Dissertations / Theses on the topic 'Rural health services Standards Australia'

Economic, political and social forces are driving the implementation of reforms in health service systems worldwide. As the health industry concentrates on ways to improve operations and to achieve overall cost effectiveness, health service organisations are developing and implementing structural changes to address issues of cost containment, utilisation and resource allocation. One approach has been to devolve resource allocation and utilisation decisions to the program or unit level. Clinical practitioners have been required to assume general management responsibilities in addition to their clinical role. A new type of clinician, the clinician manager has emerged to take on this task. Despite the trend towards the clinician manager role in many sections of health care world wide, there is little research in the area and a poor understanding of the experience of the role.The aim of this research was to explore clinician managers' perceptions of their experiences in their adaptation to and their enactment of the new role. The study was based in the symbolic interactionist paradigm. Sensemaking, the process by which individuals ascribe meaning to the events in their environment, provided a theoretical context that directed the inquiry. Grounded theory was the methodological approach. The research sample was made up of Directors of Nursing/Health Service Managers, a clinician manager role that had emerged from the restructuring of rural health services in Western Australia. Data was gathered from in-depth interviews.Findings suggested that sensemaking was influenced by structural and personal elements. Structural elements were created by the stakeholders, individuals and groups who relied on the clinician manager for the achievement of their goals but upon whom, in turn, the clinician manager relied upon for their support and cooperation. The sensemaking process of the clinician manager was mediated by the interaction with the stakeholders - the most influential factors being the clinician manager's perceptions of the trustworthiness of the stakeholders, the political behaviour that characterised the interactions with the stakeholder and role stress. In particular, role conflict, role ambiguity and role overload emerged. Personal elements were the personal characteristics of the clinician manager - the most salient being the experience of role strain, self-efficacy (i.e. their belief in their ability to do the job) and their commitment to the sensemaking process.Circumstances in the environment constrained their reliance on others for validation of their explanations of events and the actions they took. Most made decisions based on intuition and "gut feeling" - validating these decisions with subjective evaluations of outcomes and retrospective explanations. These processes were further mediated by the characteristics of the individual, particularly perceptions of self-efficacy. The ways in which the clinician managers adapted to and interpreted their role was diverse, which made the role more an expression of individual preferences than a coherent part of a larger organisational structure. Findings indicated that the clinician managers relied on their sensemaking processes in order to explain the ambiguous nature of their practice environment and to plan actions within the context of a role that was poorly defined by the organisation.

Economic, political and social forces are driving the implementation of reforms in health service systems worldwide. As the health industry concentrates on ways to improve operations and to achieve overall cost effectiveness, health service organisations are developing and implementing structural changes to address issues of cost containment, utilisation and resource allocation. One approach has been to devolve resource allocation and utilisation decisions to the program or unit level. Clinical practitioners have been required to assume general management responsibilities in addition to their clinical role. A new type of clinician, the clinician manager has emerged to take on this task. Despite the trend towards the clinician manager role in many sections of health care world wide, there is little research in the area and a poor understanding of the experience of the role.The aim of this research was to explore clinician managers' perceptions of their experiences in their adaptation to and their enactment of the new role. The study was based in the symbolic interactionist paradigm. Sensemaking, the process by which individuals ascribe meaning to the events in their environment, provided a theoretical context that directed the inquiry. Grounded theory was the methodological approach. The research sample was made up of Directors of Nursing/Health Service Managers, a clinician manager role that had emerged from the restructuring of rural health services in Western Australia. Data was gathered from in-depth interviews.Findings suggested that sensemaking was influenced by structural and personal elements. Structural elements were created by the stakeholders, individuals and groups who relied on the clinician manager for the achievement of their goals but upon whom, in turn, the clinician manager relied upon for their support and cooperation. The sensemaking process of the ++
clinician manager was mediated by the interaction with the stakeholders - the most influential factors being the clinician manager's perceptions of the trustworthiness of the stakeholders, the political behaviour that characterised the interactions with the stakeholder and role stress. In particular, role conflict, role ambiguity and role overload emerged. Personal elements were the personal characteristics of the clinician manager - the most salient being the experience of role strain, self-efficacy (i.e. their belief in their ability to do the job) and their commitment to the sensemaking process.Circumstances in the environment constrained their reliance on others for validation of their explanations of events and the actions they took. Most made decisions based on intuition and "gut feeling" - validating these decisions with subjective evaluations of outcomes and retrospective explanations. These processes were further mediated by the characteristics of the individual, particularly perceptions of self-efficacy. The ways in which the clinician managers adapted to and interpreted their role was diverse, which made the role more an expression of individual preferences than a coherent part of a larger organisational structure. Findings indicated that the clinician managers relied on their sensemaking processes in order to explain the ambiguous nature of their practice environment and to plan actions within the context of a role that was poorly defined by the organisation.

