In today's climate of consumer consultation in the development of client sensitive hospital and community based services, some voices have remained silent. Among this group are disabled children and young people, who receive professional care in a climate of 'in their best interest', firmly based on notions of abnormality and the inherent tragedy of disability. New paradigm childhood research and the social model of disability provide the theoretical framework for this qualitative study into the health and health care experiences of disabled children and young people. Both approaches demand a flexible and participatory approach in order to challenge the traditional relations of research production. Twenty young people aged 9-18 years met with the researcher up to four times, with a choice after the initial meeting of individual or group meetings. All had a physical disability, some also had communication or learning difficulties. Conversations with the young people covered a range of topics. The obvious ones related to hospitals, appointments, splints and therapy. About what it is like having a carer. Commonly held assumptions that hospitalisation is a significant feature of disabled childhoods is challenged by the data, appointments however reflect an ongoing surveillance. The young people spoke of experiences of empowerment and of powerlessness within a triad of parent:professional:young person. Concern that many treatments are an experiment and that outcomes are hard to balance with the pain and inconvenience of surgery or therapeutic devices raises questions regarding professional versus young person's definitions of success. It also demands debate regarding how much remedial intervention is enough. This is a difficult issue in a medical and social climate that idealises normality, but normality is not often an option. Health care constitutes only a narrow perspective of health and made up only a part of the discussion. It is the day to day health experiences that are more prominent in the lives of participants than intermittent professional services. The young people showed a recognition of factors that contributed to their health and sense of well being. Commonly the talk was about living in a world that considers them as different and the effect that has on them. These young people are making links between racism and their own disability experience, however they have no contact with disabled adults, some with no other disabled young people and no understanding of disability history or politics. This lack became even more evident when the participants talked about who understands what their life is like, of role models, realistic aspirations and dreams for quiet moments. School issues raised concerns such as equity in access, being different, having to prove oneself, limited school sport involvement and issues of friendship and teasing. One very powerful finding is that just like anyone else they are all different but that stereotypes of disability limit the lives of disabled young people and influence the responses of other people to them. This demanded from the researcher an interaction with the different experiences and responses to experiences of participants or risk creating another, albeit different stereotype. / thesis (PhD)--University of South Australia, 2001.

Poor urban Australians face a substantial health disadvantage: on average, they can expect to die earlier and suffer more physical disease, mental illness and injuries than wealthier Australians. This thesis examines the potential of one approach to reducing the problem of health disadvantage, namely, systematically intervening in disadvantaged locations. Such an approach is gaining support, especially in the United Kingdom and Australia; there is therefore a need to determine its possibilities and limitations. The thesis is written from the theoretical perspectives of critical social science and political economy of health. The research synthesises empirical data and critical analysis, combining findings from the health inequalities literature and analyses of contemporary political and economic contexts. It also includes two original studies: a quantitative analysis of the patterning of socio-economic disadvantage in Sydney suburbs, and a qualitative case study of a disadvantaged location: Mt Druitt, NSW. The health inequalities research shows that reducing health disadvantage is largely a question of reducing socio-economic disadvantage. A model of social exclusion is used to show how socio-economic disadvantage develops in capitalist societies. Following from this analysis, it is argued that a locational approach can have little impact on the macro political and economic antecedents of socio-economic and health disadvantage. Given these macro constraints, the thesis examines the possible ameliorative impact of a locational approach to health disadvantage here too, there are many limitations. A locational approach would have a limited population reach as most health disadvantaged people do not live in identifiably disadvantaged locations. Location itself creates only a modest independent burden on health, thus improving the amenity of disadvantaged locations will contribute little to reducing health disadvantage. In Australia, the creation of the most visibly disadvantaged urban locations is almost entirely a consequence of policies to concentrate public housing. Although it can be expected that locational interventions will be focused in these locations, there are substantial policy barriers to addressing the major socioeconomic determinants of health , low income, unemployment and sole parent poverty, in public housing estates, Location based policies to alleviate aspects of health and socio-economic disadvantage are assessed. In general locational policies and interventions have had a disappointing track record in buffering populations against issues such as poverty, unemployment and childhood disadvantage. Four specific policies are examined. There is a case to provide improved health services in disadvantaged locations. Measures to improve social capital or change the social mix of locations will have a very small, if any, impact on health. Early intervention in disadvantaged locations is rational in that the precursors of health and socioeconomic disadvantage occur in early life; however, population reach is limited and only the most expensive and intensive of these programs have produced good results. The case study of Mt Druitt shows that agencies are willing to implement a wide range of interventions to alleviate location based socio-economic and health disadvantage. Some of these interventions can be expected to have good results for some individuals. However, there is a lack of a systematic approach to problems in this location, and substantial barriers exist to creating widespread positive change. Overall, despite growing interest in a locational approach to addressing health disadvantage, and evidence of considerable energy at grass root level, a locational approach can be expected to contribute little to improving the health of socio-economically disadvantaged urban Australians. / Doctor of Philosophy (PhD)

