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Purpose To investigate the effectiveness of a home-based social media use intervention to enhance the social networks of rural youth with disabilities. Method Participants were nine youth (mean age = 17.0 years) with disabilities from two rural Australian communities. The intervention consisted of providing appropriate assistive technology and social media training on individualised goals. Using mixed methods, quantitative (a single group pre-post) and qualitative (interviews with participants and their carers) measures were used to examine outcomes of training, individual experiences of the intervention, and changes to online social networks. Results Participants increased their performance and satisfaction with performance on social media problem areas post-intervention; paired t -tests showed statistical significance at p .001. There was also a significant increase in the number of online communication partners; Wilcoxon Signed Ranks showed statistical significance at p .05. The interviews highlighted increased social participation, independence and improvements to literacy. Ongoing parental concerns regarding cyber safety and inappropriate online content were noted. Conclusions The findings suggest that social media training is a feasible method for increasing social networks among rural-based youth with disabilities. To sustain ongoing benefits, parents need knowledge and training in integrating assistive technology and social media.

Background: Nepal formulated a range of policies related to maternal and neonatal survival, especially after the year 2000. Nevertheless, Nepal’s perinatal mortality remains high, particularly in disadvantaged regions. Policy analysis can uncover the underlying values, strategies and policy formulation processes that shape the potential to reduce in-country health inequities. This paper provides a critical account of the main policy documents relevant to perinatal survival in Nepal. Methods: Six key policy documents covering the period 2000–2015 were reviewed using an adapted framework and were analyzed through qualitative content analysis. Results: The analysis shows that the policies focused mainly on the system: improvement in provision of birthing facilities; targeting staff (Skilled Birth Attendants) and health service users by providing cash incentives to staff for bringing patients to services, and to users (pregnant women) to attend health institutions. Despite a growing focus on saving women and newborn babies, there is a poor policy focus and direction on preventing stillbirth. The policy documents were found to emphasize tensions between birthing at home and at health institutions on the one hand, and between strategies to provide culturally appropriate, woman-centered care in communities and medically orientated services on the other. Policies acknowledge the need to provide and address woman-centered care, equity, social inclusion, and a rights-based approach, and identify the community based approach as the mode of service delivery. Over and above this, all policy documents are aimed at the national level, and there is no specific policy direction for the separate ecological, cultural or geographic regions such as the mountainous region, which continues to exhibit higher mortality rates and has different cultural and demographic characteristics to the rest of Nepal. Conclusions: To better address the continuing high perinatal mortality rates, particularly in disadvantaged areas, national health policies should pay more attention to the inequity in healthcare access and in perinatal outcomes by integrating both stillbirth prevention and neonatal survival as policy agenda items. To ensure effective translation of policy into practice, it is imperative to tailor the strategies according to acknowledged policy values such as rights, inclusion and socio-cultural identity. Refereed/Peer-reviewed

Intersectoral action between public agencies across policy sectors, and between levels of government, is seen as essential for effective action by governments to address social determinants of health (SDH) and to reduce health inequities. The health sector has been identified as having a crucial stewardship role, to engage other policy sectors in action to address the impacts of their policies on health. This article reports on research to investigate intersectoral action on SDH and health inequities in Australian health policy. We gathered and individually analysed 266 policy documents, being all of the published, strategic health policies of the national Australian government and eight State/Territory governments, current at the time of sampling in late 2012-early 2013. Our analysis showed that strategies for intersectoral action were common in Australian health policy, but predominantly concerned with extending access to individualized medical or behavioural interventions to client groups in other policy sectors. Where intersectoral strategies did propose action on SDH (other than access to health-care), they were mostly limited to addressing proximal factors, rather than policy settings affecting the distribution of socioeconomic resources. There was little evidence of engagement between the health sector and those policy sectors most able to influence systemic socioeconomic inequalities in Australia. Refereed/Peer-reviewed

Despite the seeming ubiquity of young people's Internet use, there are still many for whom access to the Internet and online social networking remains inequitable and patterned by disadvantage. The connection between information technology and young people with disabilities is particularly under-researched. This article contributes to the field of critical information systems research by exposing significant barriers and facilitators to Internet accessibility for young people with disabilities. It uses Bourdieu's critical theory to explore how the unequal distribution of resources shapes processes of digital inclusion for young people with disabilities. It highlights access needs and experiences that are both disability and non-disability related. The article draws on interviews in South Australia with 18 young people aged 10–18 years with a physical disability (such as cerebral palsy) or acquired brain injury and with 17 of their family members. Interviews evaluated participants' and parents' reflections on the benefits of a home-based, goal-oriented intervention to increase the young person's Internet use for social participation purposes. The Bourdieuian analysis demonstrated how varying levels of accrued individual and family offline capital resources are related to digital/online resources and disability-specific online resources. This revealed how unequal resources of capital can influence technology use and hence digital inclusion for young people with disabilities. Our study demonstrates that young people with particular types of disabilities require intensive, personalised and long-term support from within and beyond the family to ‘get online’. We conclude that Internet studies need to more frequently adopt critical approaches to investigate the needs of users and barriers to information technology use within sub-groups, such as young people with disabilities. © 2016 John Wiley & Sons Ltd

Background This paper aims to examine the health care contexts shaping perinatal survival in remote mountain villages of Nepal. Health care is provided through health services to a primary health care level—comprising district hospital, village health facilities and community-based health services. The paper discusses the implications for future policies and practice to improve health access and outcomes related to perinatal health. The study was conducted in two remote mountain villages in one of the most remote and disadvantaged mountain districts of Nepal. The district is reported to rank as the country’s lowest on the Human Development Index and to have the worst child survival rates. The two villages provided a diversity of socio-cultural and health service contexts within a highly disadvantaged region. Methods The study findings are based on a qualitative study of 42 interviews with women and their families who had experienced perinatal deaths. These interviews were supplemented with 20 interviews with health service providers, female health volunteers, local stakeholders, traditional healers and other support staff. The data were analysed by employing an inductive thematic analysis technique. Results Three key themes emerged from the study related to health care delivery contexts: (1) Primary health care approach: low focus on engagement and empowerment; (2) Quality of care: poor acceptance, feeling unsafe and uncomfortable in health facilities; and (3) Health governance: failures in delivering health services during pregnancy and childbirth. Conclusions The continuing high perinatal mortality rates in the mountains of Nepal are not being addressed due to declining standards in the primary health care approach, health providers’ professional misbehaviour, local health governance failures, and the lack of cultural acceptance of formalised care by the local communities. In order to further accelerate perinatal survival in the region, policy makers and programme implementers need to immediately address these contextual factors at local health service delivery points. Electronic supplementary material The online version of this article (10.1186/s41043-018-0148-y) contains supplementary material, which is available to authorized users.

