantages compared with urban regions. Primary health care yields the best health outcomes in situations characterised by limited resources. However, few rigorous longitudinal evaluations have been conducted to systematise them; assess their transferability; or assess sustainability amidst dynamic health policy environments. This paper describes the study protocol of a comprehensive longitudinal evaluation of a successful primary health care service in a small rural Australian community to assess its performance, sustainability, and responsiveness to changing community needs and health system requirements. METHODS/DESIGN: The evaluation framework aims to examine the health service over a six-year period in terms of: (a) Structural domains (health service performance; sustainability; and quality of care); (b) Process domains (health service utilisation and satisfaction); and (c) Outcome domains (health behaviours, health outcomes and community viability). Significant international research guided the development of unambiguous reliable indicators for each domain that can be routinely and unobtrusively collected. Data are to be collected and analysed for trends from a range of sources: audits, community surveys, interviews and focus group discussions. DISCUSSION: This iterative evaluation framework and methodology aims to ensure the ongoing monitoring of service activity and health outcomes that allows researchers, providers and administrators to assess the extent to which health service objectives are met; the factors that helped or hindered achievements; what worked or did not work well and why; what aspects of the service could be improved and how; what benefits have be

Medication overdose is a common method of non-fatal self-harm. Previousstudies have established which mental health disorders are commonly associated with thebehaviour (affective, substance use, anxiety and personality disorders) and whichmedications are most frequently implicated (benzodiazepines, antidepressants, antipsychoticsand non-opioid analgesics). However, few studies have explored patient experiencesof medication overdose. We address this gap by examining patient stories of a recentmedication overdose event, including severity of depression, intended outcomes and patientexperiences of emergency medical care, in part to determine the unmet needs of this groupof patients. Semi-structured interviews were conducted with 31 patients attending an urbanEmergency Department (ED) in Melbourne, Australia, following a medication overdoseregarding their mental health history, state of mind at the time of the overdose,circumstances of the overdose, and experiences of emergency medical care. Participantswere heterogeneous regarding the severity of depressive symptomatology at the time ofoverdose. Participant ratings of how accidental or deliberate the overdose was and howstrongly they intended to die were also diverse. Stories relating to the overdose usuallycovered the themes of precipitating events, negative feeling states, and intended outcomes(ambivalent or contradictory). Few problems were identified in relation to the care receivedin relation to the current overdose. However, histories of extensive mental health problems

Background Medication overdose accounts for >80% of hospital presentations for self-harm. Previous research has identified typical characteristics of medication overdose cases; however, these cases have not been well differentiated from other similar presentations, namely (1) illicit drug overdose and (2) self-harm by means other than overdose. Method A 12-month audit of medication overdose cases (both intentional and unintentional) attending the emergency department (ED) of a major metropolitan public hospital in Melbourne, Australia was conducted. Comparison was made with patients attending for illicit drug overdose or for self-harm by means other than overdose.Results Medication overdose cases (n=453) showed a broadly comparable profile with those found in earlier studies (predominantly female gender, aged in their 30s and referred for psychosocial assessment). A similar though not identical profile was noted for self-harm cases (n=545). In contrast, patients attending for illicit drug overdose (n=409) could be characterised as male, in their 20s and not referred for psychosocial assessment. Illicit drug overdose cases were more likely than either the medication overdose or self-harm cases to be triaged in the most urgent category (19.3, 3.8 and 3.9% respectively), suggesting a high level of acuity in this group. However, the illicit drug overdose group on average spent less time in the ED than medication overdose patients, and were less likely to require hospital admission. Conclusion On both demographic and treatment variables, patients attending the ED following a medication overdose more closely resemble those attending for self-harm by means other than overdose than those attending for illicit drug overdose.

Objective: This study aimed to investigate which categories of medication are most commonly implicated in overdose, to compare this information with prescription data and to explore how the medications used in overdoses are typically acquired. Methods: A 12-month audit (11/2003–10/2004) of all medication overdose presentations to an inner-Melbourne ED was conducted and the medications compared to published population-based prescription data. Interviews were conducted with 31 patients who attended the ED following a medication overdose and typical stories regarding the acquisition of medications reported.Results: The same broad categories of medications identified in earlier studies were found to contribute to the majority of overdoses in this study, namely benzodiazepines, antidepressants, analgesics and antipsychotics. Two benzodiazepine medications, diazepam and alprazolam, appeared to be over-represented in the overdose data relative to their population rates of prescription. Patient interviews revealed three main reasons for the original acquisition of the medications used in overdose: treatment purposes (77%); recreational use (16%); and overdose (7%). The most common source of medications (68%) used in overdose was prescription by the patient's usual doctor. Conclusion: The high representation of benzodiazepines among medications used in overdose is of ongoing concern. Implications: The time of medication prescription and dispensing may be an ideal opportunity for overdose prevention, through judicious prescribing, consideration of treatment alternatives, patient education and encouraging the safe disposal of unused medications.