Australia is experiencing widespread ecosystem degradation, including dryland salinity, erosion and vegetation loss. Approximately 1 million hectares (5.5%) of the south-west agricultural zone of Western Australia is affected by dryland salinity and is predicted to rise to 5.4 million hectares by 2050. Such degradation is associated with many environmental outcomes that may impact on human health, including a decrease in primary productivity, an increase in the number of invasive species, a decrease in the number of large trees, overall decrease in biodiversity, and an increase in dust production. The resulting degradation affects not only farm production but also farm values. This study examines the effects of such severe and widespread environmental degradation on the physical and mental health of residents. Western Australia has an extensive medical record database which links individual health records for all hospital admissions, cancer cases, births and deaths. For the 15 diseases examined in this project, the study area of the south west of Western Australia (excluding the capital city of Perth) contained 1,570,985 morbidity records and 27,627 mortality records for the 15 diseases examined in a population of approximately 460,000. Environmental data were obtained from the Western Australian Department of Agriculture?s soil and landscape mapping database. A spatial Bayesian framework was used to examine associations between these disease and environmental variables. The Bayesian model detected the confounding variables of socio-economic status and proportion of the population identified as Aboriginal or Torres Strait Islander. With the inclusion of these confounders in the model, associations were found between environmental degradation (including dryland salinity) and several diseases with known environmentally-mediated triggers, including asthma, ischaemic heart disease, suicide and depression. However, once records of individuals who had been diagnosed with coexistent depression were removed from the analysis, the effect of dryland salinity was no longer statistically detectable for asthma, ischaemic heart disease or suicide, although the effects of socio-economic status and size of the Aboriginal population remained. The spatial component of this study showed an association between land degradation and human health. These results indicated that such processes are driving the degree of psychological ill-health in these populations, although it remains uncertain whether this 4 is secondary to overall coexisting rural poverty or some other environmental mechanism. To further investigate this complex issue an instrument designed to measure mental health problems in rural communities was developed. Components of the survey included possible triggers for mental health, including environmental factors. The interview was administered in a pilot study through a telephone survey of a small number of farmers in South-Western Australia. Using logistic regression a significant association between the mental health of male farmers and dryland salinity was detected. However, the sample size of the survey was too small to detect any statistically significant associations between dryland salinity and the mental health of women. The results of this study indicate that dryland salinity, as with other examples of ecosystem degradation, is associated with an increased burden of human disease.

Australia and many other developed communities are ageing rapidly, placing a strain on the delivery of health services. This thesis examines the use of innovative health services management coupled with information and communication technology (ICT) to more efficiently deliver services to disabled older people in the hospital, community and residential care. The hypothesis explored is that ICT can provide clinical services to older people in poorly serviced communities and groups, thus extending the influence and capabilities of specialist health care professionals. The relevance of these studies is predominantly for those people who live outside the metropolitan regions, particularly in remote and rural communities, and also for those frail older people, who because of disability, are unable to travel to specialist health services. There are a series of studies presented in this thesis which have all been published. They have demonstrated that in a community and rural setting, ICT use in the assessment and management of geriatric syndromes such as dementia is valid and practical. This included the validation of commonly used assessment tools via Telehealth. A Telehealth protocol for assessment of Alzheimer's Dementia (AD) was developed and published. The use of ICT to link health services clinical and administrative data for determining stroke outcomes and disability has been evaluated and a resource utilization prediction model developed. Finally, in residential care a survey and a qualitative study of poor uptake of ICT services in hostels and nursing homes revealed insights into ICT perception by the older people in care facilities and their professional staff. The implications and future development of these studies have been discussed, especially barriers to increased uptake of ICT, cost comparisons and the potential of future technologies such as video conferencing mobile phones.

