The Individual, Health and Society: SWK 4420 Associate Professor Rosemary Sheehan & Dr Ralph Hampson Subject enquiri

1. The Individual, Health and Society: SWK 4420 Associate Professor Rosemary Sheehan & Dr Ralph Hampson Subject enquiries: rosemary.sheehan@med.monash.edu.au ralph.hampson@med.monash.edu.au

2. Workshop timetable

3. SWK 4420 The Individual, Health and Society - Texts Grbich, Carol (Ed) (2004) Health in Australia : sociological concepts and issues(3rd ed.), Prentice Hall. Pritchard, Colin (2005) Mental Health Social Work [electronic resource] London : Routledge. Available via World Wide Web - access via Monash library (internet resource).  Unit guide refers to: Meadows, Graham and Singh, Bruce (Eds) (2006) Mental health in Australia : collaborative community practice (2nd ed.) Oxford University Press, Melbourne. Bloch, S and Singh, B (2006) Foundations of Clinical Psychiatry(2nd ed) Melbourne University Press, Melbourne

4. Recommended supplementary reading: Alston, M and McKinnon, J (Eds) (2005) Social Work: Fields of Practice - Second Edition. Oxford University Press, Melbourne - It provides a detailed analysis of social work practice.

5. Context • Shift over time from public health issues which were the concerns of the late 19th, early 20th Centuries. • Health is a major focus of Government policy • Evidence that ill health is closely linked to low income, unemployment, poor housing. • Health system can be a safety net and/or it can operate as a preventive/health promotion project. • Late 20th Century emphasis on: equity, access, equality and participation • Increasing focus on consumer involvement.

6. Principal feature of the Australian health care system • A private, for profit component (GPs, pharmacists, dentists, private hospitals, private specialists and alternative practitioners) • A public component (community health centres, maternal and child health, mental health, hospital, HACC) • A non-government, not-for-profit (FPA, welfare services) • A domestic component – carers at home (Adapted from Owen and Lennie, 1992)

7. Australian HealthCare System • Medibank – Whitlam Government 1970s • Community Health Program – 1973 • Medicare levy – 1.25% levy 1984 • More recently -Increased focus on private health insurance after a drop off in the number of people taking out primary health insurance • Introduction of the private health insurance rebate by the Howard Liberal Government.

8. Key health policies and programs • Commonwealth National Health Act (1953) – universal health insurance scheme & creation of the Pharmaceutical Benefits Scheme • Medibank 1975/Medicare 1984 • Council of Australian Governments (1995)

9. Key health policies and programs – community health • Community health program 1973 • Local community involvement • Deinstitutionalisation • 1980 Community health became a state responsibility • Is it marginal to the ‘main game’?

10. National Health Strategy 1990s • Needs of populations • Inequality • Efficiency • Cost effectiveness • Public engagement in debate • Rights and responsibilities

11. Health Policy • Universal access to basic health care • Services should be of a high quality • Financing of health care should be equitable • Services are delivered through a mix of public and private system • Accountability and efficiency

12. PRIMARY SERVICES General Practice (usually in Private Practice) and Primary Health – Allied Health and Community Health SECONDARY SERVICES General Hospital Care - Private and Public Specialist Services TERTIARY SERVICES Specialist Services e.g. nursing homes, transplant services, mental health Levels of Service Delivery

13. Primary health care • Multidisciplinary in nature • Based community needs • Integration of health, welfare, private, public, not for profit – a partnership approach – tensions can emerge • Social context • Data traditionally not collected in a consistent manner

14. Funding • 2004–05, the majority of spending in health was funded by governments (68.2%) • Australian Government contributing $39.8 billion (45.6%) • State, Territory and local governments contributing $19.8 billion (22.6%) • Non-government sector funded the remaining $27.7 billion (31.8%)

16. Challenges facing Health Services • Private and publicmix • Prevention, early intervention and treatment • Pressure Medicare /PBS -costs • Bulk billing declining • Tensions between State and Federal Governments • Ageing of the population • Infrastructure/Technology • shorter admissions, high costs, emphasis on throughput • Power of hospitals – can they become self serving organizations • Dental health services

17. What changes to health care services have you noticed in your area in the past five years?

18. What factors have brought about these changes? • Concern about increasing costs • Clinical Governance, risk and safety issues • Demographic changes • Public/Private split • Increasing consumer expectations • Legal issues and medical insurance

19. What is health? Health is shaped by: • Attitudes, beliefs and values • Sex, age, religion and socio-cultural groupings • History, knowledge and dominant understandings about health and illness • Professional versus consumer experiences