Objective and the context This paper examines the beliefs and experiences of women and their families in remote mountain villages of Nepal about perinatal sickness and death and considers the implications of these beliefs for future healthcare provision. Methods Two mountain villages were chosen for this qualitative study to provide diversity of context within a highly disadvantaged region. Individual in-depth interviews were conducted with 42 women of childbearing age and their family members, 15 health service providers, and 5 stakeholders. The data were analysed using a thematic analysis technique with a comprehensive coding process. Findings Three key themes emerged from the study: (1) ‘Everyone has gone through it’: perinatal death as a natural occurrence; (2) Dewata (God) as a factor in health and sickness: a cause and means to overcome sickness in mother and baby; and (3) Karma (Past deeds), Bhagya (Fate) or Lekhanta (Destiny): ways of rationalising perinatal deaths. Conclusion Religio-cultural interpretations underlie a fatalistic view among villagers in Nepal’s mountain communities about any possibility of preventing perinatal deaths. This perpetuates a silence around the issue, and results in severe under-reporting of ongoing high perinatal death rates and almost no reporting of stillbirths. The study identified a strong belief in religio-cultural determinants of perinatal death, which demonstrates that medical interventions alone are not sufficient to prevent these deaths and that broader social determinants which are highly significant in local life must be considered in policy making and programming.

Older people in rural communities increasingly rely on the Internet to access essential health, finance, education, and other social services. However, their abilities to participate in the online service system are often undermined by a continuing ‘digital divide’. This divide may be exacerbated by the strategies of service providers who fail to recognise and respond to the needs of older rural clients. This paper is based on a case study in Clare, a small rural town in South Australia, and examines the experiences of older residents and local service providers in trying to engage online for digital service delivery. Drawing on two sets of in-depth interviews, the study uses a mix of thematic content analysis and social network analysis to identify the nature and extent of digital interactions between older people and service providers, and the enablers and challenges for online service engagement. Older participants demonstrated considerable interest in learning how to use the Internet for accessing particular services, with social support networks and third party facilitators being crucial enablers. Service providers’ ambitions to engage with older people online appeared more limited as a result of entrenched stereotypes of older non-users, a lack of internal digital skills, as well as organisational and funding constraints. The case study findings emphasise the importance of balancing the views of older people and service providers in the design of online engagement strategies. These insights are critical for improving online service delivery in rural communities affected by an increasing withdrawal of physical services. Refereed/Peer-reviewed

Migrant well-being can be strongly influenced by the migration experience and subsequent degree of mainstream language acquisition. There is little research on how older Culturally And Linguistically Diverse (CALD) migrants who have 'aged in place' find health information, and the role which digital technology plays in this. Although the research for this paper was not focused on cancer, we draw out implications for providing cancer-related information to this group. We interviewed 54 participants (14 men and 40 women) aged 63-94 years, who were born in Italy or Greece, and who migrated to Australia mostly as young adults after World War II. Constructivist grounded theory and social network analysis were used for data analysis. Participants identified doctors, adult children, local television, spouse, local newspaper and radio as the most important information sources. They did not generally use computers, the Internet or mobile phones to access information. Literacy in their birth language, and the degree of proficiency in understanding and using English, influenced the range of information sources accessed and the means used. The ways in which older CALD migrants seek and access information has important implications for how professionals and policymakers deliver relevant information to them about cancer prevention, screening, support and treatment, particularly as information and resources are moved online as part of e-health.

Objectives To examine the role of socioeconomic, sociodemographic, and social capital factors in buffering or exacerbating the mental health impacts of job loss. Methods A 2-year longitudinal cohort study of 300 workers experiencing job loss from a motoring manufacturer in Adelaide, South Australia. Data were collected on mental health (12-item version of the General Health Questionnaire) and socioeconomic, sociodemographic, and social capital factors. Analysis used linear mixed-effects regression. Results Workers had poorer mental health than the general population. Female gender, less years at the plant, and not being partnered were associated with poorer mental health. The effects of financial status depended on current employment and levels of social support. Trust and social contact were associated with better mental health. Conclusion A number of socioeconomic, sociodemographic, and social capital factors influence mental health in workers experiencing job loss, offering clues on how to support workers.

Youth with complex communication needs (CCN) face increased barriers to their social participation due to limited communication abilities and opportunities. Youth today use the internet as a social tool and youth with CCN may also benefit from internet use to increase their social participation. Five youth between the ages of 10–18 with CCN who are unable to use speech for everyday communication and require augmentative and alternative communication were provided with assistive technology and a tailored 1:1 intervention at home to learn to use the internet for connecting with others. Pre and post assessments measured changes in performance on internet use goals, social networks, loneliness and self-concept. Multiple measures were used to examine the impact of internet use for social networking on a range of outcomes and to gather emerging evidence in this area. Results showed that the intervention was effective in increasing performance and satisfaction with goals for increasing internet use to connect with others and for increasing the number of online communication partners. There was no significant change in loneliness or self-concept. This study shows that the internet may be a viable tool in increasing the social participation of youth with CCN. However, some youth and their families required intensive support and technical assistance to gain confidence in internet use and in use for social purposes. Refereed/Peer-reviewed

This paper examines the background and limitations of maternity care policy and provision in Australia using the Boundary Critique (BC) method from critical systems thinking. We argue that the historical legacy of funding maternity care within medically dominated fee-for-service structures and acute hospital budgets is seriously flawed. Furthermore, it cannot deliver the policy goals of healthy and socially equitable birth practices. Despite the 2009 national Maternity Services Review (MSR) and progress of a National Maternity Services Plan (2011), most mainstream Australian maternity services remain out-of-step with both health service research and evidence-based ‘best practice’. The present system drives unnecessary clinical interventions, increased expenditure, short-term adverse health outcomes and the potential for a larger, unacknowledged legacy of future chronic disease. By contrast, BC analysis suggests that redesigning for good maternity service provision can act as a population-level preventative health strategy, offering better value, better health and improved equity in maternity care.