Objective: To examine the impact on dental utilisation following the introduction of a participating provider scheme (Regional and Rural Oral Health Program {RROHP)). In this model dentists receive higher third party payments from a private health insurance fund for delivering an agreed range of preventive and diagnostic benefits at no out-ofpocket cost to insured patients. Data source/Study setting: Hospitals Contribution Fund of Australia (HCF) dental claims for all members resident in New South Wales over the six financial years from l99811999 to 200312004. Study design: This cohort study involves before and after analyses of dental claims experience over a six year period for approximately 81,000 individuals in the intervention group (HCF members resident in regional and rural New South Wales, Australia) and 267,000 in the control group (HCF members resident in the Sydney area). Only claims for individuals who were members of HCF at 31 December 1997 were included. The analysis groups claims into the three years prior to the establishment of the RROHP and the three years subsequent to implementation. Data collection/Extraction methods: The analysis is based on all claims submitted by users of services for visits between 1 July 1988 and 30 June 2004. In these data approximately 1,000,000 services were provided to the intervention group and approximately 4,900,000 in the control group. Principal findings: Using Statistical Process Control (SPC) charts, special cause variation was identified in total utilisation rate of private dental services in the intervention group post implementation. No such variation was present in the control group. On average in the three years after implementation of the program the utilisation rate of dental services by regional and rural residents of New South Wales who where members of HCF grew by 12.6%, over eight times the growth rate of 1.5% observed in the control group (HCF members who were Sydney residents). The differences were even more pronounced in the areas of service that were the focus of the program: diagnostic and preventive services. Conclusion: The implementation of a benefit design change, a participating provider scheme, that involved the removal of CO-payments on a defined range of preventive and diagnostic dental services combined with the establishment and promotion of a network of dentists, appears to have had a marked impact on HCF members' utilisation of dental services in regional and rural New South Wales, Australia.

Objective: To examine the impact on dental utilisation following the introduction of a participating provider scheme (Regional and Rural Oral Health Program {RROHP)). In this model dentists receive higher third party payments from a private health insurance fund for delivering an agreed range of preventive and diagnostic benefits at no out-ofpocket cost to insured patients. Data source/Study setting: Hospitals Contribution Fund of Australia (HCF) dental claims for all members resident in New South Wales over the six financial years from l99811999 to 200312004. Study design: This cohort study involves before and after analyses of dental claims experience over a six year period for approximately 81,000 individuals in the intervention group (HCF members resident in regional and rural New South Wales, Australia) and 267,000 in the control group (HCF members resident in the Sydney area). Only claims for individuals who were members of HCF at 31 December 1997 were included. The analysis groups claims into the three years prior to the establishment of the RROHP and the three years subsequent to implementation. Data collection/Extraction methods: The analysis is based on all claims submitted by users of services for visits between 1 July 1988 and 30 June 2004. In these data approximately 1,000,000 services were provided to the intervention group and approximately 4,900,000 in the control group. Principal findings: Using Statistical Process Control (SPC) charts, special cause variation was identified in total utilisation rate of private dental services in the intervention group post implementation. No such variation was present in the control group. On average in the three years after implementation of the program the utilisation rate of dental services by regional and rural residents of New South Wales who where members of HCF grew by 12.6%, over eight times the growth rate of 1.5% observed in the control group (HCF members who were Sydney residents). The differences were even more pronounced in the areas of service that were the focus of the program: diagnostic and preventive services. Conclusion: The implementation of a benefit design change, a participating provider scheme, that involved the removal of CO-payments on a defined range of preventive and diagnostic dental services combined with the establishment and promotion of a network of dentists, appears to have had a marked impact on HCF members' utilisation of dental services in regional and rural New South Wales, Australia.