20. Definitions of Health • World Health Organization (WHO): “a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity.” • Bircher: “a dynamic state of well-being characterized by a physical and mental potential, which satisfies the demands of life commensurate with age, culture, and personal responsibility.” • Saracchi: “a condition of well being, free of disease or infirmity, and a basic and universal human right.” • Australian Aboriginal people: “…Health does not just mean the physical well-being of the individual but refers to the social, emotional, spiritual and cultural well-being of the whole community.” This is a whole of life view and includes the cyclical concept of life-death-life. http://www.who.int/bulletin/bulletin_board/83/ustun11051/en/

21. WHO definition of ‘Health’ – critical appraisal • WHO definition of health is utopian,inflexible, and unrealistic, and that including the word “complete” in the definition makes it highly unlikely that anyone would be healthy for a reasonable period of time • ‘a state of complete physical mental and social well-being’ corresponds more to happiness than to health • words ‘health’ and ‘happiness’ designate distinct life experiences, whose relationship is neither fixed nor constant • Failure to distinguish happiness from health implies that any disturbance in happiness, however minimal, may come to be perceived as a health problem. http://www.who.int/bulletin/bulletin_board/83/ustun11051/en/

22. Assumptions about health and illness • People can choose to be sick or well? • Encouraged to express ‘dis-ease’ through the physical • Changes over time: childbirth, children’s hospitals, homosexuality, sexual abuse, mental illness

23. Sociology of health Sociological lens – • social patterns – age, sex, race, class, culture, geography, community profiles • processes – interest groups, beliefs and history • social relationships – power

24. Risk factors • Diet • Environment • Occupational health • Stress • Unemployment • Poverty

25. Role of social work • Interrelationship between health and human functioning • Individuals, families, groups and communities can have health concerns • Social workers are both professionals and consumers of health services

26. Social Workers bring to Health • Systemic thinking • Political awareness and critical thinking • Ethics • Practice skills – assessments and interventions • Human development • Social theory • Macro and micro awareness • Passion and idealism

27. Typical Health seeking • First port of call is the GP • Beliefs, gender, family history, tolerance of pain e.g. men, pap smears • Language/Culture • Labeling of illness – blame and sympathy

28. What does this mean for social work? • Health is political • Social workers are part of the system and ‘outside’ it at the same time • Resources, access and information • Social activist and/or ‘keeper of the peace’.

29. History - Social Work • 1905 Massachusetts General Hospital • Australia – growth in the health field – Hospital Almoners • Understanding our history - is this important? • Psychosocial approach • Family domestic and social situations • Complying with medical treatment • Hospital and the wider community • Home visits – a lost art perhaps?

30. 1960s • Influence of psychoanalytic traditions • Social investigation • Diagnosis and treatment • Caseworker, therapist – splits in the profession • Genericism versus Specialism 1970s • Civil Rights movement • Feminism • Rights movements • Anti-psychiatry – encounter groups, humanism • “Radical social work” – structuralism • Community health • Community development 1990s • Targeted benefits • Economic rationalism • Effectiveness • Evidence based practice • Accountability • Competition

31. Theoretical frameworks • Bio-psycho-social • Psycho-analytical • Ego psychology • Systems theory • Behaviourism • Feminist • Strengths based • Solution focused • Others?

32. Issues and Practice • Shorter length of stay • Family support • Short term nature – crisis • Discharge planning – ‘bed blockers’ • Person in ‘environment’ • Counselling • Advocacy • Community linkages • Financial, accommodation, benefits • Team work

33. Crisis intervention Constructive Relative homeostasis Destructive

34. Group Work • Bereavement Service – Royal Children’s Hospital • Stroke Support Group • Incest survivors group • Children of parents with a mental illness • Parenting skills • Siblings of children with cancer • Transplant Support

35. MultidisciplinaryInterdisciplinary • Allied health profession • Ownership of the patient • Sharing of roles • Emergence of case management • Sharing of roles with others • Negotiating boundaries and roles

36. Allied Health Psychology ? Taken from Austin Health promotion – The Well Wisher Olivia Newton John Cancer Center Appeal Spring 2007

37. Rural & remote – challenges • Being a member of the same community • Dual and multiple roles • Lack of anonymity • Confidentiality and privacy • Personal safety • Supervision and debriefing

38. Advanced Multi-Systemic Approach (AMS) • Biological Dimension – the ‘mind-body’ connection • Psychological/Emotional Dimension • Family Dimension • Religious/Spiritual/Experiential Dimension • Social Environmental – community, culture, class, social/relational, legal history, community resources • Macro dimension – e.g. policies, legislation, oppression, poverty, homophobia, sexism [Ref: Johnson, L J; Grant, G (2005) Medical Social Work Pearson, New York]

39. Case examples • Mark, a baby, is born with spina bifida. You have been asked to work with the parents re: the diagnosis. • What are some of the areas you may cover in your work with the family? • Mrs Smith comes into hospital has a diagnosis of cancer which will require radiation and chemotherapy • Referred to social work as she is depressed and does not want to have treatment, says “she would rather die.” • What would you do?