Background Youth use the Internet for a variety of purposes including social networking. Youth with disabilities are limited in their social networks and friendships with peers. The aim was to investigate the effectiveness of tailored one-on-one support strategies designed to facilitate social participation of youth with disabilities through the use of the Internet for social networking. Methods Eighteen youth aged 10–18 years with cerebral palsy, physical disability or acquired brain injury received support, training and assistive technology at their home to learn to use the Internet for building social networks. The Canadian Occupational Performance Measure (COPM) and Goal Attainment Scale (GAS) were used to evaluate objective changes in performance and satisfaction. Interviews with the youth identified subjective changes they experienced through participation in the programme and to determine whether and how the intervention influenced their social participation. Results Youth showed an increase in performance and satisfaction with performance on identified goals concerning social networking on the COPM; Paired T-test showed that these differences were statistically significant at P 50) for 78% of the youth. Interviews showed that youth were positive about the benefits of hands-on training at home leading to increased use of the Internet for social networking. Conclusions The Internet could be a viable method to facilitate social participation for youth with disabilities. Youth identified the benefits of one-to-one support at home and training of the family compared with typical group training at school. Despite its success with this group of youth, the time and effort intensive nature of this approach may limit the viability of such programmes. Further longitudinal research should investigate whether Internet use is sustained post intervention, and to identify the factors that best support ongoing successful and safe use.

Author's version made available in accordance with Publisher's copyright policy., Background: Australia has high rates of breastfeeding initiation, with a consistent decline over the first year. Furthermore, there is a growing trend of maternal employment and rising numbers of children enrolled in different types of child care services, both of which can have a negative impact on breastfeeding. Objectives: To provide evidence to better inform implementation of breastfeeding-friendly strategies in child care settings, this study examined breastfeeding policy and practice in child care centers in metropolitan Adelaide. Methods: The paper reports on a survey sent to 292 child care centers in metropolitan Adelaide in 2010. The survey collected information on center location and type, number of enrolled children under age 2, and number of breastfed babies. The survey also included questions about breastfeeding facilities and support, breastfeeding policies, staff training, and barriers to and recommendations to enhance breastfeeding support in child care centers. Results: Of the 62 completed returned surveys (21% response rate), 43 centers (69.4%) reported that they currently have children who receive breast milk at the center; however, in most centers, the total number of breastfed children was reported to be between 1 and 4; 76% reported that the center was supportive of exclusive breastfeeding for 6 months; and 80.6% had statements on breastfeeding as part of their food and nutrition policies or guidelines. Furthermore, 64.5% reported there was no formal or informal training for staff on breastfeeding support, but 50% reported that staff members do provide breastfeeding advice to mothers of children in their center. Conclusions: Despite some strategies in place to support breastfeeding, there are no standards on breastfeeding policies, practices, and training in child care settings.Therefore, the extent and scope of such support depend on parental request and the perceptions and attitudes of child care center staff toward breastfeeding.

Public policy strategies impact on population health by acting on the effectiveness, availability and distribution of the social determinants of health. Reducing obesity and promoting healthy weight is a key focus of governments, health promoters and researchers, and can benefit from a systems approach with 'upstream' policy action beyond the health sector. Although the literature identifies many areas for hypothetical non-health policy action, and in particular relating to food and activity environments, few have identified practical, politically viable and relatively cost-free processes by which non-health sectors would want to commit to such action. This article details how the Government of South Australia used the Health in All Policies (HiAP) approach in the SA HiAP Healthy Weight Project. It mapped the core business and policy directions of 44 state departments against research on 'what works' to address obesity. Negotiations then developed high-level policy commitments to address factors promoting healthy weight which predominantly changed ways of working rather than requiring new expenditure and also assisted departments in meeting their own goals; departmental chief executives endorsed the commitments. By starting from departmental documents, and not restricting the project to departments with more 'obvious' obesity prevention potential, we gained commitment to a broader range of policy actions than identified elsewhere; for example, for prisons, environment and botanic gardens, housing and vocational education. The SA HiAP Healthy Weight Project provides one example of a workable, evidence-based systems approach to increase commitment to practical and politically viable opportunities across government to address the non-health environments supporting healthy weight. Refereed/Peer-reviewed

Evidence on social determinants of health and health equity (SDH/HE) is abundant but often not translated into effective policy action by governments. Governments’ health policies have continued to privilege medical care and individualised behaviour-change strategies. In the light of these limitations, the 2008 Commission on the Social Determinants of Health called on health agencies to adopt a stewardship role; to take action themselves and engage other government sectors in addressing SDH/HE. This article reports on research using analysis of health policy documents – published by nine Australian national or regional governments – to examine the extent to which the Australian health sector has taken up such a role.We found policies across all jurisdictions commonly recognised evidence on SDH/HE and expressed goals to improve health equity. However, these goals were predominantly operationalised in health care and other individualised strategies. Relatively few strategies addressed SDH/HE outside of access to health care, and often they were limited in scope. National policies on Aboriginal health did most to systemically address SDH/HE.We used Kingdon's (2011) multiple streams theory to examine how problems, policies and politics combine to enable, partially allow, or prevent action on SDH/HE in Australian health policy.

In most developed nations, ageing migrants represent a growing proportion of the older population. Policies that emphasise care in the community depend on older migrants having access to formal services along with informal support, yet little is known about how older migrants experience community-based formal services. By examining the views of both Greek elders in Australia and those of formal service providers, this research fills an important gap in the literature around access to and acceptability of formal community-based services for older migrants. A research team including two Greek background researchers used existing social groups and a snowball sampling method to conduct face-to-face interviews and focus groups with seventy older Greeks in Adelaide, Australia. In addition, 22 community-based service providers were interviewed over the telephone. Results from users and providers showed that while many older Greeks experience service access issues, they also relied heavily on family for support and assistance at home. Reliance on family was both in preference to formal services or where formal services were used, to locate, negotiate and monitor such services. Common barriers identified by both groups included cost, transport and availability, but additional challenges were posed by language, literacy and cultural attitudes. Demographic changes including greater employment mobility and female workforce participation among adult children will have implications for both formal and informal care providers. Formal service providers need to ensure that services are promoted and delivered to take account of the important role of family in informal support while also addressing the access challenges posed by language and literacy. Research conducted by researchers from the same cultural background in the respondent’s native language can further advance knowledge in this area.