It is well documented that rural and remote Australian residents have poorer access to medical services than their counterparts in capital cities. According to the Australian Institute of Health and Welfare in 1998 there were 75.3 vocationally registered general practitioners per 100,000 population in rural and remote areas, compared with 103.0 per 100,000 in metropolitan areas. In 1998 28.7% of the Australian population lived in rural and remote areas, so a substantial proportion of the Australian population is adversely affected by the unequal distribution of general practitioners. Australian country communities highly regard the services of general practitioners and they continue to demand residential medical services. Demand is driven by need for access to health services, but also by the intimate inter-relationships between the general practice and community sustainability. For example, the general practice contributes to the viability of the local hospital which is often a major employer in the district. Consequently, many country communities strive to keep their general practice by contributing to practice infrastructure, providing governance, raising funds for medical equipment, and actively helping recruitment.
thesis (PhDHealthSciences)--University of South Australia, 2004.

Over the last seven years the recruitment of overseas trained doctors (OTDs) has formed a significant part of Australia’s policy to address the medical workforce issue of geographic maldistribution to ensure that communities in rural and remote Australia have access to adequate general practice (GP) services. This policy has not been without problems, particularly in the areas of assessment of skills and qualifications, appropriate orientation and integration into Australian communities, and retention of these doctors within rural and remote communities. To date there has been little evidence-based research on the role of OTDs in the medical workforce in Australia. This study explores the service provision and quality of care provided by OTDs using the 5 Year OTD Scheme as the case study. In doing so, it assesses the adequacy of this strategy and discusses the implications for future workforce policies and programs. A mixed method design was used in the study. The quantitative component involved secondary analysis of Medicare Australia data for all OTDs participating in the 5 Year OTD Scheme in 2002 and all Australian trained doctors (ATDs) practising in rural and remote Australia in the same year. A log Poisson regression model was used to assess the interactive effect of the various GP characteristics, such as age, sex, experience and practice location with OTD/ATD status on the rate of a particular service item per patient, adjusted for patient age and sex. The qualitative component involved two focus groups with OTDs which were used to help explain the relationships between variables found in the quantitative component of the study. Template analysis was used to identify themes from the focus group. Significantly different rates per patient between OTDs and ATDS were found across most service items and GP characteristics examined. The greatest variation was found among items relating to in-surgery consultations and non-surgery consultations such as nursing home visits. Fewer differences were found between groups relating to pathology, imaging or procedural services. Analysis of surrogate quality items identified few differences between OTDs and ATDs. The focus group identified a number of other factors that influenced their patterns of service and accounted for some of the differences identified in the quantitative analysis. These factors included knowledge of the health care system in Australia, cultural and communication influences, health conditions of patients, patient and community attitudes, remuneration influences and training influences. These had varying degrees of influence on their patterns of service. The reasons for the differences found between OTDs and ATDs are partially explained by the characteristics of the GPs examined and partially explained by other external influences that relate to the particular circumstances of the OTDs, such as knowledge of the Australian health care system and cultural and communication issues. Understanding the nature of practice is central to ensuring appropriate professional support measures. The study findings highlight the need for a targeted training program for OTDs that address the areas that have the greatest influence on patterns of service to ensure that rural and remote communities receive the same quality of service from OTDs as provided by ATDs.
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Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

Over the last seven years the recruitment of overseas trained doctors (OTDs) has formed a significant part of Australia’s policy to address the medical workforce issue of geographic maldistribution to ensure that communities in rural and remote Australia have access to adequate general practice (GP) services. This policy has not been without problems, particularly in the areas of assessment of skills and qualifications, appropriate orientation and integration into Australian communities, and retention of these doctors within rural and remote communities. To date there has been little evidence-based research on the role of OTDs in the medical workforce in Australia. This study explores the service provision and quality of care provided by OTDs using the 5 Year OTD Scheme as the case study. In doing so, it assesses the adequacy of this strategy and discusses the implications for future workforce policies and programs. A mixed method design was used in the study. The quantitative component involved secondary analysis of Medicare Australia data for all OTDs participating in the 5 Year OTD Scheme in 2002 and all Australian trained doctors (ATDs) practising in rural and remote Australia in the same year. A log Poisson regression model was used to assess the interactive effect of the various GP characteristics, such as age, sex, experience and practice location with OTD/ATD status on the rate of a particular service item per patient, adjusted for patient age and sex. The qualitative component involved two focus groups with OTDs which were used to help explain the relationships between variables found in the quantitative component of the study. Template analysis was used to identify themes from the focus group. Significantly different rates per patient between OTDs and ATDS were found across most service items and GP characteristics examined. The greatest variation was found among items relating to in-surgery consultations and non-surgery consultations such as nursing home visits. Fewer differences were found between groups relating to pathology, imaging or procedural services. Analysis of surrogate quality items identified few differences between OTDs and ATDs. The focus group identified a number of other factors that influenced their patterns of service and accounted for some of the differences identified in the quantitative analysis. These factors included knowledge of the health care system in Australia, cultural and communication influences, health conditions of patients, patient and community attitudes, remuneration influences and training influences. These had varying degrees of influence on their patterns of service. The reasons for the differences found between OTDs and ATDs are partially explained by the characteristics of the GPs examined and partially explained by other external influences that relate to the particular circumstances of the OTDs, such as knowledge of the Australian health care system and cultural and communication issues. Understanding the nature of practice is central to ensuring appropriate professional support measures. The study findings highlight the need for a targeted training program for OTDs that address the areas that have the greatest influence on patterns of service to ensure that rural and remote communities receive the same quality of service from OTDs as provided by ATDs.
Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

