Designing Initiatives for Vulnerable Families: From Theory to Design in Sydney, Australia.

Introduction: Intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours require innovative models of health care delivery to break them. We describe a programme of research informed service development targeting vulnerable families in inner metropolitan Sydney, Australia that is designed to build and confirm a "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)". We describe the development of an intervention design and business case that drew on earlier realist causal and programme theoretical work.

A Critical Realist Translational Social Epidemiology Protocol for Concretising and Contextualising a "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)", Sydney Australia.

Background: We will describe here a translational social epidemiology protocol for confirming a critical realist "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD). The approach will include the concretising and contextualising of the above causal theory into programme theories for child and adolescent interventions that aim to break intergenerational cycles of disadvantage and poor life outcomes. In undertaking this work we seek to advance realist translational methodology within the discipline of applied perinatal and paediatric social epidemiology.

Realist theory construction for a mixed method multilevel study of neighbourhood context and postnatal depression.

Background: We have recently described a protocol for a study that aims to build a theory of neighbourhood context and postnatal depression. That protocol proposed a critical realist Explanatory Theory Building Method comprising of an: (1) emergent phase, (2) construction phase, and (3) confirmatory phase. A concurrent triangulated mixed method multilevel cross-sectional study design was described.

Being alone and expectations lost: a critical realist study of maternal depression in South Western Sydney.

The study reported here is part of a critical realist multilevel study. It seeks to identify and explain complex perinatal contextual social and psychosocial mechanisms that may influence the developmental origins of health and disease, with a focus on the role of postnatal depression. The aims of the greater study are to: (1) describe the phenomenon of postnatal depression in South Western Sydney; and (2) identify mechanisms that would add to our understanding of the psycho-social causes of maternal depression.

Realist identification of group-level latent variables for perinatal social epidemiology theory building.

We have previously reported in this journal on an ecological study of perinatal depressive symptoms in South Western Sydney. In that article, we briefly reported on a factor analysis that was utilized to identify empirical indicators for analysis. In this article, we report on the mixed method approach that was used to identify those latent variables.

Bayesian hierarchical spatial regression of maternal depressive symptoms in South Western Sydney, Australia.

Background: There is increasing interest in the role played by maternal depression in mediating the effects of adversity during pregnancy and poor infant outcomes. There is also increasing evidence from multilevel regression studies for an association of area-level economic deprivation and poor individual mental health. The purpose of the study reported here is to explore the spatial distribution of postnatal depressive symptoms in South Western Sydney, Australia, and to identify covariate associations that could inform subsequent multilevel studies.

Realist explanatory theory building method for social epidemiology: a protocol for a mixed method multilevel study of neighbourhood context and postnatal depression.

A recent criticism of social epidemiological studies, and multi-level studies in particular has been a paucity of theory. We will present here the protocol for a study that aims to build a theory of the social epidemiology of maternal depression. We use a critical realist approach which is trans-disciplinary, encompassing both quantitative and qualitative traditions, and that assumes both ontological and hierarchical stratification of reality.

Immigrant maternal depression and social networks. A multilevel Bayesian spatial logistic regression in South Western Sydney, Australia.

The purpose is to explore the multilevel spatial distribution of depressive symptoms among migrant mothers in South Western Sydney and to identify any group level associations that could inform subsequent theory building and local public health interventions. Migrant mothers (n=7256) delivering in 2002 and 2003 were assessed at 2-3 weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were Edinburgh Postnatal Depression Scale scores (EPDS) of >9 and >12.

Why are advance care planning decisions not implemented? Insights from interviews with Australian general practitioners.

Background: Advance care planning (ACP) is thought to enhance patient autonomy and improve end-of-life care. However, there is evidence that when patients engage in ACP, the resultant plans are often not implemented. This has been attributed to either nonadherence by health professionals or inadequacies in ACP such as inaccessibility of the plans, plans providing ambiguous or conflicting instructions, and inappropriate focus on the completion of documents rather than communication.

Neighborhood adversity, ethnic diversity, and weak social cohesion and social networks predict high rates of maternal depressive symptoms: a critical realist ecological study in South Western Sydney, Australia.

The aim of the study reported here is to explore ecological covariate and latent variable associations with perinatal depressive symptoms in South Western Sydney for the purpose of informing subsequent theory generation of perinatal context, depression, and the developmental origins of health and disease. Mothers (n = 15,389) delivering in 2002 and 2003 were assessed at two to three weeks after delivery for risk factors for depressive symptoms. The binary outcome variables were Edinburgh Postnatal Depression Scale (EPDS)> 9 and > 12.

Clusters of maternal depressive symptoms in South Western Sydney, Australia.

The purpose of this study is to explore the spatial distribution of perinatal depressive symptoms in South Western Sydney, Australia, and to identify any clusters that could inform subsequent qualitative, ecological and multilevel studies and local public health interventions. A routine survey of mothers with newborn infants was commenced in 2000. The survey included the Edinburgh Postnatal Depression Scale (EPDS).