Job loss has negative consequences for health and evidence shows that the agency of workers experiencing job loss is affected by labour market and welfare policy. The policy environment into which workers emerge after losing their jobs strongly influences the way job loss and its aftermath is experienced. This article draws on findings from two waves of in-depth semi-structured interviews with 33 retrenched South Australian automotive workers. It discusses how, within the context of Australian welfare and industrial policy, workers experienced the consequences of mass job losses that occurred at Mitsubishi Motors during 2004 and 2005. Key findings include largely negative experiences associated with negotiating welfare-to-work policy, and a more precarious employment environment further entrenched under industrial relations policy. Job loss is both a personal and a structural story and we use an agency and structure perspective to examine how workers’ agency was enabled, but more often constrained, by policy.

This article contributes to research on the impact of job loss on families. It is based on survey responses from 371 workers and in‑depth interviews with 39 of them about the family impacts of their job loss from the Mitsubishi car factory in Adelaide in 2004‑2005. A majority of workers said family life had been affected by their job loss. Quantitative analysis identified four variables significantly associated with family impacts: marital status, children living at home, employment status and financial management. Qualitative responses showed the predominantly negative impacts were financial strain, loss of relationship stability, and general stress and worry, although few faced catastrophic impacts from their job loss. However, in contrast to most previous research, the in‑depth interviews also revealed positive impacts from job loss, such as having more time at home and to spend with their family. We conclude that the existence of ongoing income support and public health insurance in Australia were important in avoiding catastrophic financial impacts on these workers and their families., The authors acknowledge support from the National Health and Medical Research Council Capacity Building Grant (324724). The research was also supported by the SA Department of Health and the SA Department of Families and Communities through the Human Services Research and Innovation Program (HSRIP), and the Australian Research Council Linkage Program (LP0562288), with the Department of Health serving as Industry Partner. Professor Fran Baum was supported by an ARC Federation Fellowship and Drs Newman and Ziersch by the SA Premier’s Science and Research Fund.

Breastfeeding policies and practices were analysed in childcare settings in the metropolitan area of Adelaide, South Australia. Childcare centres were purposively selected based on their geographical location, type and socioeconomic score of the area. Qualitative inquiry approach was employed by undertaking interviews with childcare centres' director or baby house coordinator to explore their perception towards breastfeeding practice and support within their centre. Breastfeeding related policy documents, where available, were also collected during the interviews to triangulate data. A total of 15 face-to-face interviews were conducted. Six childcare centres had a written policy specifically on breastfeeding support, although the technical issues of handling breastmilk were included in most centres' food and nutrition guidelines. Most participants believed that decision to breastfeed is the personal choice of parents, and hence saw the childcare centre's role as supporting parental choice whether it is breastfeeding or not. The provision of physical space to breastfeed and facilities to store the expressed breast milk were the most common practices in support of parents who had chosen to continue breastfeeding. Participants perceived mothers' work-related issues such as distance from the centre, time, and unsupportive workplace the most important barriers that led to early introduction of bottle feeding or breastfeeding cessation. Most childcare centres support breastfeeding in a more passive than active way. Breastfeeding promotion needs to be an integral part of childcare centres training, policy and practice if an increased rate of breastfeeding is to be achieved particularly amongst working mothers.

This article argues that the continuing reluctance on the part of professional and bureaucratic bodies in Australia to provide for and support planned attended homebirth for low-risk women is unfounded according to the research evidence. It also suggests that such lack of support might be encouraging some planned but intentionally unattended homebirths to occur in Australia, particularly as in recent years there appears to have been an increase in popularity in freebirth (or do-it-yourself homebirth). The article calls for RANZCOG and Australian state health departments to support planned attended homebirth for low-risk women in the face of what is now a considerable amount of evidence showing its safety, when compared with unplanned homebirth and hospital birth. The article raises a number of challenging issues for obstetricians, midwives and managers or planners of maternity services.

The low-fertility debate in developed countries has focused on the limits to family size posed by the financial costs of raising children, and difficulties combining work and family. Little attention has been given to the physical and socio-psychological experiences of conception, pregnancy, birth and early parenthood, and their potential effect on parity progression. Women's rising education and workforce participation rates are often seen as key factors in fertility decline, offering attractive alternatives to motherhood, but research suggests that they also undermine levels of knowledge, confidence and interest in motherhood. Demographers have made almost no link between people having fewer children than they might otherwise have had and their previous child-bearing and childrearing experiences. Interviews conducted in South Australia in 2003-04 with parents of both small and large families show that fertility and family size are influenced both negatively and positively by experiences of having had children. The paper argues that if low fertility rates are to be stabilized or raised in developed countries, then researchers and policymakers must consider the physical and socio-psychological costs of having children for parents, and provide support mechanisms so that experiences of parenthood contribute as little as possible to fertility gaps and delayed fertility.

Background: Despite evidence of benefits of telehealth networks in increasing access to, or providing, previously unavailable mental health services, care providers still prefer traditional approaches. For psychiatric assessment, digital technology can offer improvements over analog systems for the technical and, subsequently, the social quality of provider-client interaction. This is in turn expected to support greater provider uptake and enhanced patient benefits. Objective: Within the framework of Innovation Diffusion Theory, to study service providers' experiences of an existing regional telehealth network for mental health care practice twelve months after digitisation in order to identify the benefits of digital telehealth over an analog system for mental health care purposes in rural Australia. Methods: Qualitative interviews and focus groups were conducted with over 40 service providers from June to September 2013 in South Australia, ranging from the metropolitan central operations to health providers located up to 600 km away in rural and remote areas of the same state. Participants included rural mental health teams, directors of nursing at rural hospitals, metropolitan-based psychiatrists and registrars, the metropolitan-based mental health team dedicated to rural provider support, rural GPs, administrative staff, and the executive group of the state rural health department. Fieldwork was conducted 12 months after the analog system was digitised. The interview and focus group data were analysed using thematic analysis, focusing on three key areas of innovation diffusion theory: relative advantage, technical complexity and technical compatibility. Results: Five themes with 11 sub-themes were identified: (1) “Existing Uses”, with three sub-themes: current mental health use, use by GPs, and use for staff support; (2) “Relative Advantage”, with four sub-themes: improved technical quality, improved clinical practice, time and cost benefits for providers, and improved patient care; (3) “Technical Complexity”; (4) “Technical Compatibility” with two sub-themes: technical-clinical and technical-administrative; and (5) “Broader Organisational Culture”, with two sub-themes: organizational policy support and ‘digital telehealth' culture. Conclusions:The digitised telehealth network was generally well received by providers and adopted into clinical practice. Compared with the previous analog system, staff found advantages in better visual and audio quality, more technical stability with less “drop-out”, less time delay to conversations and less confusion for clients. Despite these advantages, providers identified a range of challenges to starting or continuing use and they recommended improvements to increase uptake among mental health service providers and other providers (including GPs), and to clinical uses other than mental health. To further increase uptake and impact of telehealth-mediated mental health care in rural and remote areas, even with a high quality digital system, future research must design innovative care models, consider time and cost incentives for providers to use telehealth, and must focus not only on technical training but also how to best integrate technology with clinical practice and must develop an organization-wide digital telehealth culture. Refereed/Peer-reviewed