The social phenomenon of stress and workplace burnout has spanned over five decades. Despite a plethora of literature that exists, there still remain problematic issues that neither scientific investigation or government legislation have been able to resolve. The literature examined throughout this research is extensive and does reflect this 50-year period. It demonstrates that studies into this phenomenon have attempted to define stress, identify causal factors of workplace stress, workplace burnout and environmental congruence; and discusses strategies (focused on both the individual and organizational levels) that have been implemented to effect beneficial outcomes for individuals affected by any one of these. As this thesis continues, the more recent literature gives a greater recognition to violence in the workplace and legislative enactments as preventative measures to reduce the heavy burden of costs, both physical and financial, to organizations. This extensive literature review indicates no answer to the problem has been identified to date and that this phenomenon remains, giving a clear indication that further scientific investigation is required to find a solution to what was described as the most serious health issue of the 20th century. Based on the literature examined this health issue has now gone well beyond the 20th century, giving relevance to the research study described in this thesis. The investigation is validated as vital and should be used as a basis for further research. This study undertook a collaborative social process, action research, empowering participants to identify and change stressful factors identified within their practice indicative to rural remote community mental health teams. A critical social theory arose out of the problems within the context of the research setting, based on the ideal that the significant issues for this group of individuals within this organization could be solved through the action research process. The group ‘existed’ within the issues indicative to this rural remote area, however these issues were outside their control. Through the implementation of the action research process courses of actions were undertaken that provided enlightenment in self-knowledge with dialogue heightening collective empowerment to effect change within their practice. The action research process, being a holistic process, facilitated this change in practice, developed and refined theory as it proceeded in a cyclic fashion within this local setting. It concerned actual not abstract practices in the social world in which these participants practice. This methodology facilitated examining the significant stressors identified by the Community Mental Health Support Team (CMHST) that caused distress, allowing them to implement changes in their practice. The forum provided an avenue that could reduce stressors significantly and prevent ongoing occupational stress that contributes to workplace burnout. It offered an opportunity to work with a group of participants in a nonhierarchical and non-exploitative manner and enabled members of this group to identify their roles as effective practitioners, empowering them to effect the changes they deemed as essential criteria to reduce the stress they were experiencing indicative to their remoteness. Critical reviewing throughout the data collection attempted to understand and redefine these significant issues. It aimed to acknowledge the way things were relative to how things could be improved from organizational, personal and wider community perspectives. Simple principles and guidelines of action research were followed potentiating acceptance as a rigorous research approach from a positivist perspective whilst retaining the attributes that characterise action research. There are solutions to the dilemma of the employee overcoming the debilitating effects of stress leading to workplace burnout. This includes the cooperation of managers, policy makers, academic researchers and government officials working collaboratively to reduce the impact of occupational stress. Through this collaborative process, changes can be effected to ensure the health of the nation improves and that relevant recognition is given to the fact that there is a significant threat to a healthy workforce. Examining the nursing profession from a social perspective provides alternatives to medicalising workplace injuries and illnesses.
Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

