Step 1: Workforce needs assessment
What is the problem to be addressed?
There was a high level of agreement between service managers and teams on the range of problems to be addressed in disadvantaged populations. All three AHSs were experiencing changes in demographic structures: some people moving into the area then needed to travel long distances to work; an increase in retirees; and low income residents being pushed to the edges of settlement with resultant social isolation. Lack of infrastructure including transport, employment, human services (including health services) and poor amenity in the communities were consistently mentioned as problems. Managers generally saw these communities as having the same health problems as the community as a whole but were supported by less service infrastructure. In particular, they were concerned at the lack of services to enable mandatory child protection and domestic violence reporting.
Public health units reported that while their work priorities were largely dictated by national and state imperatives, they were trying to influence the planning of new communities – with some success.
Managers reported a tension between providing child and family services and aged services for groups who were easy to reach and comparatively well-off and providing the same services for disadvantaged populations. More than one team expressed concern that identification of disadvantaged communities would lead to negative images of these communities that were often reinforced in the media.
The survey respondents identified four main problem areas: problems created by the social determinants of health (such as unemployment, crime, lack of transport); the poor health status of people in these communities; service delivery issues; and spatial and environmental issues such as poor amenity and rubbish.
What is the work that needs to be done?
Both managers and teams had difficulty in untangling the difference between the problems to be addressed and the work that needed to be done. Participants in the focus groups identified improving school retention rates, improving local amenity, community engagement and partnerships with other agencies as potential areas of work.
Survey respondents identified a different set of actions that included implementing work already identified in existing plans and priorities, use of local health data and community needs assessments, and consultation with other stakeholders (including residents). They also stated that much of their work was reactive to changes in local conditions.
All three groups of respondents primarily focused on the process for identifying the work to be done rather than details of the work itself.
What is the best way to address the issues?
Managers and teams identified comprehensive needs assessments as a key basis for intervention. These needs assessments generally were seen as involving consultation with the local community, other government departments, non-government organisations and community groups. Building trust and rapport with the local community was considered critical to successful intervention by the managers, teams and survey respondents. Managers and survey respondents also mentioned tailoring or adapting standard approaches to make them acceptable and appropriate as being important in undertaking interventions.
A range of barriers to effective implementation of interventions was also identified by managers and teams; these included the demand of health sector funding bodies for interventions that are innovative or pilots, with heavy reliance on short-term funding and limited capacity (even when the intervention was effective) to be integrated into mainstream services. Lack of time to develop and implement programs was also seen as problematic, as were different perceptions of success by different stakeholders.
A major tension mentioned by teams was balancing differences between community priorities and priorities of the health services (which were often set at state and national levels). A similar problem was identified by Ridoutt et al. in a study of the public services of a large outer metropolitan area health service .
What is the capacity of the organisation and workforce to do this work?
Managers were concerned at the difficulties in recruiting and retaining staff to work in disadvantaged communities. They spoke of new graduates working in the AHS until they had enough experience to be employed in more competitive job markets. They also noted that where the workforce had become entrenched there was resistance to new ways of working, especially in taking more proactive approaches such as home visiting or outreach services. Managers saw skill development in two ways: some spoke of the need for higher order planning, research and epidemiological skills, while others saw skill development more in terms of higher order communication skills with flexibility in responding to community needs. Debriefing of inexperienced workers and safety were seen as being areas that require attention.
The majority of teams felt that the levels of skill and experience needed to work in disadvantaged areas were higher than for other communities; new graduates expressed concern that they did not have the required skill level. Experience in working in these communities was seen as important in preventing "burn out" in staff.
Experienced staff were able to manage the stress of working with a variety of inter-sectoral partners, dealing with the service structures and other government procedures, meeting sometimes conflicting community demands and dealing with the longer timeframes needed when working with disadvantaged communities and clients.
The survey assessed the capacity of the workforce at the team level in recognition that all the skills that may be required to work effectively in disadvantaged communities may not be found in one person. Survey respondents were asked to rate their team's ability against the core functions of public health. A large proportion of respondents rated their team's ability to perform assessments or address environmental issues as 'very good' or 'excellent'. In contrast, the ability of respondents' own teams to address the needs of vulnerable groups and communities was rated as 'somewhat weak' or 'poor' by a half and a third of the respondents respectively.
Almost two-thirds of the sample believed that personal security was an issue of concern for public health workers in disadvantaged communities. Half of the survey respondents, who came from a wide range of disciplinary backgrounds, reported that they spent more than 60% of their time working on public health issues. Three-quarters of respondents reported that they spent up to 60% of their time working on health issues in specific neighbourhoods or communities or working with clients from disadvantaged backgrounds.
What workforce and organisational development is needed to do this work?
Managers – especially in rural areas – expressed concern that the high levels of annual mandatory training left them with limited budgets to provide additional training opportunities. They identified the lack of suitable training, and its cost, as preventing uptake of training in new and innovative areas. These issues were supported by teams who also mentioned the importance of mentors.
The majority of survey respondents reported that they were interested in attending public health, statistics, research, and evaluation courses over the next 1 to 3 years. Others were interested in management and leadership and train-the-trainer courses.
Key organisational development needs identified included the recruitment and retention of staff and the provision of support. Some managers felt it was time to see locational disadvantage work as "core business" and not as a series of pilot projects.
Major tables from the report are included as Additional file 1.
Step 2: Identification of workforce competencies
The skills, knowledge and attitudes needed to work effectively in disadvantaged communities were found to be both generic (e.g. the ability to work collaboratively with others is required in many domains of work) and specific (e.g. understanding the difference between contextual and compositional factors within disadvantaged communities). Most of the skills, knowledge and attitudes cited by at least two data sources were generic in nature. However, the skills, knowledge and attitudes that were specific to disadvantaged communities were often identified by only one data source and often pointed to the need to include new ways of thinking about or working in disadvantaged communities (such as monitoring the underlying determinants of health).
The identified competencies were then mapped to the competencies in the National Health Training Package (HLT07). Many of the 30 generic competencies we had identified matched 'perfectly' or 'sufficiently' to units of competency already detailed in the current Training Package; for example, 'conducting needs assessments' and 'building relationships and partnerships'. However, 10 of the 12 competencies that we identified as specific and critical to working in disadvantaged communities matched 'poorly' or 'not at all' (that is there was no suitable unit of competence) . The report of the mapping is included as Additional file 2.
The research that informed the mapping exercise was then used to develop module descriptors for a course on working in disadvantaged communities within the vocational sector. This course is planned to have three modules: identification of disadvantaged communities; assessment of those locational factors (contextual and compositional) that impact on health; and development and evaluation of interventions to improve health in disadvantaged communities (see Appendix 1).