Social determinants of health

In the past 10–20 years there has been increasing interest in the relationship between spirituality and health. I interviewed six patients from community mental health centres, using a phenomenological approach to explore how concepts of spirituality, occupation and mental illness/mental health are related. One person’s story is presented to illustrate the issues. Four main themes were identified: Spirituality is a phenomenon that provides meaning to life. Spirituality can help a person cope with mental illness. Spiritual beliefs can make everyday occupations more meaningful and health-enhancing. Some people find it valuable to engage in shared occupations that focus on spirituality. Spirituality is an important and relevant issue to be discussed between patients and health practitioners, provided that practitioners can exercise sensitivity, caution, tolerance and acceptance of values that may differ from their own.

Clare Wilding BAppSc(OT), MAppSc(OT)

There is evidence that Australia is not meeting its obligations to Aboriginal and Torres Strait Islander peoples for their right to the “highest attainable standard” of health, required under the International Covenant on Economic, Social and Cultural Rights (ICESCR). Poor access to primary health care for Aboriginal peoples and substantial shortfalls in government spending to address this are in violation of the ICESCR. Aboriginal and Torres Strait Islander peoples’ share of the universal health coverage expenditure offered to all Australians is less per person than for other Australians. The failure to monitor the provision of mainstream health services to Aboriginal peoples and inequitable distribution of health facilities and services compound these violations. Equality in health between Indigenous and non-Indigenous Australians is achievable, but not until the shortfall in health services expenditure for Indigenous Australians is addressed.

Sophie Couzos FRACGP, FACRRM, FAFPHM · Dea Delaney Thiele PGDipHlthMgt

Providing spiritual care is about tapping into the concept of spirituality: core meaning, deepest life meaning, hope and connectedness. The search for meaning, connectedness and hope becomes more significant as older people are faced with the possibilities of frailty, disability and dementia. Spirituality, ageing and meaning in life can be discussed in the context of an alternative view of “successful ageing”. A model of spiritual tasks in older age can help explain the spiritual dimension and provide a starting point for spiritual assessment.

Elizabeth B MacKinlay PhD · Corinne Trevitt RN, MN, GradDipGerontics

Objective: To identify the prevalence of mental health problems, rates of suicidal ideation and behaviour, and use of professional mental health services among children and adolescents residing in home-based foster care, and to compare these rates with those reported for children and adolescents in the general Australian community.Design: Cross-sectional survey.Participants and setting: 326 children and adolescents (aged 6–17 years) residing in home-based foster care in the Adelaide metropolitan region between August 2004 and January 2006.Main outcome measures: Prevalence of emotional and behavioural problems, suicidal ideation and behaviour, and use of professional services to obtain help for emotional and behavioural problems.Results: 61.0% of children and adolescents living in home-based foster care scored above the recommended cut-off for behaviour problems on the Child Behavior Checklist and 35.2% of adolescents scored above the cut-off on the Youth Self Report. 6.7% of 13–17- year olds in home-based foster care reported a suicide attempt that required medical treatment during the previous year. Caregivers reported that 53.4% of children needed professional help for their mental health problems but only 26.9% had obtained help during the previous 6 months.Conclusion: Children in home-based foster care experience high rates of mental health problems but only a minority receive professional help for their problems.

Michael G Sawyer PhD, FRCPC, FRANZCP · Josephine A Carbone BA(Hons) · Amelia K Searle BPsych(Hons) · Philip Robinson PSM, DipAppPsych, MPsych

Objective: To identify whether the rate and average daily dose of stimulant prescribed for attention deficit hyperactivity disorder (ADHD) in Western Australia differed according to the geographical remoteness and socioeconomic status of the patient.Design and data sources: Secondary analysis of population-based administrative pharmacy data from 2004, stratified by the Accessibility/Remoteness Index of Australia (ARIA+) categories and the Index of Relative Socio-Economic Disadvantage (IRSD) quintiles for WA (2001 Census).Outcome measures: Rate ratios of stimulant prescription and mean average daily dose (in dex-equivalents) stratified by age (2–17, 18+ years), sex, ARIA+ category and IRSD quintile.Results: The rate of stimulant prescription was 2.3 to 5.3 times greater in major cities in WA compared with remote and very remote parts of the state. The association between socioeconomic disadvantage and the rate of stimulant prescription was highly variable. Adults with the least socioeconomic disadvantage were significantly more likely to receive stimulants compared with their most disadvantaged counterparts; however, the reverse association was seen with children. The average daily dose of stimulant prescribed did not vary greatly across remoteness or socioeconomic categories.Conclusion: Remoteness and socioeconomic disadvantage are significantly associated with rate of stimulant prescription for ADHD in WA, but not associated with average daily dose of stimulant prescribed. Further research is needed to understand why considerable variation exists in the use of prescribed stimulants for ADHD.

