Editorial Issue 1 2009
Understanding the environment in which we work

Putting people and their families at the centre of care is a welcome principle in the deliberations of the National Health and Hospital Reform Commission and other reform initiatives within Australia and internationally. However, a necessary condition for people centred care is that health care providers and health promoters understand the attitudes, capacities, beliefs and values of the people they work with. People vary greatly in what they believe about their health and health risks. These beliefs develop through ‘lay epidemiology’, a term which describes ‘a process by which a person interprets health risk through routine observation and discussion of health and death in personal networks in the public arena as well as from formal and informal evidence arising from other sources such as television and magazines’ (Frankel et al. 1991).

The concept of lay epidemiology is related to some extent to that of health literacy. People whose functional literacy is poor are at a disadvantage in learning from printed materials including the internet. They may also be less able to use the language of health care so that they can interact effectively in a health care setting. Their beliefs are therefore likely to be more influenced by their own experiences and those of their network, without the tempering effect of the printed material or communications with health care providers whom they understand. However, health literacy is not just a set of functional capabilities that may influence health outcomes. It is also the outcome of education and communication, reflecting the skills and capacities that enable people to exert greater control over their health (Nutbeam 2008).

Effective health promotion requires providers to take into account both lay epidemiology and health literacy. The greater the gap between provider and the people they work with, in age, gender, ethnicity, location, economic situation, work setting and culture, the greater the need to gain knowledge about their perspective. As a colleague in a secondary school once suggested to me, the two most dangerous words in teaching are ‘assume’ and ‘obvious’, and the same applies to health promotion and education. Rather than following our assumptions, the range of lay understandings should be explored to enhance the traditional models of communication between provider and patient (Walter et al. 2004).

Four of the papers in this issue illustrate research undertaken to understand the perspectives of different groups of people, in order to conduct more effective health promotion. Berryman et al. explore people’s concerns, knowledge and beliefs around prevention of diabetes, to identify marketing messages and strategies for engaging participants in a diabetes prevention program. Howat et al. report on perceptions of cancer prevention and screening among a sample of Western Australians aged 60 years and older, along with implications for prevention. Participants were able to cite examples of people who had been physically active and developed cancer, which influenced their perceptions. Awareness programs specifically tailored to seniors may be desirable to promote cancer prevention within a context of general chronic disease prevention. In the childhood obesity domain, Pettigrew et al. used focus groups to look at parents’ attitudes and behaviours relating to child-feeding practices among families of different socioeconomic profiles. The results are relevant to primary care providers who interact with parents and have the opportunity to discuss issues relating to children’s weight. A fourth paper by Carter et al. takes a slightly different approach, by finding out about the knowledge, attitudes and practices regarding smoking cessation of Aboriginal Health Workers who are at the vanguard of tackling the high smoking rate among Indigenous people.

Another group of papers in this issue looks at different ways to find evidence at program level. Foley’s evaluation of a community day rehabilitation program, using careful measurement of relevant outcomes including strength gains, provides a sound foundation for further controlled studies that could include measures of cost effectiveness. Such evaluations can then contribute to systematic literature reviews, as used by Wilson et al. as a basis for evidence informed policy development. Wilson et al. reviewed the literature review to identify the health needs of young offenders in secure care, as well programmes and interventions that assist detained youth through focussed discharge planning. At the national level in Sri Lanka, Barraclough et al. reviewed published and unpublished official documents and recent local research to present a comprehensive overview of school health programmes in Sri Lanka, to identify problems with their content and implementation, and to suggest ways for strengthening them. The extent of the issues and problems, compounded by a long war and a devastating cyclone and tsunami, make a powerful statement. The authors call for a comprehensive national school health policy, that not only addresses the essentials of planning and coordination, but also serves to reorient school health to embrace the promotion of physical and psychosocial health. As AJPH is very interested in expanding its content to include international papers, this paper on Sri Lanka school health policy is most welcome.

Methodology papers also contribute to the body of knowledge in primary health, and build our capacity to undertake research more effectively, by building on other’s experience. Van Dyke’s paper is an excellent example of thoughtful reflection on a research method, to inform other researchers planning similar types of projects by describing the design and conduct of surveys dealing with sensitive social issues. Computer aided telephone interviews are a relatively inexpensive and practical way to gather information from the public compared with in-person interviews or self-administered pencil and paper questionnaires, but there are traps for the unwary.

All the articles in this issue illustrate varying ways in which primary health care researchers, practitioners and policy makers increase their understanding of the environment in which they work. Sharing these experiences through publishing is essential for the progress of primary health care. It is a privilege to be part of this journal as Co-editor in Chief with Rae Walker, and I look forward to the experience.

Libby Kalucy
Co-editor in Chief