The social phenomenon of stress and workplace burnout has spanned over five decades. Despite a plethora of literature that exists, there still remain problematic issues that neither scientific investigation or government legislation have been able to resolve. The literature examined throughout this research is extensive and does reflect this 50-year period. It demonstrates that studies into this phenomenon have attempted to define stress, identify causal factors of workplace stress, workplace burnout and environmental congruence; and discusses strategies (focused on both the individual and organizational levels) that have been implemented to effect beneficial outcomes for individuals affected by any one of these. As this thesis continues, the more recent literature gives a greater recognition to violence in the workplace and legislative enactments as preventative measures to reduce the heavy burden of costs, both physical and financial, to organizations. This extensive literature review indicates no answer to the problem has been identified to date and that this phenomenon remains, giving a clear indication that further scientific investigation is required to find a solution to what was described as the most serious health issue of the 20th century. Based on the literature examined this health issue has now gone well beyond the 20th century, giving relevance to the research study described in this thesis. The investigation is validated as vital and should be used as a basis for further research. This study undertook a collaborative social process, action research, empowering participants to identify and change stressful factors identified within their practice indicative to rural remote community mental health teams. A critical social theory arose out of the problems within the context of the research setting, based on the ideal that the significant issues for this group of individuals within this organization could be solved through the action research process. The group ‘existed’ within the issues indicative to this rural remote area, however these issues were outside their control. Through the implementation of the action research process courses of actions were undertaken that provided enlightenment in self-knowledge with dialogue heightening collective empowerment to effect change within their practice. The action research process, being a holistic process, facilitated this change in practice, developed and refined theory as it proceeded in a cyclic fashion within this local setting. It concerned actual not abstract practices in the social world in which these participants practice. This methodology facilitated examining the significant stressors identified by the Community Mental Health Support Team (CMHST) that caused distress, allowing them to implement changes in their practice. The forum provided an avenue that could reduce stressors significantly and prevent ongoing occupational stress that contributes to workplace burnout. It offered an opportunity to work with a group of participants in a nonhierarchical and non-exploitative manner and enabled members of this group to identify their roles as effective practitioners, empowering them to effect the changes they deemed as essential criteria to reduce the stress they were experiencing indicative to their remoteness. Critical reviewing throughout the data collection attempted to understand and redefine these significant issues. It aimed to acknowledge the way things were relative to how things could be improved from organizational, personal and wider community perspectives. Simple principles and guidelines of action research were followed potentiating acceptance as a rigorous research approach from a positivist perspective whilst retaining the attributes that characterise action research. There are solutions to the dilemma of the employee overcoming the debilitating effects of stress leading to workplace burnout. This includes the cooperation of managers, policy makers, academic researchers and government officials working collaboratively to reduce the impact of occupational stress. Through this collaborative process, changes can be effected to ensure the health of the nation improves and that relevant recognition is given to the fact that there is a significant threat to a healthy workforce. Examining the nursing profession from a social perspective provides alternatives to medicalising workplace injuries and illnesses.
Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

The appropriate oral intake for labouring women has long been a controversial issue among midwives and anaesthetists. Anaesthetists argue that any type of food and, to some extent, fluid consumption during labour, will increase a woman’s risk of gastric content aspiration if general anaesthesia is required. Many midwives believe that aspiration, being such a rare event with contemporary medical practice, is unlikely in the hands of a skilled obstetric anaesthetist. These midwives believe that labouring without any form of sustenance other than water or clear fluids may be detrimental for the woman, her baby and the progress of labour. To date, research has been unable to provide reliable information to support either side of this debate. This thesis presents a series of studies (three surveys and a comparative trial) designed to enhance the body of knowledge available for decisions about labouring women’s oral requirements. The surveys were conducted to describe the policies of hospitals in New South Wales, Australia, and the views and practices of anaesthetists and midwives regarding the oral intake of labouring women. The main findings of this thesis come from a comparative study conducted to explore the effect of eating or not eating food on labour and birth outcomes of 217 nulliparous women with low risk pregnancies, (Eating group = 123; Non-eating group = 94). The study employed a naturalistic approach to its design in order to capture the actual eating behaviour of labouring women rather than the manipulated approach used in a randomised control trial. The findings from this series of studies suggest women should be informed of the lack of evidence to support any dietary regime for labour, along with the possible risks and benefits, and allowed to make their own decisions about their oral intake needs for labour. Although this thesis has augmented knowledge, it has been unable to demonstrate that eating food during labour improves labour and birth outcomes. However, it did not find this practice to be harmful for mothers or babies. The lack of reliable research evidence on which to base practice decreases the ability of midwives to be assured of the ‘best practice’ for labouring women’s oral intake. Further research is essential to ascertain ‘best practice’ for this aspect of care.
Doctor of Philosophy (PhD)