Janine Calver PhD · David Preen PhD · Max Bulsara MSc · Frank Sanfilippo PhD

To the Editor: An important factor in the well documented shortfall of organs and eyes for transplantation is the apparent reluctance of people to agree to donate.1 One nearly universal strategy in attempting to raise donation rates has been to encourage individuals to register their wishes about donation. Although evidence that this strategy increases donation rates is lacking, there is some evidence that more individuals make and communicate a decision with appropriate education.2 Most families consent to donation when the deceased had indicated this was their wish, and virtually none override a stated wish not to donate.3 When wishes are unknown, half of families consent and half refuse.3 Encouraging declaration of intention aims to increase the rate of consent for families who would otherwise not know the deceased individual’s wishes. For this to be successful, most individuals newly recording their wishes must indicate a desire to donate. This assumption has underpinned Australian education campaigns, including “Talk about it”, “Share your life, share your decision”, and most recently the national “Sign on to save a life” campaign.4 A simple review of New South Wales Roads and Traffic Authority organ donation data over the period of these campaigns suggests this assumption may not hold. From 1997 to 2004, a significant proportion of drivers licence holders newly indicated a preference about donation; the proportion indicating some decision rose from 59.4% to 78.6%. Over the same period, the proportion indicating yes to donation of all organs rose from 35.6% to 41.9% (a 17.7% increase); however, the proportion indicating no to any donation rose from 19.9% to 31.4% (a 57.8% increase).5 These results raise the possibility that encouraging individuals to make a decision about donation may increase the number of families who refuse donation. Individuals who had previously not made a decision about donation, when encouraged to do so, displayed an unwillingness to become organ donors at twice the rate of those who indicated willingness. Although it is imperative to recognise and respect the decision of individuals to refuse organ donation, this unwillingness may reflect either formalisation of a considered desire not to donate, or a decision made without personal discussion of fears and concerns about donation. Generalised education campaigns are limited in that they encourage action without addressing fears and concerns. Further policy should recognise a possible danger in simply exhorting the public to make a decision, and research should investigate why individuals are refusing to become organ and eye donors.

Mitchell Lawlor · Frank A Billson

To the Editor: We read with interest the article by Couper et al on the psychosocial impact of prostate cancer (PCA) on patients and their female partners.1 We agree that involvement of partners in the research pro-cess is pivotal to understanding the relational dimension of how PCA is both understood and approached by men and their partners.2 However, this could be extended to consider the unique experiences of gay men diagnosed with PCA and their partners. Heteronormative viewpoints are commonplace in PCA research. This bias is unfortunate, as there is a 28% possibility that one of the men in a gay relationship will develop PCA over the course of his lifetime.3 While it is probable that gay men and their partners have some of the same concerns regarding PCA as heterosexual couples, there are also unique concerns that are specific to gay men and their partners. Such considerations may include (but are not limited to): the prostate gland as a site of sexual pleasure and the associated implications of being able to engage in penetrative anal sex after prostate surgery;4 homophobia and/or disregard for sexuality within the health care system5 when being diagnosed with and treated for PCA; and the impact of polygamous (open) relationships and the ambiguous position of gay partners having to care for their mates.4 At this stage, the above concerns are purely speculative, as there is a paucity of literature on gay men and PCA.4,6 We believe future research on the psychosocial impacts of PCA should consider the experiences and special concerns of gay men with PCA, as well as those of their partners.

James A Smith · Shaun M Filiault · Murray J Drummond · Robert J Knapman

In reply: We thank Smith et al for their acknowledgement of the importance of the relational dimension to understanding how prostate cancer (PCA) is understood and approached by men and their partners. The psychosocial implications of prostate cancer for same-sex couples are important and need specific investigation. However, there are methodological difficulties in attempting to quantify the impact of PCA on same-sex couples and in comparing their experience with other couples. In our review of the literature,1 we discovered that where previous researchers had included same-sex partners in their studies, insufficient numbers were recruited for meaningful quantitative statistical comparisons. For example, Perez and colleagues,2 Neese and colleagues3 and Davison and colleagues4 each recruited only one same-sex couple into their studies of 134, 164 and 74 couples, respectively. We believe that a qualitative approach is needed, specifically seeking out and examining the experiences of a group of same-sex couples and comparing and contrasting their experiences with those of a group of male–female couples. This is an approach we are considering in future studies to help us develop and refine an effective but broadly applicable couple-focused psychosocial intervention for PCA.

Jeremy W Couper

Objective: To report on perceptions about the risk of infectious diseases from new arrivals to Australia arising from a wider study of mothers’ attitudes to childhood vaccination.Design, participants and setting: Six focus groups on perceptions about the benefits and risks of vaccination with 37 mothers of children aged 5 weeks to 18 years, mostly conducted in middle-class areas of Sydney between 6 October and 15 December 1999.Main outcome measures: Mothers’ views about infectious disease risk posed by immigration as a major reason to favour immunising children.Results: The idea of immigration being the primary source of infectious diseases was striking, and arose among a number of participants in every group conversation. Mothers expressed their dread of new diseases “from overseas”, and a sense that there are “more germs nowadays”, mostly from increased immigration to Australia and international travel. Some perceived people coming from other countries as having more disease because of an innate susceptibility or through cultural practices.Conclusion: Recent media coverage about infectious diseases importation by African refugees not only feeds, but reflects, community concerns about new arrivals as a source of allegedly rampant infection threatening Australians. These concerns have little evidence base. Public health advocates need to be proactive with the media to provide sophisticated counter-messages that expose the underlying subtexts and educate the community about the true risks of infectious diseases.