Changing settings to be more supportive of health and healthy choices is an optimum way to improve population health and health equity. This article uses the World Health Organisation's (1998) (WHO Health Promotion Glossary. WHO Collaborating Centre for Health Promotion, Department of Public Health and Community Medicine, University of Sydney, NSW) definition of settings approaches to health promotion as those focused on modifying settings' structure and nature. A rapid literature review was undertaken in the period June-August 2014, combining a systematically conducted search of two major databases with targeted searches. The review focused on identifying what works in settings approaches to address the social determinants of health inequities, using Fair Foundations: the VicHealth framework for health equity. This depicts the social determinants of health inequities as three layers of influence, and entry points for action to promote health equity. The evidence review identified work in 12 settings (cities; communities and neighbourhoods; educational; healthcare; online; faith-based; sports; workplaces; prisons; and nightlife, green and temporary settings), and work at the socioeconomic, political and cultural context layer of the Fair Foundations framework (governance, legislation, regulation and policy). It located a relatively small amount of evidence that settings themselves are being changed in ways which address the social determinants of health inequities. Rather, many initiatives focus on individual behaviour change within settings. There is considerable potential for health promotion professionals to focus settings work more upstream and so replace or integrate individual approaches with those addressing daily living conditions and higher level structures, and a significant need for programmes to be evaluated for differential equity impacts and published to provide a more solid evidence base. Refereed/Peer-reviewed

Purpose: The purpose of this study is to investigate the effectiveness of a home-based intervention using social media to enhance social networks of young people with disabilities and communication difficulties. Method: Eight young people (M-age= 15.4 years) with communication disabilities participated from two rural Australian towns. The intervention provided assistive technology and training to learn social media use. A mixed-method design combined pre- and post-assessments measuring changes in performance, satisfaction with performance, attainment on social media goals, and social network extension, and interviews investigated the way in which the intervention influenced social participation. Results: Participants showed an increase in performance, and satisfaction with performance, on the Canadian Occupational Performance Measure; paired t-tests showed statistical significance at p

The old issue of religion and fertility is examined in relation to women s level of education. In-depth interviews exploring influences on parity for Adelaide parents in 2003–04 suggest that more frequent attendance at religious services in childhood, and affiliation with particular religious denominations, are related to both higher preferred and higher achieved parity, even for women with university education. For some university-educated women, their religious upbringing appears to play a part in negating the traditional relationship between higher education and lower fertility. Quantitative data on religion, fertility and educational level from the 1996 Census for women aged 40–44 in South Australia show that women with No Religion had lower fertility than those With a religion, while university-educated women in New Protestan-New Christian groups had higher fertility than university-educated women in other denominations. The findings provide an understanding of some social conditions that support higher fertility in a low-fertility population. Future fertility research in developed countries should include consideration of the influence of religious affiliation and religiosity at disaggregated levels of inquiry.

We are delighted to have been invited to guest edit this special issue of the Australian Journal of Primary Health and to bring you 13 papers looking at aspects of the rhetoric and reality of e-health in relation to primary health. We were pleased to see the enthusiastic reaction from authors to the call for papers and have thoroughly enjoyed reading the submitted papers and guiding them through the reviewing and revision processes. In developing the special issue, several things have been foremost in our mind. First, what exactly is e-health, and is it different from telehealth, information and communication technologies (ICT) for health, online health and other terms? The World Health Organization (WHO) defines e-health as the use of information and communication technologies for health, with e-health innovations including electronic health records, computer-assisted prescription systems and clinical databases, ICT-supported clinical care, online health information for the general public and scientific information for professionals, platforms for publishing and disseminating health alerts and supporting administrative functions (World Health Organization 2006). The papers in this special issue reflect awide understanding of e-health and cover topics including health professional training to use online health systems, issues around access and equity for consumers, and electronic records and management. The papers cover areas such as maternity care, dentistry, general practice, mental health, cancer care, chronic disease, nursing and community health. Second, we were keen to develop this special issue in light of the techno-optimism that we feel prevails within some parts of government and of the health professions in Australia in relation to e-health, and which is not always balanced by a critical perspective of who actually benefits, or of unintended consequences of its introduction or expansion. Australia’s national E-Health Strategy (Australian Health Ministers Advisory Council 2008) envisages ‘a safer and more sustainable health system that is equipped to respond to emerging health sector cost and demand pressures’, and it sees this being achieved by changing the way information is accessed and shared across the health system. This means that interactions with the health system by consumers, care providers and healthcare managers will increasingly be through electronic means. In particular, the Strategy notes the ‘potentially important role e-healthmayplay in deliveringAustralians a higher quality, safer, more equitable and more efficient health system’ and that ‘e-health should be considered a means to potentially address the ever-increasing costs of Australian health care’ (Australian Health Ministers Advisory Council 2008, p. 23). Australia’s national E-Health Strategy has substantial goals, including that by 2018 (i.e. in just 5 years from now) up to 20% of consultations will be by electronic consultation or telehealth capability, and over 90%of care providerswill be using standards compliant systems for patient, clinical and practice management that support e-health priority solutions such as the electronic transfer of prescriptions, test orders/results, referrals and event summaries. It also envisions that by 2018, 50% of consumers will be actively accessing and using a personal Electronic Health Record tomanage their health and interact with the health system. The Strategy sees ‘latent capacity in the system represented by consumers themselves playing a more active role in the protection and management of their personal health outcomes’ (Australian Health Ministers Advisory Council 2008, p. 1), although it does not detail how all consumers will be up-skilled and resourced to be able to this. Similarly, Australia’s E-Mental Health Strategy (Department of Health and Ageing 2012) focuses on mainstreaming the provision of online health information and online support services for consumers and carers, seeing these as widely accessible (but with little acknowledgement of the inequities in technical Internet access by geography and socioeconomic status across Australia, or of how social/cultural and educational barriers to successful Internet use can be overcome to provide e-mental health that is truly accessible by all). The Strategy also outlines the need for training of the mental health workforce to provide services in these ways. TheNational E-health Strategy sees the approach as threefold: (1) to improve the quality and safety of the Australian health system(and thereby reduce avoidabledemand forhealth-care services) through improved data and monitoring, access to decision support tools for care providers and up-to-date consumer information and knowledge sources at the point of care; access to better quality datasets of treatment effectiveness; automatic monitoring of individual care; and access to timely and comprehensive data for more effective health surveillance and management.