This thesis examines the place of metaphor in biomedical knowledge about two major public health problems: cancer and coronary heart disease (CHD). Specifically, it considers why cancer is constituted by biomedicine in obviously metaphorical concepts that are also highly pejorative. Conversely, the metaphorical dimension of the biomedical knowledge concerning CHD is less obvious and less negative in its connotations. This thesis posits that the difference in linguistic styles associated with cancer and CHD can be accounted for by whether knowledge about them confirms or challenges the knowledge and value system of modernity. Cancer, as construed by biomedicine, appears to confound some important tenets of the epistemology and knowledge of modernity. In particular, it confounds the idea that the body is a machine and that nature is an inert order obeying objective laws. It thus suggests that the universe, including that of bodies, is not entirely subject to rational understanding and control. Women having irrational bodies and an affinity with unruly nature are primary sites for cancer. It is therefore hardly surprising that cancer's metaphors express a fear that order based on masculine rational agency is fragile. By contrast, biomedical knowledge about CHD appears to confirm key aspects of modernist knowledge. Specifically, it suggests that the (masculine) body can be understood as a machine that exists as part of a wider domain of nature that is inert and is fuelled by objective laws. Unlike cancer, which is depicted as mysterious and arcane, CHD is presented as an ailment with causes that are well understood and treatment that is effective, thus affirming the truth of rationality and technology. Coronary heart disease is construed overwhelmingly as a disease affecting men exercising their capacity for rational agency, free from the 'dictates' of an irrational body. Coronary heart disease is depicted as a disruption of supply and demand rather than as a threat to social order itself. In Durkheimian terms, sacred things can be pure and beneficent or they can take impure and threatening forms. Cancer expresses the impure, threatening dimension of sacredness in exposing threats to the knowledge and order of modernity. Conversely, coronary heart disease is profane, in those terms, since it offers apparent confirmation of the knowledge and order of modernity. Cancer makes us aware of deeply held values by making us conscious of threats to them but the knowledge of CHD is so congruent with the knowledge system of modernity, that it does not provoke us to examine that framework; it merely affirms our routine and mundane view of the world. These findings suggest that biomedicine can be regarded as a secular religion because it acts as a cosmology. Knowledge of the body and its ailments is set within a wider conceptual framework and value system recognizing and naming sources of order and danger. This further suggests that while biomedicine may be rightly regarded as a technical and instrumental body of knowledge, it is nevertheless fuelled by and intertwined with deeply held values and convictions that are beyond the domain of rationality. The unexamined, a-rational elements of biomedicine have been virtually ignored within public health and explain some of its limitations in defining and responding to familiar public health problems. / Thesis (Ph.D.)--Department of Public Health, 2003.