Julie Leask PhD, MPH, DipAppSci · Mohamud Sheikh-Mohammed MIPH, MHSc, DipMedLabSci · C Raina MacIntyre FRACP, FAFPHM, PhD · Alexander Leask MPH, DipAppEpi, BAgSci · Nicholas J Wood MB BS, FRACP

The past is another country: they do things differently there. Hartley LP. The go-between1 One indulgence accorded to those of us in our senior years is the ability to reflect on life’s circumstances many decades ago and compare them with those of today. My recollections of medical practice, as the son of a surgeon, stretch back to my schooldays. A lasting memory is of the many gifts, the so-called “grateful patients”. Glassware, silverware, bowls, paintings and books were the permanent items; flowers, Scotch and home-made delicacies the temporary ones. These often came from patients who had paid my father’s full fees, but more often from people for whom he had reduced his fees (generally people he considered to be impoverished) or whom he didn’t charge at all (mostly friends, ministers of all religions, colleagues and medical students). I remember other courtesies. He would never see patients who lacked a detailed letter from their general practitioner, and his replies were equally detailed, often complemented by a telephone call. Asked for a second opinion, he gave it to the patient and the GP and allowed them to decide whether surgery should be done by the first surgeon consulted or by himself. He was available, day and night, to advise GPs baffled by obscure clinical presentations. If asked, he would accompany a GP to a patient’s home. This joint visit had formal rules, including rules about who entered the room first and who exited last. When surgery was needed, he invited the GP to assist. His reputation relied on the success of his surgical interventions and on the opinions of the GPs who saw his work at close quarters. Those were the 1940s and 50s: a long time ago. What would my father have made of today’s intraprofessional relations? I doubt that he would even have understood commercialism, mercantilism (including advertising and self-promotion) and competition policy. Even if he had, would he have thought that they could ever apply to the practice of medicine? Sir Robert Menzies, born a decade or so before my father, commented about the universities in language my father would have applied to medicine: Are the universities mere technical schools, or have they as one of their functions the preservation of pure learning, bringing in its train not merely riches for the imagination but a comparative sense for the mind, and leading to what we need so badly — the recognition of values which are other than pecuniary?2 (my emphasis) Today, Australian doctors jealously hold onto their patients. Many GPs will not share an after-hours roster because they are worried that their colleagues might poach their patients. GPs no longer phone a patient’s former GP to let him or her know that the patient is now attending their practice and to obtain information that could be useful in the patient’s future care. GPs no longer write comprehensive referral letters to consultants. Today, letters of referral are notoriously inadequate.3 Specialist physicians now often arrange to manage referred patients on a regular basis, without sending them back to the referring GP for follow-up. The next time the GP sees the patient is when the patient asks for a new referral to the physician in question, who is now the patient’s specialist — no longer the GP’s consultant — and is, of course, not available after hours. Specialists now rarely refer patients back to their GP with the advice that they see another physician with a special interest in their problem, instead referring them directly — leaving the GP out of the loop. The explosion of knowledge in each field means that care is more “expert”, with more assured results, than in my father’s day. But it comes at a cost. If the patient’s condition worsens after-hours, the GP has to manage without feedback from the specialists. Where once we could discuss with our pathologist or radiologist colleagues just which tests or studies should be done on a particular patient, now the briefest of request forms, containing minimal clinical information, suffices for the laboratory technician or radiographer to perform the requested investigations and for the pathologist or radiologist to interpret the results. When we doctors attend a multi-doctor practice as patients, we will often be seen by a doctor we don’t know, who is not aware that we are colleagues. Even if the request form is marked Dr rather than Mr or Ms, we become just another first name called out by the nurse or radiographer. With billing now separated from the delivery of the service, we are frequently charged fees. Many doctors now charge their colleagues not just the Medicare rebate, or even the Medicare schedule fee, but their full, private fee. Why have things changed so much? Politicians after Menzies have persuaded the public — our patients — that medical services are like any other commodity. Each service has a government-designated value. Competition policy applies to the medical practitioner as much as to the television repair man or motor mechanic. Advertising and marketing are commonplace. Many doctors no longer own their practices, but are employed by profit-seeking enterprises beholden to shareholders. What once were thought of as being reasonable professional fees to cover a doctor’s training, skills, experience and equipment are now commercial fees expected to deliver a healthy profit to remote shareholders. Universal medical insurance (Medibank/Medicare) began the pro-cess. Once we all had to pay our levy and were “covered” for medical expenses, we began to insist on passing the rebate on to our colleagues for their formerly free medical services. This also relieved us of the burden of having to deliver a “grateful patient” at Christmas or on some other suitable occasion. It was not too difficult to persuade our treating practitioner to bill us for the rebate. Practice costs have also risen incommensurably with Medicare rebates. Increasing demands such as standards in occupational health and safety, sterilisation procedures, building and fire regulations, management of patient records, confidentiality procedures, and responsibility for following up on advice to patients are all worthy in themselves, but have combined to create an intolerable financial burden for solo practitioners and small group practices. The expensive practice manager has become an essential. Flourishing malpractice litigation has resulted in “procedural” GPs and some specialists having to charge much higher fees than those rebated by Medicare, and patients, even if they are colleagues, must bear the financial cost. There are those who say that doctors should be treated no differently from other patients. This might stem from a loathing of privilege of any sort (what the Russians call protektzia) or a reluctance to place additional pressure on treating doctors by burdening them with the knowledge that they are treating a colleague. Doctors, we know, make poor patients; furthermore, one interpretation of Murphy’s Law states that, if something might go wrong, it will go wrong when the patient is a doctor! In the United States, some legal experts even contend that it is illegal for doctors to reduce their fees for colleagues.4,5 With the commercialisation of medical practice, many of the courtesies formerly extended between colleagues have disappeared. The remaining septuagenarians might regret these changes, but that is of little practical moment. What does matter is what now confronts Australian patients seeking care from GPs and appropriately recommended specialists. In theory, Australia has one of the world’s highest standards of care in our “centres of excellence”. But the reality for most Australians, even for many of the minority with private health insurance, is based on a changed ethic. Financial self-interest has come to all but dominate medical practice, even inside hospitals, where it once played no role. Cui bono?* Not the patient’s. * For whose benefit? It is no longer “worth it” for GPs to do house calls or visits to nursing homes, to assist at their patients’ operations or to be available after hours. It is no longer worth it for GPs to acquire a diploma in a special field of interest: patients insist on attending a registered specialist. It is no longer worth it for GPs to spend time phoning specialists to discuss their patients’ problems. Cui bono? Not the patient’s. It is in the interests of specialists to offer continuing care to patients rather than to refer them back to their GPs. It is in the interests of specialists to refer patients to other specialists, bypassing the referring GP. This sets up a new pattern of inter-specialist referrals that, in turn, benefits all specialists, leaving the GP out of the management loop. Cui bono? Not the patient’s. It is in the interests of hospital-based specialists to have patients opting to be admitted as private patients, enabling them to raise fees for their services. It is in the interests of hospital management to have this additional source of income. Cui bono? Not the patient’s. The professional courtesies of the 1940s and 50s might seem old-fashioned today. But if, back in those days, we had asked my father, “Cui bono?”, he would have had no hesitation in replying “The patient’s!”