40. Meaning of health and illness • People experience illness differently • Lens’ – for example • Culture • Class • Gender • Age • Sexuality

41. Immigration (Gbrich,2004) • Immigration program post WW2 • Waves of immigrants: • Britain and Northern Europe • Southern Europe • 1973 White Australia Policy abandoned • Asia • Skilled migration/Family • Refugees – Humanitarian • Assimilation • Multiculturalism • Cultural Pluralism

42. Overseas Born Health Status (AIHW, 2006) • Australia has one of the largest proportions of immigrant populations in the world • 24% of the total population (4.75 million people) in 2004 estimated to have been born overseas • More than half of these—one in eight Australians—were born in a non-English-speaking country • Research has found that most migrants enjoy health that is at least as good, if not better, than that of the Australian-born population. • Immigrant populations often have lower death and hospitalisation rates, as well as lower rates of disability and lifestyle-related risk factors (Ref: AIHW: Singh & de Looper 2002)

43. ‘healthy migrant effect’ (AIHW, 2006) Believed to result from two main factors: • a self-selection process which includes persons who are willing and economically able to migrate and excludes those who are sick or disabled; and a • government selection process which involves certain eligibility criteria based on health, education, language and job skills (Hyman, 2001) but • As length of residence in a destination country increases, the health status of immigrants—as gauged by health behaviours and by morbidity and death rates—tends to converge towards that of the native-born population.

44. Refugee Health • Refugees, asylum seekers and detainees share similar life experiences • Experience higher rates of unemployment and welfare dependency than other migrants • Health and trauma – imprisonment, sexual assault, torture • Witnessing of death in refugee camps – disease etc • Loss and Grief • Understanding health within a global framework • Holistic approach to health • Social capital and well being • Preventing disease, promoting health and prolonging life • Shift away from ‘othering’ of the migrant • Paradigm shift? New perspectives on migrant and refugee health (Gbrich, 2004:119)

45. Gender & Health (Gbrich, 2004, Ch6) • Life Expectancy – women have outpaced men but gap is narrowing • 1920-22 Male 59.1:Female 63.3 • 1950-62 Male 67.9:Female 74.1 • 2000 Male 76.6:Female 82.1 • Why do men die younger? • Violent behaviour • Aggression • Excessive alcohol use • Dangerous driving • Smoking • Quality of relationships

46. Gender & Health (Gbrich, 2004, Ch 6) • Social Model of Health • Holistic approach • Health Service Utilisation: • Women access health services more than men • Women’s health issues associated with reproduction • Medicalisation of women’s health • Men’s health – legal problems, being a lad – growth in the issue of men’s health

47. Explaining gender differences • Fixed roles and expectations – mediated by age and responsibilities – dual responsibilities of women and increased burden • Sex role socialisation • masculinity and femininity – stoicism of men, women more likely to report medical – no evidence • Clinician bias • Critical and feminist theory • ‘messiness’ of women’s health Blinkers – what are some you can think of?

48. Social Class • Class analysis – social conflict – used to explain social health inequalities • Social stratification – focuses on social consensus – used to describe social health inequalities using socioeconomic status • Consistent pattern – death rates go up as socio-economic status goes down • Physical, psychological and social dimensions of illness all show that illness rates go up as socioeconomic status goes down (Smoking? [The Age, 190209]) • Conflict Theory – the physical work environment and the way work is organised lead to higher levels of illness for working class • Consensus – it’s not what they do at work – it’s what they do outside of work that causes the problems – consumption/risk taking

49. Indigenous health … DVD – Bringing Them Home

50. Trauma Trauma refers to situations where a person is confronted with situations that exceed and overwhelm their coping capacity. These situations threaten the physical and psychological integrity of the person and cause an intense reaction of horror. Typically there is a significant impact on at least immediate functioning, if not long term, involving distress and disturbance and, for some, disorder. Harms,L (2005) Understanding Human Development: A Multidisciplinary Approach, OUP, 146