"January 2004" / Includes bibliographical references (leaves 252-273) / xxiii, 276, [6] leaves : ill. ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (Ph.D.)--University of Adelaide, Dept. of Social Inquiry, 2004

<p><strong>Background:</strong> The past three decades have seen a growth in health promotion research and practice, stimulated by the epidemiologic transition of the leading causes of death from infectious to chronic diseases. An estimated 50% of mortality from the 10 leading causes of death is due to behaviour, which suggests individuals can make important contributions to their own health by adopting some health-related behaviours and avoiding others. Motivational interviewing (MI) has emerged as a brief counselling approach for behavioural modification that builds on a patient empowerment perspective by supporting self-esteem and self-efficacy. MI has become increasingly popular in a variety of health care settings as well as non-health care settings.</p><p><strong>Aims:</strong> The overall aim of this thesis is to contribute to improved understanding of the different factors that impact on the learning and practice of MI. The aim of study I was to identify barriers and facilitators to use MI with overweight and obese children in child welfare and school health services. The aim of study II was to identify barriers, facilitators and modifiers to use MI with pharmacy clients in community pharmacies.</p><p><strong>Methods:</strong> Participants in study I were five child welfare centre nurses from the county council and six municipally-employed school health service nurses, all from Östergötland, Sweden. Participants in study II were 15 community pharmacy pharmacists in Östergötland Sweden. Data for both studies were obtained through focus group interviews with the participants, using interview guides containing open-ended questions related to the aims of the studies. Study II also included five individual interviews. Interview data were interpreted from a phenomenological perspective.</p><p><strong>Results:</strong> In study I, important barriers were nurses’ lack of recognition that overweight and obesity among children constitutes a health problem, problem ambivalence among nurses who felt that children’s weight might be a problem although there was no immediate motivation to do anything, and parents who the nurses believed were unmotivated to deal with their children’s weight problem. Facilitators included nurses’ recognition of the advantages of MI, parents who were cooperative and aware of the health problem, and working with obese children rather than those who were overweight. In study II, pharmacists who had previously participated in education that included elements similar to MI felt this facilitated their use of MI. The opportunity to decide on appropriate clients and/or healthrelated behaviours for counselling was also an important facilitator. The pharmacists believed the physical environment of the pharmacies was favourable for MI use, but they experienced time limitations when there were many clients on the premises. They also experienced many difficulties associated with the practical application of MI, including initiating and concluding client conversations.</p><p><strong>Conclusions:</strong> Learning and practicing MI effectively is difficult for many practitioners as it requires a new way of thinking and acting. Practitioners’ use of MI is not effective unless there is recognition that there is an important health-related problem to be solved. Practitioners feel more confident using MI with clients who have health-compromising behaviours and/or risks in which the practitioners feel they have expertise. Possessing considerable MI counselling skills does not compensate for insufficient knowledge about a targeted health-related behaviour and/or risk. Feedback from clients plays an important role for the quality and quantity of practitioners’ MI use.</p>

<p>The number of persons who are not employed has increased in Sweden since the early 1990s. Unemployment has been found to influence health, especially when unemployment rates are low. The extent to which unemployment affects health when unemployment is high is less clear, and this needs to be further studied. To improve health in the population, the health care system should offer equal access to health care according to need. It is important to study whether the employment status hinders the fulfilment of this goal. </p><p>This thesis is based on four papers: Paper I and II aimed at analysing self-rated health versus mortality risk in relation to employment status, during one period of low unemployment and one period of high unemployment. Paper III and IV assessed the use of medical health care services and unmet care needs among persons who were unemployed or otherwise not employed. The goal was to analyse what health problems lead people to either seek or abstain from seeking care, and what factors encumber or facilitate this process. </p><p>The overall results indicate that being unemployed or outside the labour force was associated with an excess risk of poor self-rated health, symptoms of depression, mental and physical exhaustion and mortality. The differences in self-rated health between the unemployed and employed were larger when unemployment levels were high, than when they were low. More groups of the unemployed were also afflicted with poor health when unemployment was high. Thus, poor health among the unemployed seems to be a public health problem during high levels of unemployment. Lack of employment was related to abstaining from seeking care, despite perceiving a need for care, and this was related to psychological symptoms. To deal with the needs of the unemployed and others who are outside the labour force it would be useful to develop and implement interventions within the health care system. These should focus on psychological and psychosocial problems. Future research should analyse how to facilitate health-promoting interventions among persons who are not anchored in the labour market. </p>