Peter C Arnold BSc, MB BCh, BA

To the Editor: A young man, a minor when sentenced in Sydney, was diagnosed with lymphoma soon after incarceration. Appropriate treatment was initiated, including pretreatment collection and storage of his semen. A local newspaper report that his sperm was collected and stored at taxpayers’ expense prompted outrage in some sections of the community. In response, the New South Wales Government drafted the Corrective Services Legislation Amendment Bill 2006, which would make it a crime for an individual imprisoned or awaiting sentencing for a “serious indictable offence”, such as homicide, rape or terrorism to store “reproductive material” (semen or ova).1 It is routine (many would say mandatory) for men of reproductive age who are about to undergo therapy for cancer to be offered the option to store semen. Without this option, male cancer survivors might be unable to father their own offspring. There is no current routine technology for storing unfertilised ova. In current practice for male prisoners, semen is stored before commencing treatment for cancers or similar conditions that may induce temporary or permanent infertility. This is the accepted standard of care, offered before such treatment to men who may not have completed their families. It is not current practice in NSW to store prisoners’ semen in any other circumstances. The proposed Bill will discriminate against prisoners in the quality and costs of their health care. Members of our community who require chemotherapy for cancer are offered collection and storage of their semen, provided free of charge by several public services in NSW. Under the proposed Bill, prisoners are required to pay storage fees during their imprisonment, even if their sperm were placed in storage before their incarceration. Discriminating against certain prisoners by demanding payment for otherwise free services could be seen as a “cruel and unusual punishment”. The NSW Legislative Assembly passed the Bill on 25 May 2006. Medical, legal and human rights organisations, and individuals expressed concern to parliamentarians. In the Legislative Council on 7 June 2006, a majority vote referred the Bill to the General Purposes Standing Committee No. 3. This Committee has received submissions and will provide recommendations as to how the Bill should proceed. If passed into law, the Bill would breach the principle of equivalence of health care for prisoners. The Australian Medical Association position statement on the Health care of prisoners and detainees states: “The duty of medical practitioners to treat all patients professionally with respect for their human dignity and privacy applies equally to the care of those detained in prison, whether convicted or on remand, irrespective of the reason for their incarceration.”2 I argue that the Bill implies an intention to rid society of “criminal seed” and begins a move towards eugenics. If our society really accepts the idea that inmates of correctional facilities may one day return to a full and productive life, then it is unreasonable to deny them the possibility of having their own children because they developed a serious cancer. If this legislation is passed, a discriminatory practice of medicine according to convict status will be enshrined in NSW law.