Internationally, public policies encourage "aging in place," and the majority of older Australians requiring care in the community receive informal care, supplemented by publicly subsidized formal services. The effect of contemporary social changes on informal care in aging migrant communities is poorly understood. This articles explores the perceptions of older Greek-Australians toward changes in the nature of family support. Bicultural and bilingual researchers carried out in-depth interviews (n = 27) and five focus groups (n = 63 total participants) with older Greek-Australians in modern Greek. While "cultures of care" remain among Greek-Australian families, the means for a family to assist have shifted, and these compromises are met with considerable powerlessness among older Greek-Australians. Implications for policy include the need to better involve older migrants and their families in decisions about their care needs, potentially involving consumer-directed care models. Service providers may also need to adopt the use of new technologies to communicate with increasingly time-pressured family members.

Main themes that emerged from the qualitative exploration of the psychological distress of job loss included stress, changes to perceived control, loss of self-esteem, shame and loss of status, experiencing a grieving process, and financial strain. Drawing on two models of agency we identified the different ways workers employed their agency, and how their agency was enabled, but mainly constrained, when dealing with job loss consequences. Respondents’ accounts support the literature on the moderating effects of economic resources such as redundancy packages. The results suggest the need for policies to put more focus on social, emotional and financial investment to mediate the structural constraints of job loss. Our study also suggests that human agency must be understood within an individual’s whole of life circumstances, including structural and material constraints, and the personal or interior factors that shape these circumstances., The authors acknowledge support from the National Health and Medical Research Council Capacity Building Grant (324724). The research was supported by the SA Department of Health and the SA Department of Families and Communities through the Human Services Research and Innovation Program (HSRIP), and the Australian Research Council Linkage Program (LP0562288), with the Department of Health (DOH) serving as Industry Partner. Professor Fran Baum was supported by an ARC Federation Fellowship and Drs Newman and Ziersch by the SA Premier’s Science and Research Fund.

Published version made available in accordance with Publisher copyright agreement., Today, young people use the Internet for social networking, learning and recreation. Young people with disabilities have fewer friends and reduced social networks. The aim was to investigate the effectiveness of one-on-one training to increase the use of the Internet by young people with disabilities to enhance their social networks and reduce loneliness. Eighteen young people aged 10-18 years with cerebral palsy, physical disability or acquired brain injury completed a social networks inventory and level of loneliness measure. Participants received assistive technology and training at their home to learn to use the Internet for building social networks. Post intervention testing revealed that the number of online communication partners increased significantly; however, there was no difference in measured levels of loneliness. Future research with larger number of participants with disabilities needs to be followed up longitudinally including investigating the meaning and role of online social connections for this group

Background: The beneficial effects of breastfeeding for mothers and babies are well recognized. When maternal breast milk is not available in sufficient quantity, donor breast milk is recommended as an alternate source of nutrition, particularly in preterm and other high-risk infants. Australia lags behind the rest of the developed world in establishing and promoting human milk banks; there is no human milk bank in South Australia and little is known concerning mothers’ perceptions of using human milk banks in that state. Objective: This study explored mothers’ knowledge of and attitudes toward human milk banks, to inform the development of human milk banking policies and guidelines in South Australia should a milk bank be established. Methods: In-depth semistructured interviews were conducted with 12 mothers who were breastfeeding and/or had preterm or sick babies. In addition, 2 focus groups were conducted—1 with breastfeeding mothers as potential donors (n = 5) and the other with mothers of preterm or high-risk infants (n = 4)—to answer questions raised by early analysis of the individual interview data. Results: Breastfeeding mothers, as potential donors, unanimously supported donating their breast milk to a human milk bank, provided it would be easy (especially if required to drop off milk) and not overly time consuming. Mothers of preterm or sick infants would use a human milk bank if they were assured the milk was safe and appropriate for their babies. Conclusion: Study participants would welcome having access to a human milk bank for both donating and receiving milk in South Australia.

Community informatics links economic and social development efforts at the community level with emerging opportunities in Information and Communication Technologies (ICTs). In recent years in public health there has been an increased focus on the broader social determinants of health and on social inclusion, as evidenced in the 2008 Final Report of the Commission on Social Determinants of Health1. Broader determinants include education, income, social connection, and other opportunities that support improved health and wellbeing.

Digital technologies are increasingly important as ways to gain access to most of the important social determinants of health including employment, housing, education and social networks. However, little is known about the impact of the new technologies on opportunities for health and well-being. This paper reports on a focus group study of the impact of these technologies on people from low socio-economic backgrounds. We use Bourdieu's theories of social inequities and the ways in which social, cultural and economic capitals interact to reinforce and reproduce inequities to examine the ways in which digital technologies are contributing to these processes. Six focus group discussions with 55 people were held to examine their access to and views about using digital technologies. These data are analysed in light of Bourdieu's theory to determine how people's existing capitals shape their access to and use of digital technologies and what the implications of exclusion from the technologies are likely to be for the social determinants of health. The paper concludes that some people are being caught in a vicious cycle whereby lack of digital access or the inability to make beneficial use reinforces and amplifies existing disadvantage including low levels of reading and writing literacy. The paper concludes with a consideration of actions health promoters could take to interrupt this cycle and so contribute to reducing health inequities.