<p>One of the most vulnerable groups in Swedish society today is single parent families, a group that has increased over the last thirty years in proportion to married and cohabiting parents. The aims of this thesis are to study inequality and inequity in health and health care utilization with regard to whether parents are single or couple (married/cohabiting), to investigate whether the concept of social capital may provide us with further understanding when analyzing inequality and inequity in health and to investigate how the mental health of single parent children may differ from couple parent children and to what extent this difference may be due to parental socio-economic and socio-demographic characteristics, including social capital. The results from the papers on which this thesis is based indicate that both single mothers and single fathers have poorer health than couple mothers and fathers. Single mothers also refrain from seeking medical care to a greater extent. The financial advantage of single fathers, in comparison with single mothers, might have an impact on their medical care utilization, since they seemingly seek and consume health care to an extent that matches their poorer health. Social capital has as robust an association with self-rated health as any traditional social determinant of health. Four parental characteristics were found to be independently associated with children’s mental health; being a single parent, ‘poor parental health’, limited social support and low levels of social capital. The uneven distribution of all investigated determinants of health, including social capital, gives us reason to conclude that our findings indeed raise concerns about equity. Action taken by society to enable single parents to increase their social capital might improve their and their children’s health. It may also be clearly stated that financial status has a major impact on both health and health care utilization. This particular characteristic is also rather accessible to alteration, for example through financial transfers between groups in society. </p>

<p>Mortality statistics are much used although their accuracy is often questioned. Producers of mortality statistics check for errors in death certification but current methods only capture obvious mistakes. This thesis investigates whether non-obvious errors can be found by linking death certificates to hospital discharge data.</p><p>Data: 69,818 deaths in Sweden 1995. Paper I: Analysing differences between the underlying cause of death from the death certificate (UC) and the main discharge condition from the patient’s last hospitalization (MDC). Paper II: Testing whether differences can be explained by ICD definitions of UC and MDC. Paper III: Surveying methods in 44 current studies on the accuracy of death certificates. Paper IV: Checking death certificates against case summaries for: i) 573 deaths where UC and MDC were the same or the difference could be explained; ii) 562 deaths where the difference could not be explained.</p><p>Results: In 54% of deaths the MDC differed from the UC. Almost two-thirds of the differences were medically compatible since the MDC might have developed as a complication of the UC. Of 44 recent evaluation studies, only 8 describe the methods in such detail that the study could be replicated. Incompatibility between MDC and UC indicates a four-fold risk that the death certificate is inaccurate. For some diagnostic groups, however, death certificates are often inaccurate even when the UC and MDC are compatible.</p><p>Conclusion: Producers of official mortality statistics could reduce the number of non-obvious errors in the statistics by collecting additional information on incompatible deaths and on deaths in high-risk diagnostic groups. ICD conventions contribute to the quality problem since they presuppose that all deaths are due to a single underlying cause. However, in an ageing population an increasing number of deaths are due to an accumulation of etiologically unrelated conditions.</p>

One of the most vulnerable groups in Swedish society today is single parent families, a group that has increased over the last thirty years in proportion to married and cohabiting parents. The aims of this thesis are to study inequality and inequity in health and health care utilization with regard to whether parents are single or couple (married/cohabiting), to investigate whether the concept of social capital may provide us with further understanding when analyzing inequality and inequity in health and to investigate how the mental health of single parent children may differ from couple parent children and to what extent this difference may be due to parental socio-economic and socio-demographic characteristics, including social capital. The results from the papers on which this thesis is based indicate that both single mothers and single fathers have poorer health than couple mothers and fathers. Single mothers also refrain from seeking medical care to a greater extent. The financial advantage of single fathers, in comparison with single mothers, might have an impact on their medical care utilization, since they seemingly seek and consume health care to an extent that matches their poorer health. Social capital has as robust an association with self-rated health as any traditional social determinant of health. Four parental characteristics were found to be independently associated with children’s mental health; being a single parent, ‘poor parental health’, limited social support and low levels of social capital. The uneven distribution of all investigated determinants of health, including social capital, gives us reason to conclude that our findings indeed raise concerns about equity. Action taken by society to enable single parents to increase their social capital might improve their and their children’s health. It may also be clearly stated that financial status has a major impact on both health and health care utilization. This particular characteristic is also rather accessible to alteration, for example through financial transfers between groups in society.