Relationship of postnatal depressive symptoms to infant temperament, maternal expectations, social support and other potential risk factors: findings from a large Australian cross-sectional study.

Background: From 2000 a routine survey of mothers with newborn infants was commenced in South Western Sydney. The survey included the Edinburgh Postnatal Depression Scale (EPDS). The aim of the study was to determine the prevalence and risk factors for postnatal depressive symptoms in women living in metropolitan Sydney, Australia.

The essential elements of health impact assessment and healthy public policy: a qualitative study of practitioner perspectives.

Objectives: This study uses critical realist methodology to identify the essential and contingent elements of Health Impact Assessment (HIA) and Healthy Public Policy (HPP) as operationalised by practitioners.

Design: Data collection-qualitative interviews and a workshop were conducted with HIA and HPP practitioners working in differing contexts.

Data Analysis: Critical realist analytical questions identified the essential elements of HIA and HPP, the relationship between them, and the influences of public policy and other contingencies on the practice of both.

Advance care planning and interpersonal relationships: a two-way street.

Background: Advance care planning (ACP) has been gaining prominence for its perceived benefits for patients in enhancing patient autonomy and ensuring high-quality end-of-life-care. Moreover, it has been postulated that ACP has positive effects on families and health professionals and their relationship with the patient. However, there is a paucity of studies examining the views of GPs on this issue.

Uptake and implementation of Advance Care Planning in Australia: findings of key informant interviews.

Objective: Advance Care Planning (ACP) has an important role in enhancing patient autonomy and guiding end-of-life care. However, there is low uptake of ACP and evidence that advance care plans are often not implemented. We explored these issues in interviews with expert clinicians and representatives of key stakeholder organisations with interest in end-of-life care.

A rapid equity focused health impact assessment of a policy implementation plan: An Australian case study and impact evaluation.

Background: Equity focused health impact assessments (EFHIAs), or health equity impact assessments, are being increasingly promoted internationally as a mechanism for enhancing the consideration of health equity in the development of policies, programs and projects. Despite this there are relatively few examples of examples of completed EFHIAs available. This paper presents a case study of a rapid EFHIA that was conducted in Australia on a health promotion policy implementation plan.

An exploration of how clinician attitudes and beliefs influence the implementation of lifestyle risk factor management in primary healthcare: a grounded theory study.

Background: Despite the effectiveness of brief lifestyle intervention delivered in primary healthcare (PHC), implementation in routine practice remains suboptimal. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about the process by which clinicians' perceptions shape implementation. This study aims to describe a theoretical model to understand how clinicians' perceptions shape the implementation of lifestyle risk factor management in routine practice.

Explaining the variation in the management of lifestyle risk factors in primary health care: a multilevel cross sectional study.

Background: Despite evidence for the effectiveness of interventions to modify lifestyle behaviours in the primary health care (PHC) setting, assessment and intervention for these behaviours remains low in routine practice. Little is known about the relative importance of various determinants of practice.This study aimed to examine the relative importance of provider characteristics and attitudes, patient characteristics and consultation factors in determining the rate of assessment and intervention for lifestyle risk factors in PHC.

Health impact assessment and urbanisation. Lessons from the NSW HIA Project.

Health impact assessment (HIA) can ensure that health is a core element of sustainable urban planning. Based on the experience of the NSW HIA Project, we discuss the current strengths of HIA and challenges facing it as an urban sustainability tool across five areas: the use of evidence; integrating HIA with environmental impact assessments; including consideration of equity; recognising wider determinants of health; and building capacity.

Building health impact assessment capacity as a lever for healthy public policy in urban planning.

Building capacity to improve health through applying health impact assessment (HIA) increases the range of people, organisations and communities who are able to address health problems and, in particular, the problems that arise out of social inequity and social exclusion. To achieve this, a range of strategies is required across the areas of organisational development, workforce development, resource allocation, leadership and partnerships. A conceptual framework to guide understanding of capacity building evolved during a three-year capacity building project that supported the implementation of HIA.

Strengthening the effectiveness of 'whole of government' interventions to break the cycle of violence in disadvantaged communities.

'Whole of government' interventions are increasingly being used in disadvantaged communities to improve safety and break the cycle of violence. This paper draws on learning from the evaluation of two whole of government interventions in western Sydney that arose in response to community violence and extensive property damage. Methods for strengthening program logic and overcoming differences in perspective are outlined.

Multidisciplinary care plans for diabetes: how are they used?

Objective: To understand how multidisciplinary care plans are being used in the management of patients with diabetes, and to explore the role of collaboration in care planning.

Design: Grounded theory interview study.

Setting: Primary care, June 2005 to October 2006.

Changes in community nursing in Australia: 1995-2000.

Aim: This paper reports a study whose aim was to examine the congruence between community nurses' perceptions and the realities of changes in their work.

Background: There have been increasing challenges to the delivery of community nursing services in Australia over the past decade. Acute care sector changes and the recent focus on health promotion, prevention, early identification and intervention adds pressure and creates tensions for community nurses, which are well-documented in the literature.