The articulation of strong evidence and moral arguments about the importance of social determinants of health (SDH) and health equity has not led to commensurate action to address them. Policy windows open when, simultaneously, an issue is recognised as a problem, policy formulation and refinement happens and the political will for action is present. We report on qualitative interviews with 20 former Australian Federal, State or Territory health ministers conducted between September 2011 and January 2012 concerning their views about how and why the windows of policy opportunity on the SDH did or did not open during their tenure. Almost all ex-health ministers were aware of the existence of health inequalities and SDH but their complexity meant that this awareness rarely crystalised into a clear problem other than as a focus on high needs groups, especially Aboriginal people. Formulation of policies about SDH was assisted by cross-portfolio structures, policy entrepreneurs, and evidence from reviews and reports. It was hindered by the complexity of SDH policy, the dominance of medical power and paradigms and the weakness of the policy community advocating for SDH. The political stream was enabling when the general ideological climate was supportive of redistributive policies, the health care sector was not perceived to be in crisis, there was support for action from the head of government and cabinet colleagues, and no opposition from powerful lobby groups. There have been instances of Australian health policy which addressed the SDH over the past twenty five years but they are rare and the windows of opportunity that made them possible did not stay open for long.

Objective. To present research findings on access to, and use of, digital information and communication technologies (ICTs) by Australians from lower income and disadvantaged backgrounds to determine implications for equitable consumer access to digitally-mediated health services and information. Methods. Focus groups were held in 2008-09 with 80 residents from lower income and disadvantaged backgrounds in South Australia, predominantly of working- and family-formation age (25 to 55 years). Qualitative analysis was conducted on a-priori and emergent themes to describe dominant categories. Results. Access to, and use of, computers, the Internet and mobile phones varied considerably in extent, frequency and quality within and across groups due to differences in abilities, resources and life experience. Barriers and facilitators included English literacy (including for native speakers), technological literacy, education, income, housing situation, social connection, health status, employment status, and trust. Many people gained ICT skills by trial and error or help from friends, and only a few from formal programs, resulting in varied skills. Conclusion. The considerable variation in ICT access and use within lower income and disadvantaged groups must be acknowledged and accommodated by health initiatives and services when delivering digitally-mediated consumer-provider interaction, online health information, or online self-management of health conditions. If services require consumers to participate in a digitally-mediated communication exchange, then we suggest they might support skills and technology acquisition, or provide non-ICT alternatives, in order to avoid exacerbating health inequities. 1. What is known about the topic? Government and health provider use of digitally-mediated information and communication is rapidly increasing. However, national data show that ICT access is distributed unevenly across Australia’s population. Furthermore, this distribution mirrors the health gradient. There is little qualitative data on the extent to which, and ways in which, ICTs are used within lower income and disadvantaged groups - those with greater health need. 2. What does this paper add? This paper augments the scant literature to describe ICT access and use in a range of lower income and disadvantaged groups. It indicates barriers and facilitators, and highlights the need for formal supports to level up the whole population to have the skills, confidence and resources to use and benefit from ICT-mediated communication. 3. What are the implications for practitioners? As health services and governments increase the level of digitally-mediated information and communication connection with consumers/patients, it is important to understand and find ways to address differential consumer access to and use of ICTs, so that equity of access to services and information is promoted. This is particularly important as lower income and disadvantaged groups are likely to have both poorer health and lower ICT use.

There has been an explosive growth in the use of the Internet as a social networking tool and as a major venue for leisure and recreation among children and young people. It is not known whether children with disabilities are using the new medium for similar purposes. The aim of this project was to investigate the current patterns and frequency of Internet use and its impact, facilitators and barriers to use by children and young people with physical disabilities. Fifteen participants with physical disabilities with a mean age of 14.6 years were interviewed exploring the above issues. The research found the young people who participated in this study used the Internet for a variety of purposes and friends played a key role in teaching them Internet skills as well as interacting with them online. Family resources and the computer/Internet literacy skills of parents were significant factors influencing usage. The findings suggest the need for further research involving a larger cohort of children and young people with varying abilities, especially those who are currently not using the Internet, to explore reasons for not using the Internet, and to identify the supports required to increase access and participation. Refereed/Peer-reviewed

This paper describes a partnership between researchers and policy actors that was developed within a short timeframe to produce a rapid appraisal case study of a government policy initiative – South Australia’s Social Inclusion Initiative – for the Social Exclusion Knowledge Network of the international Commission on Social Determinants of Health. The paper does not focus on the case study findings or content, but rather on the researcher–policy actor partnership that developed in the process of producing the case study and its report. The paper is set against the broader literature on researcher–policy collaboration and is written to share lessons that may help others quickly establish or improve researcher–policy partnerships. It sets out six key elements for success in a framework for partnership that can meet policy rather than academic timeframes and which can effectively co-produce knowledge that meets both research and policy objectives.

This paper offers lessons to in-coming health ministers on how they can act to reduce inequities and take action on social determinants. It draws on an interview study of twenty former Australian State, Territory and Federal health ministers about the extent to which they were able to do these things during their tenure. In order to take effective health equity action the health ministers advised: ensure evidence is used to develop a strong party policy platform for health equity; install policy entrepreneurs for health equity and social determinants in the health ministry; build popular constituencies through processes of deliberative democracy; establish context appropriate cross-department mechanisms to co-ordinate action on social determinants; and be elected in the context of a political party which values social justice and redistribution.

Despite decades of concern about reducing health inequity, the Commission on the Social Determinants of Health (CSDH) painted a picture of persistent and, in some cases, increasing health inequity. It also made a call for increased evaluation of interventions that might reduce inequities. This paper describes such an intervention-the Social Inclusion Initiative (SII) of the South Australian Government-that was documented for the Social Exclusion Knowledge Network of the CSDH. This initiative is designed to increase social inclusion by addressing key determinants of health inequity-in the study period these were education, homelessness and drug use. Our paper examines evidence from a rapid appraisal to determine whether a social inclusion initiative is a useful aspect of government action to reduce health inequity. It describes achievements in each specific area and the ways they can be expected to affect health equity. Our study highlighted four factors central to the successes achieved by the SII. These were the independent authority and influence of the leadership of the SII, the whole of government approach supported by an overarching strategic plan which sets clear goals for government and the clear and unambiguous support from the highest level of government. We conclude that a social inclusion approach can be valuable in the quest to reduce inequities and that further research on innovative social policy approaches is required to examine their likely impact on health equity.