John E J Rasko

Stem cells. Controversy at the frontiers of science. Elizabeth Finkel. Sydney: ABC Books, 2005 (vi + 282 pp). ISBN 0 7333 1248 9. There has been no more controversial area in medical science in recent years than the discovery that embryonic and adult stem cells have the potential to generate a range of different tissues, possibly even organ repair and regeneration. As the field has evolved at a blistering pace, several important strands can be discerned. Firstly, the science, while complex, is of great interest to the lay reader. For the public to adequately understand and appraise the importance and potential of these new developments, it is crucial that the current state of scientific development be explained in readily understandable terms. Secondly, the area of stem cell therapy, especially embryonic stem cells and their development, raises many complex ethical issues divisive in our society. Thirdly, Australian scientists have played a major role both in the development of in-vitro fertilisation, the precursor to the embryonic stem cell age, and in the development of embryonic and adult stem cells as potential treatments of the future. Elizabeth Finkel, a distinguished science journalist with a strong background in embryology, has written an intriguing account of the stem cell story. She has brought together all three strands into a very readable account of the field. On one level, for those interested in human stories in science, this is a very good read with great human achievement and political drama. It is also one of the best accounts of the scientific achievements with stem cells to date and of the basis for arising ethical issues. Finkel makes no secret that she is an enthusiast for developing stem cell science as a viable treatment, with both embryonic and adult stem cell research. In some of the examples she covers, most notably Parkinson’s disease, she may overstate the current state of success of stem cell therapies just a little, but does so in an attempt to give a balanced story. One of her key conclusions, that scientific facts must be presented and discussed dispassionately, and that ethical considerations and viewpoints should not be allowed to bias interpretation and presentation of the science to the general public, is a pivotal one in all aspects of science. Stem cell therapy, whether derived from embryonic or adult stem cells, has a great way to go before we will know for sure whether it will be a viable treatment in a major sense for human illness. Elizabeth Finkel’s book makes clear that it is an area of very considerable promise, and I commend this riveting account to all who have an interest in the area. Edward ByrneDean of Medicine, Nursing and Health Sciences, Monash University, VIC Competing interests: Professor Byrne is the current Dean of Medicine at Monash University, where much of the stem cell work in this book was carried out. “Stem cells” won the Science Writer’s Award in the 2005 Queensland Premier’s Literary Awards

Edward Byrne

Objective: To identify sociodemographic factors associated with help-seeking behaviour for reproductive health disorders in middle-aged and older Australian men.Design: A cross-sectional, population-based, computer-assisted telephone interview exploring sociodemographic factors and general and reproductive health.Participants and setting: Analysis of data from the Men in Australia Telephone Survey (MATeS) of 5990 Australian men aged 40 years and older interviewed between September and December 2003.Main outcome measures: Self-reported diagnosis of prostate disease and erectile dysfunction (ED), help-seeking behaviour (including visiting a doctor, prostate-specific antigen testing, treatment of prostate disease, speaking to a health professional about ED and treatment of ED).Results: Age was a significant predictor of all help-seeking behaviour studied, other than treatment for ED. Controlling for all predictor variables, never-married status predicted a lower likelihood of visiting a doctor (odds ratio [OR], 0.68 [95% CI, 0.48–0.97]) or speaking to a health professional about ED (OR, 0.44 [95% CI, 0.21–0.93]), while divorced/separated status predicted lower likelihood of having a prostate-specific antigen test (OR, 0.63 [95% CI, 0.50–0.79]). Living in a regional or remote area or being from a non-English-speaking background predicted lower likelihood of receiving treatment for ED (ORs, 0.62 [95% CI, 0.42–0.92] and 0.41 [95% CI, 0.24–0.72], respectively), but did not influence screening for prostate disease.Conclusion: Seeking advice or treatment for male reproductive health disorders is predicted by sociodemographic factors specific to different reproductive health problems. As middle-aged and older men do attend doctors, opportunities exist for health professionals to optimise their consultations by routinely discussing reproductive health with all men, to identify under-reported male reproductive health disorders.

Carol A Holden PhD · Damien J Jolley MSc(Epidemiol), AStat · Robert I McLachlan MB BS, PhD · Marian Pitts PhD · Robert Cumming PhD · Gary Wittert MB BCh, PhD · David J Handelsman MB BS, PhD · David M de Kretser MB BS, PhD

Objective: To assess the psychosocial impact of the diagnosis of either localised or metastatic prostate cancer (PCA) on patients and their female partners.Design: Observational, prospective study at Time 1 and 6 months later at Time 2 of two groups of couples facing PCA. Time 1 was when patients were first diagnosed with histologically confirmed localised (potentially curable) PCA or metastatic (incurable) PCA.Main outcome measures: Depression and anxiety disorders according to the Diagnostic and statistical manual of mental disorders 4th edition (DSM-IV); psychological distress; marital satisfaction.Results: At Time 1, partners had rates of DSM-IV major depression and generalised anxiety disorder twice those of women in the Australian community, and considerably higher than the patients’ rates. At Time 2, psychological distress in partners had lessened but that in patients had increased. On the other hand, at Time 2, partners’ marital satisfaction had deteriorated.Conclusions: To be fully effective, interventions aimed at reducing the psychosocial morbidity of PCA must involve both patient and partner, rather than the patient alone.