Statistics show that Australia has an ageing population which will experience radical changes over the next 50 years due to the progression into retirement of generations born in the ‘baby boom’ years (1945-1965). Statistics also show that the proportion of Australian people over 65 is increasing and, as the majority of deaths occur in this age group the demand for palliative care, or care of the dying, is also likely to increase. Many retiring baby boomers looking for a sea change, gravitate towards coastal and rural areas may well be contributing to Foskey’s (1998) notion of ‘Aged Care Ghettos’ where these areas may not have the desired infrastructure to deal with an increased demand for health services including palliative care services. An increasing focus on, and public interest in palliative care research will likely emerge in keeping with the changing needs of an ageing population. It will become particularly important that relevant research undertakings are initiated to establish a clearer understanding of the issues and problems surrounding palliative care. At the present time there exists a limited research base in relation to palliative care and related services in Australia. While there has been a concentration of palliative support services in urban settings this has not been the case in rural based settings. Palliative Care Australia (2000) reported that half of the people receiving palliative care in Victoria in 1997 died in rural and regional areas, which may be attributed to harsher living environments, poor access to health services, specialists, and health professionals, lower socio-economic status and employment levels, and exposure to occupational hazards. This thesis is concerned with examining palliative care services and related needs in a selected rural area within the Australian state of Victoria. The overall aim of this research was to investigate the availability of palliative care services, trends in ageing and to examine the relationship between the two. Methodology used in this research incorporated a sequential mixed methods approach of quantitative and then qualitative methodology to determine the relationship between the needs of an ageing population and rural palliative care service delivery in Australia. The data collection included demographic statistics from the Australian Bureau of Census and Statistics and Palliative Care Australia, and were used for descriptive purposes to inform and support this research. Other ordinal data were obtained using a questionnaire. These data were analysed in the context of the research. Qualitative data were obtained through interviews with focus groups. The Gippsland area provided an excellent area for this research and the findings of this research would appear to be consistent with the literature relating to access and equity issues faced in rural areas. Other rural areas may replicate the data gathering used in this research. A number of conclusions are able to be drawn from this research based on the review of literature and examination of the emerging issues, results and findings. Statistical projections into ageing indicate that the health of all Australians will have significant consequences for our society as we generally live longer and healthier lives. Health and ageing predictions and projections should prompt key stakeholders including baby boomers, the aged cohorts of the future, to plan and prepare, perhaps redefining ageing in the attempt. Findings further show that planning should include preparations for the expected rise of dementia related diseases and the implications of gender on health which will have ramifications for an ageing population, and in particular for women as carers in our society. As a result of this research recommendations are made for a model for the delivery of palliative care services in rural areas, which is specific to the needs of an ageing population. These recommendations are made in acknowledgement and with respect and consideration for the concerns of the rural community where feedback from focus group participants suggests that rather than another ‘model’, a hospice is what is needed to meet the current and future needs of rural communities. “Another ‘Model’ is the last thing we need, it’s not the how we are doing things, it’s the where – we desperately need a hospice down here” and, “It’s bricks and mortar we want down here, not more theories”. Evidence collected from this research also suggests that a ‘rural attitude’ to death and dying may prevail. In its simplest form, this attitude emerges in statements such as: ‘it’s the country you expect to get less’ and ‘we just look after our own when we can’. It is also apparent that while people in rural areas have the same medical and palliative care needs as those in metropolitan areas, this research shows that they are differentially disadvantaged when it comes to accessing palliative care services. This research has found that a negative relationship exists between ageing trends in a selected rural area of Australia chosen for this study and the availability of palliative care services.