This paper presents children’s accounts from Adelaide, South Australia, about parental job losses from automotive manufacturing: an industry that is being restructured globally. The research is informed by the “new sociology of childhood” and nests within a longitudinal, mixed-method study of 372 displaced workers. We interviewed 35 boys and girls aged 4 to 19 from 16 families. Findings support calls for children’s voices to be heard. Many children did not see the job loss as a major problem, some felt they now had a better life, and many valued not moving for new work. While some reported social, health and financial impacts, others were shielded by parents. Parents consented to their children’s involvement in 23% of in-scope families and those who had moved interstate were not included. Nevertheless, the children’s accounts contribute a better understanding of adult domains, including the value of family-friendly work patterns; they also highlight the benefits of including children’s perspectives on social and economic change. Economic and policy contexts that may have limited the job loss impact include the welfare state, trade unions, a low unemployment rate and government intervention to manage job loss.

Two consumer representatives were participants in the development of their state government’s Policy for Planned Birth At Home in South Australia. It was released in November 2007 to guide staff in public hospital and community midwifery programs, and the first hospital-based home birth service is commencing in February 2009. Consumer experiences of policy development and perceived benefits of consumer involvement for policy and transparency processes are described. Inclusion of consumers widely and actively during development and reform of maternity care is essential if real consumer participation is to occur and contribute to care that is truly woman-centered. (BIRTH 36:1 March 2009)

This article details family size differences by socio-economic area in metropolitan South Australia and suggests that these differences may be linked to cultural differences in parenting confidence and skills, and in social supports for parenting. The paper analyses Census data on average completed family size and family size distribution in six different areas. In all age groups this shows a negative correlation between family size and the socio-economic status of the area. Secondly, based on analysis of interview data with 38 mothers and 24 fathers and a small survey of 44 parents-to-be, the article suggests that the quantitative patterns may partly reflect differences in the proportions of people in each area who see being parents and having larger families as desirable and achievable undertakings for which they have the requisite personal skills and social supports to minimise adverse impacts on their own parental health and lifestyle. The article concludes by hypothesising that differential fertility levels between groups or areas partly reflect differences in levels of confidence, skills and social support for parenting, and that a cultural “crisis in parenthood” as well as a greater focus on intensive parenting may be more widespread in higher status groups which is reflected in their lower fertility.

Issue addressed: Planned actions by governments can play an important part in addressing the social determinants of health and health inequities. We assess the extent to which Australian health departments are committed to health equity as a core value, and the extent to which strategic directions and policies show evidence of action and achievement in reducing health inequities and attention to the social determinants of health. Methods: Key documents guiding each health department since 2000 were sought from a key informant in each jurisdiction (State/Territory/federal). An analysis was made of the content in terms of stated values, strategies, objectives, intended and current initiatives, collaborations, funding, and reporting of achievements in relation to the reduction of health inequities and the attention accorded to the social determinants of health. Results: All jurisdictions are explicitly or implicitly committed to reducing health inequities and to addressing the social determinants of health to at least a limited extent. The extent of commitment varies from those who make a clear statement of the importance of achieving health equity at both whole-of-government and health department level, to others who have extremely limited commitment. There is also variation in the extent to which directions are transformed into planned initiatives to improve health outcomes or access to health services for disadvantaged groups or areas, and variations in the degree of monitoring and evaluation. Conclusion: Although substantial health inequities exist in Australia there is explicit or implicit recognition of the underlying value of equity within all jurisdictions and some policies designed to increase health equity in all. However, in most jurisdictions health equity could be more explicitly incorporated into core government and health department strategies and initiatives, and there is room for the development of the capacity to monitor change over time in access to services, quality of care, and improved health outcomes. (author abstract)

Health systems and policies are important determinants of health because they influence the type and quality of health care available to a population. This study included semi-structured qualitative interviews and a questionnaire to collect demographic data and household details for a purposeful sample of 38 mothers and 24 fathers from four socioeconomic areas of metropolitan South Australia who had at least one child aged between 1 and 6 years of age. The participants reported that birth experiences within the predominantly medicalised maternity system were at odds with the expectations of a significant proportion of contemporary consumers that maternity care will leave them not only with a healthy mother and baby, but also with no undue adverse impacts on their physical, mental and relationship health. There appears to be no formal mechanism in place for regular consumer feedback of experiences into system and service planning.

Background: There is a significant body of evidence that highlights the importance of addressing the social determinants of child and youth health. In order to tackle health inequities Australian governments are being called upon to take action in this area at a policy level. Recent research suggests that the health and well-being of children and youth in Australia is 'middle of the road' when compared to other OECD countries. To date, there have been no systematic analyses of Australian child/youth health policies with a social determinants and health equity focus and this study aimed to contribute to addressing this gap. Methods: Document analysis of seventeen strategic level child/youth health policies across Australia used an a priori coding framework specifically developed to assess the extent to which health departments address the social determinants of child/youth health and health equity. Policies were selected from a review of all federal and state/territory strategic health department policies dated between 2008 and 2013. They were included if the title of the policy addressed children, youth, paediatric health or families directly. We also included whole of government policies that addressed child/youth health issues and linked to the health department, and health promotion policies with a chapter or extensive section dedicated to children. Results: Australian child/youth health policies address health inequities to some extent, with the best examples in Aboriginal or child protection policies, and whole of government policies. However, action on the social determinants of child/youth health was limited. Whilst all policies acknowledge the SDH, strategies were predominantly about improving health services delivery or access to health services. With some exceptions, the policies that appeared to address important SDH, such as early childhood development and healthy settings, often took a narrow view of the evidence and drifted back to focus on the individual. Conclusions: This research highlights that policy action on the social determinants of child/youth health in Australia is limited and that a more balanced approach to reducing health inequities is needed, moving away from a dominant medical or behavioural approach, to address the structural determinants of child/youth health. Refereed/Peer-reviewed