Jeremy W Couper MB BS, MMed(Psych) · Sidney Bloch MB ChB, PhD · Anthony Love PhD · Gillian Duchesne BSc(Hons), MB ChB, MD · Michelle Macvean PhD · David W Kissane MB BS, MPM, MD

The lack of an evidence base for formulating men’s health policies means existing programs and practices for men are influenced by prevailing cultural norms concerning men or habitual health service attitudes towards them. Factors impeding the development of an effective health policy for men include a preoccupation with limited clinical perspectives (an emphasis on the prostate and erectile dysfunction) and a common assumption that all health problems in men are a result of “masculinity” and “men behaving badly”. Viewing men’s health in terms of gender and health and the socially constructed differences between men and women is important, but does not provide all the perspectives required for meeting men’s health needs. A “social determinants of health” approach to men’s health would help Australia and Australian medical practitioners move away from policies and practices that perpetuate negative views of men and ignore the complexity of their health problems. The result would be a more evidence-based approach to men’s health policy, and the likelihood of improved health outcomes.

John J Macdonald

Fathers may be unintentionally marginalised by perinatal health services and by the maternal focus of social practices surrounding new babies. There is increasing recognition that a father’s depression and anxiety in the perinatal period can have serious consequences for his family. Health services could better support new fathers by providing them with information on parenting from a father’s perspective, or by running father-specific sessions as part of routine antenatal care programs.

Richard J Fletcher MMedSci · Stephen Matthey PhD · Christopher G Marley MB BS, FRACGP

Complex societal factors unrelated to evidence of efficacy influence the increasing use of complementary and alternative therapies, which can be viewed as one form of health consumerism. The “therapeutic footprint” is a conceptual model that “plots” medical therapies and complementary and alternative therapies in relationship to one another and to their levels of risk and supporting evidence, acknowledging that medical therapies also entail risks. Philosophies about management of risk and adverse effects differ between complementary and alternative therapies and standard medical care, due to fundamental differences between professionalism within medicine and the demands of health consumerism. In standard medical care, patients’ risks are mediated prior to treatment via the doctor–patient relationship and informed consent. With complementary and alternative therapies, protection mechanisms for consumers come into effect mainly after a problem has occurred. Understanding this difference helps doctors whose patients are using complementary or alternative therapies to define the boundaries between these therapies and professional medicine and provide appropriate disclosure of risks. Discussing complementary and alternative therapies and how they differ from standard medical care can provide opportunities to explore patients’ concerns and improve the therapeutic relationship.

Christine R Sanderson BM BS, MPH, FRACP · Bogda Koczwara BM BS, FRACP, MBioethics · David C Currow BMed, MPH, FRACP

Re: “Potential for organ donation in Victoria: an audit of hospital deaths”, by Helen I Opdam and William Silvester, in the 4 September issue of the Journal (Med J Aust 2006; 185: 250-254). The acknowledgements section was omitted. It should have read:

Helen I Opdam · William Silvester

Objective: To determine the potential for organ donation in 12 Victorian hospitals.Design and setting: Prospective audit of all deaths in 12 major public hospitals in the state of Victoria between January 2002 and October 2004.Main outcome measures: Number of organ donors and potential organ donors (patients with brain death or likely to progress to brain death within 24 hours if supportive treatment continued), requests for organ donation and consents. Unrealised potential donors (organ donation not requested) were categorised by an independent panel of intensivists as category A (brain death formally diagnosed); B (brain death not formally diagnosed but criteria likely to be fulfilled); and C (potential to progress to brain death within 24 hours).Results: There were 17 230 deaths, 280 potential organ donors and 220 requests for organ donation. The 60 unrealised potential organ donors were classified as category A (3), B (17) and C (40). Consent rate was 53% to 65%, depending on the definition of potential donor (categories A, B and C or category A only). Consent rate was lower when discussions about organ donation were held by trainees or registrars (21%) than when specialists were present (57%) (P = 0.004). A maximum practically achievable organ donation rate for Victoria was estimated to be 15 to 17 donors per million population (current rate, 9 per million population).Conclusions: The potential for organ donation in Victoria is limited by a small organ donor pool. There is potential to increase the number of organ donors by increasing the consent rate (lower than expected from public surveys), the identification of potential organ donors (particularly those likely to progress to brain death if supportive treatment is continued), and requests for organ donation.