Background: About 800,000 people are risky drinkers in Sweden and the alcohol consumption has increased around 30% during the last 6 years. In order to counteract the negative effects of drinking there is a need to implement preventive measures at various levels in society. One place where risky drinkers could be identified is the healthcare setting. More than 10% of the visits at emergency departments and 20% of the injuries have been found to be alcohol‐related. So far, very few risky drinkers attending emergency departments receive advice about sensible drinking although there is good research evidence of the efficacy of such advice. Aim: The main aim was to explore the effects of a simple alcohol preventive routine in emergency care on staffs´ attitudes towards alcohol prevention and injury patients´ drinking pattern. Material and methods: A screening and simple advice routine was introduced at the emergency department of Motala County hospital. The staffs´ attitudes were explored by interviews with 12 staff members before the introduction and in 6 follow‐up interviews after a year. All the triage staffs´ attitudes were also measured by a questionnaire before the start of the routine and after 6 months. During the first 6 months of the routine 878 injury patients between 16 and 70 completed an alcohol screening questionnaire. During the next 6 months 647 patients received written advice about sensible drinking after having completed the screening questionnaire. A total of 619 patients included in the 12 months study period were followed‐up by telephone interview and changes in drinking pattern were analyzed. After a further 6 months of intervention a total of 2151 patients had been completing the questionnaire during the total study period of 18 months. The association between drinking pattern and different injury variables was analyzed in order to identify special risk groups and situations. Results: The staff was generally positive to alcohol prevention before the routine started and it was completed as intended. After 6 months of screening the staffs´ role legitimacy and perceived skills had increased. Despite of a further positive change in attitudes towards alcohol prevention the staff was uncertain after the study period whether emergency departments are appropriate settings for alcohol prevention. A total of 9% of the women and 31% of the men attending the emergency department for an injury were defined as risky drinkers. One single item in the questionnaire, concerning frequency of heavy episodic drinking, identified the majority of risky drinkers. In the cohort of patients,who was only screened, 34% was no longer engaged in heavy episodic drinking after 6 months and in the cohort that received written advice in addition to the screening the proportion was 25%. The latter group also increased readiness to change by 14%. The proportion of risky drinkers was higher among injury patients, 21% compared to 15% in the general population in the cathment area. This was mostly explained by a higher proportion of young men in the study group. When drinking pattern was compared, both risky and non‐risky drinkers proved to be significantly more likely than abstainers to be injured in amusement locations, parks, lakes or seas and during play or other recreational activities, when controlling for age and sex. Nine percent of the injury patients reported that they believed that their injury was related to alcohol. Half of this group was non risky‐drinkers. Conclusions: The triage staff performed the intervention as agreed, and in some aspects, which could facilitate further development of alcohol preventive measures, their attitudes changed positively. However, it appears difficult to expect alcohol preventive measures to involve more of the staff’s time than the routine tried, and other practical solutions have to be evaluated. A question about frequency of heavy episodic drinking identified the majority of risky drinkers and could be used as a single screening question. There was a reasonable reduction in heavy episodic drinking among the injury patients. The lack of a control group makes it difficult to fully explain whether this change is a result of the injury per se, the screening and the written advice procedure or a natural fluctuation in the patients´ drinking pattern. More studies are needed in order to establish the minimal levels of intervention in routine care that is accepted by the staff, and has a reasonable effect on risky drinkers’ alcohol consumption.