Helen I Opdam MB BS, FJFICM · William Silvester MB BS, FJFICM

To the Editor: The article by Sanson-Fisher and Lynagh criticising problem-based learning (PBL)1 has elicited surprisingly little response, especially in light of the fact that these authors are from the University of Newcastle, the institution that first introduced PBL in Australia. The authors cite evidence that PBL students have inferior overall knowledge and competence than students taught by traditional curricula. Most medical faculties now have in-house education centres which are involved increasingly in learning process rather than content. The education centre in the Faculty of Medicine, Dentistry and Health Sciences at the University of Western Australia, for example, incorporates personal and professional development “as one of the four themes” in the curriculum2 — this includes such topics as ethical behaviour, diversity (what the patient brings to the relationship), self-evaluation (what the doctor brings to the relationship), teamwork, self-care and stress management. The old adage: “Those who can, do. Those who can’t, teach. Those who can’t teach, teach teachers” applies so appropriately to these new education centres. I support Lawson-Smith in calling on the Minister for Health, the Australian Medical Council, the Australian Doctors’ Fund, the learned Colleges, all interested colleagues and medical students to support the proposal for a national exit exam based on the most important function of a medical school: core knowledge.3 Medical students and medical schools should compete nationally in an examination to assess core knowledge. “Competition promotes the pursuit of excellence” should surely be the mantra of every medical school.

Ian N Bernadt

To the Editor: I am not a regular correspondent, as, with three children and a career, I rarely have the time. But, having read the recent personal perspective on missed conception1 and the accompanying commentary,2 I felt compelled to offer my own personal perspective on how, in medicine as a profession, we value (or don’t value) childbearing. Chapman and colleagues2 discuss the need for workplace reforms as a means of reducing barriers to earlier childbearing. If we, as doctors, are serious about this issue we need to lead by example and address workplace difficulties in promoting childbearing as a positive choice in our own profession. Despite women comprising at least half the medical students, they are still under-represented in most specialties, principally because training and childbearing are realistically seen by many women as “either/or” options. From my own experience, I can offer some illustrations of very real ways childbearing is devalued or discouraged in medicine. In my interview (around 1990) to gain admission to a physician training scheme, I was asked about my plans for a family, with the clear implication that, if I was considering having children, I should reconsider my options. Once a trainee, at the same hospital, I was advised by a senior (female) physician to delay pregnancy as long as possible, as it would mean death to any career aspirations. In my final year of advanced training, I was offered a job at one hospital, only to be un-offered the job days later when they heard, on the “grapevine”, that I was pregnant. When, as a National Health and Medical Research Council Research Scholar, I became pregnant with my second child and wanted to reduce my hours to part-time, I found the scholarship income became taxable — as it was assumed that part-timers were topping up income with private work. This significantly devalued the scholarship and went nowhere near covering childcare costs! After completing my PhD, in the course of applying for research funds while still working part-time, I discovered that granting bodies in Australia have no standard methodology for assessing curricula vitae of part-timers. With mothers comprising a large proportion of the medical part-time workforce, this effectively excludes us from competing for funds unless we wish to outsource our children. As recently as 2 years ago, when discussing these sources of inbuilt bias against medical mothers with a colleague, I was told my comments were inappropriate and offensive. If we, as a profession, can’t even discuss these stories, how can we set an example of positive family planning to the community at large? In listing the events described, I am not seeking sympathy or redress or claiming my path has been unusually difficult. Nor do I regret having my three lovely children! If one speaks to any working mother, similar stories emerge. As long as women feel the problems are their individual issues to grapple with in silence and embarrassment, rather than system failures, women embarking on any career will continue to be faced with a very real choice between children and a career (as opposed to a “job”). We may not be able to solve these issues on a community-wide basis, but let’s at least look in our own backyard.

Jane M Andrews

To the Editor: We now know the outcome of the parliamentary vote on mifepristone (RU-486), which restored responsibility for its use to the Therapeutic Goods Association (TGA). Politicians from both houses used their conscience votes to support the scientific scrutiny of medical abortion. van Gend will now be worried about Australian women “demanding” abortions.1 However, abortion on demand in Australia does not exist. I refer van Gend to state laws which specify under what circumstances termination of pregnancy can take place. In no state can women “demand” an abortion whenever, wherever or however they wish. Regulations exist in all states and territories and, as a family doctor, van Gend must be aware of the multiple requirements. While there remains a lack of clarity about various state laws,2 the current position in Australia is that termination of pregnancy is available under certain conditions and in particular cases. The attempt by the Minister for Health Tony Abbott to influence women’s decisions about abortion by providing Medicare-funded, church-affiliated counselling for pregnant women3 has only further entrenched the view that the Minister is not able to speak for the majority of Australians. The previous situation whereby any Minister for Health, rather than the TGA, had the power to decide on the safety and efficacy of new medications before their entry into the pharmaceutical market place was ludicrous. Despite the endorsement of science over theology in health, and potential access to medical abortion, we still have the freedom of our own conscience. No one can force medical practitioners to prescribe mifepristone and no one can force women to accept medical (or surgical) abortions. Morals in Australia are a private matter and these decisions should be left to individuals and their families. Who would decide the authenticity of the medical grounds for abortion, mentioned by van Gend — doctors or priests, or academic ethicists, or feminists? van Gend is clearly not in favour of women deciding. I agree that more attention should be paid to the reasons for women stating they do not want to continue with a pregnancy, and, yes, we could do more to assist them. But I do not agree that excluding non-medical reasons is the answer — which, as van Gend points out, are financial hardship, relationship problems, single motherhood, and a completed family. To many, these appear convincing reasons to choose abortion. While this may not sit comfortably with van Gend’s medical paradigm, the “non-medical” reasons include the mental health of the woman (see the Menhennitt ruling which stipulates that an abortion is lawful if a doctor believes that the abortion is necessary to preserve her physical or mental health).4

Suzanne Belton

In reply: Belton is correct that “safety and efficacy of medications” is a matter for the Therapeutic Goods Association. The dispute was whether such limited criteria can meaningfully assess a drug designed to take life. The government needed to consider higher criteria for RU-486 — its ethical and medical justifiability. Doctors needed to advise the government on justifiable indications for RU-486, in contrast to the corrupt practice of abortion for non-medical reasons. That advice was withheld. The Australian Medical Association advised only on the ethically neutral question of “. . . who is best qualified to scientifically assess the safety and efficacy of a drug”.1 Such marginalisation of ethical concerns is consistent with the AMA’s earlier response in the context of late-term abortion: “There is no place for third parties — governments, over-zealous politicians and lawyers, hospital committees, or even the spectre of legal action”.2 This assertion of unchallengeable medical power over an unborn life is wrong. Belton’s notion that the morality of abortion is “a private matter” is wrong; neither parents nor doctors are above the moral and legal prohibition on intentional killing. “The law in this state has not abdicated its responsibility as guardian of the silent innocence of the unborn”,3 even if medical leaders have.

David van Gend

Female genital mutilation. Comfort Momoh, editor. Oxford: Radcliffe Publishing, 2005 (iv + 172 pp). ISBN 1 85775 693 2. We are seeing an increased prevalence of female genital mutilation (FGM) in Australia due to increased numbers of women migrating from countries where FGM is widely practised, presenting some unique and important health issues. The issues surrounding FGM need to be dealt with in the context of a cultural background where this is normal practice (in Somalia and Sudan, more than 90% of women have undergone FGM), but also with reference to the fact that the practice of FGM is prohibited in Australia by specific legislation. Most practitioners, when dealing with FGM for the first time, do not have a clear understanding of the relevant issues and can find the experience confronting. Momoh’s Female genital mutilation is one of the few texts to comprehensively address these issues. Momoh has collected a group of authors with clinical experience and expertise in the area to create a text providing a very thorough analysis of FGM. Emphasis is, however, quite heavily weighted towards the sociological issues associated with FGM. Overall the chapters are well written, interesting and informative. They are well illustrated with both line drawings and colour photographs. For the practising clinician, though, not all of the chapters are relevant. Much of the information is presented with a strong focus on the United Kingdom experience. In particular, the overviews of the practice of FGM and discussions of its clinical management provide an excellent source of information for the practising clinician, covering all of the information necessary to assist in clinical management. For those seeking a broader discussion of the many issues surrounding FGM, these are also thoroughly covered (but, as noted, mostly from a UK perspective). At 172 pages, Female genital mutilation is eminently readable and affordable. Gregory J JenkinsObstetrician and Gynaecologist, Sydney, NSW

Gregory J Jenkins

Objective: To determine the psychological wellbeing of sole mothers in Australia.Design: Cross-sectional analyses of survey data from The Australian Longitudinal Study on Women’s Health.Participants: 9689 younger women (aged 22–27 years) surveyed in 2000 and 12 338 mid-age women (aged 47–52 years) surveyed in 1998.Main outcome measures: Demographic characteristics and economic status; prevalence of suicidal thoughts, self-harm, and psychoactive medication use; depression (Center for Epidemiologic Studies Depression Scale) and psychological health (the Mental Health Component Score of the Medical Outcome Short Form Health Survey [SF-36]).Results: Among the younger women, sole mothers were more likely than other women to have experienced suicidal thoughts (odds ratio [OR], 2.18; 95% CI, 1.45–3.27) and self-harm (OR, 3.25; 95% CI, 1.97–5.38). Among the younger and mid-age women, sole mothers were the group most likely to have used medication for depression (ORs, 2.75 [95% CI, 1.76–4.30] and 2.29 [95% CI, 1.56–3.37], respectively). They were more than twice as likely to have experienced depression, and had significantly poorer psychological health (P < 0.001). After adjusting for economic status, only depression and psychological health remained significantly associated with sole motherhood, and the strength of these relationships was reduced.Conclusions: Economic status partly accounts for the relatively poorer psychological health of sole mothers. Sole mothers are more likely than other women to experience debilitating psychological health problems.

Deborah Loxton PhD, BPsych(Hons) · Rosemary Mooney BA(Hons) · Anne F Young PhD, AStat