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Reporting based frameworks do not focus on relationships, rather, they present a comprehensive listing of the factors and sub-factors involved in particular areas of health (including, for example, factors seen as affecting health). They are often used to identify gaps in the health information system, and to support the development of a comprehensive set of indicators for reporting on health. Frameworks of this type used in Australia include:
The National Health Information Management Group's (NHIMG) National Health Information Model (NHIM) provides a structure for the NHIMG's National Health Data Dictionary (NHDD), which presents all national standard health definitions. Thus it provides a structure for organising information about the full range of health services in Australia, as well as a range of population parameters. The NHIM was the precursor to the National Community Services Model described in the Family and community chapter of this book.
The National Health Performance Committee's National Health Performance Framework (NHPF) is another key framework. It provides the basis for organising data to evaluate the performance of all aspects of the health system. Later paragraphs discuss this framework in more detail.
Other health information frameworks are currently being developed, including a framework for rural health information.
Health frameworks, whether focused on relationships or reporting, generally have some common elements, and acknowledge the interaction between:
These common elements of health frameworks are discussed in more detail in the following sections, and a generalised model covering these elements (based on the Conceptual Framework of Health developed by the Australian Institute of Health and Welfare) is provided below. 3 This model also identifies the resourcing, monitoring and evaluation activity associated with health intervention, and some particular aspects of health that warrant attention (e.g. disease, symptoms, injuries, and disability).
Internationally, a number of models have been developed which attempt to map the wide variety of factors influencing the health of individuals, and populations. Generally, these factors can be classified under two broad headings: environmental factors and individual factors. These different perspectives - individual and environmental - need to be considered when selecting data items or research methods for any particular health topic. For example, when data is required on genetic illnesses, small, specific studies relating to individuals may be more pertinent than large scale population studies.
Physical, chemical and biological factors - The physical environment has always exerted a major influence on health status. Many of the gains made in the area of health in the first half of this century were the direct result of improved water quality,sewerage systems, and housing. In recent times, concern has shifted to a number of other areas, such as air: and water pollution, toxic and non-toxic waste disposal, the impact of new technology on food and health, contemporary occupational hazards, and pesticide and herbicide residues. Macro-environmental issues such as ozone depletion, global warming and natural resource degradation are also of concern, as these may result in increases in a range of health problems such as skin and other cancers, mosquito-borne diseases, and injury from natural disasters.
Social factors - The important influence of social factors on health is being increasingly recognised. These factors can include the physical and emotional care and support available to people from their immediate family environment, including their access to a good and adequate diet. The degree to which these factors in the family environment are present in early life can be particularly important longer term health determinants. Other social health determinants include the existence of friendships, of positive or negative neighbourhood or workplace relationships, of extended family or other social networks, and participation in social activities such as sports, hobbies or volunteer work. Stress related health problems can arise in the work environment where there is an imbalance between the demands placed on workers and the level of control they have over their work, or where there is an underuse of skills.2 Community and neighbourhood factors, such as population density, age distribution, and availability and adequacy of support infrastructures can also influence health outcomes. Other socio-demographic factors, such as employment status, occupation and industry of employment, educational attainment and geographical location are can also be important health determinants.
Economic factors - The economic wellbeing of a region, or family, can affect the amount and quality of health resources and services available to that region or family. Economic factors can also affect standards of housing and adequacy of neighbourhood and community facilities; accessibility of health education, promotional activity, and health care services; and the range of treatments and pharmaceuticals available.
Cultural and political factors - A person's cultural background can influence their lifestyle choices and attitudes towards health (e.g. towards diet, alcohol, drugs and safe sex behaviours), and their level of health related knowledge (e.g. knowledge about the importance of frequent breast self-examination by older women). The political structures and premises on which a society is organised can affect the priorities of health care systems, and thus people's access to health services and health related information.
Different types of individual factors affecting health will be emphasised depending on whether data is needed primarily to establish the health status of the population, identify health trends or outcomes, or to directly inform prevention and promotion activity. Many demographic factors provide insight into health outcomes and trends. Age and sex may be the largest single determinants of health, and country of birth or Aboriginal or Torres Strait Islander status can also be linked to particular health outcomes. However, while demographic information can inform prevention and promotion activity, information about lifestyle behaviours, dietary choices and health related attitudes are key areas of interest in developing health prevention measures, as these factors are modifiable.
Genetic contribution - An individual's genetic make-up plays an important role in determining their predisposition to some diseases (e.g. some forms of diabetes, haemophilia or cystic fibrosis are genetically determined), and to ill health. Many forms of cancers, with the exception of childhood leukaemia, are thought to result from genetic mutations that occur and accumulate during a person's lifetime. As an individual ages the repair mechanisms within their cells break down. Thus, the ageing process combines with genetic propensity to impact on a person's susceptibility to disease.
Attitudes and beliefs - In general, these factors relate to the level and quality of knowledge people have in regard to health, health risk factors, health facilities and health promoting behaviour. While there is some understanding of the way in which people's emotions and beliefs, about themselves, and about their life, affect their health, this area of health is relatively uncharted. Feelings of optimism, self worth and commitment, may affect the lifestyle choices people make, or the conviction with which they embrace and adhere to treatment regimes when they are ill. People's spiritual beliefs may also play a role in health processes and outcomes.
Lifestyle and behaviour - It has long been recognised that the lifestyle of individuals has a significant effect on their health status and potential years of life. In developed countries such as Australia in the last half of the twentieth century attention has focused on risk factors such as over-nutrition, as opposed to under-nutrition (which can still be a concern in relation to some population groups). Dietary issues are also focused on modern nutritional hazards such as those associated with increased consumption of saturated fats and refined foods and sugars. Other risk factors have become more prevalent as lifestyles have changed, for example, reduced physical activity due to the decrease in incidental exercise. Perennial health risk behaviours, such as harmful drug and alcohol use and gambling addiction, have remained of concern to communities and health policy makers.
Biomedical factors - Genetic factors, lifestyle and behaviour, and early childhood and other experiences lead to an individual having a variety of physical properties. Some of these can be linked directly to general health and to particular health conditions. For example, blood pressure, cholesterol and blood sugar levels, and body weight.
HEALTH STATUS AND OUTCOME INDICATORS
Health status and outcomes are commonly measured using some key indicators, such as life expectancy and infant mortality. To some extent, the focus of health status measurement will depend on which specific questions are of interest. Questions such as 'How many people have diabetes?' or 'How many hospitals are there in a particular region?' are relatively straightforward and suggest some specific and direct measures. However, a question like 'How healthy are we as a nation?' is less straightforward and can be answered in a variety of ways. Simple indicators of the presence and prevalence of diagnosed illnesses can be used; or a series of indicators can be compiled that demonstrate both positive and negative aspects of physical and mental health, socioeconomic environments and lifestyle influences. This latter approach would be more challenging. The information might be less practical and cost effective to collect, and analysis of the diverse range of factors involved would be more complex. Some key indicators of the health of the population include:
In some cases diseases or events such as birth circumstances, injuries or strokes can lead to a long term health impairment or health condition. Some people experiencing these may find it difficult to perform everyday tasks, or to take part in ordinary life situations such as school, work or community events. If everyday activities are restricted, these people are classed by the ABS as having a disability. Some examples of the impairments or long-term conditions that may result in activity limitations or restricted participation include loss of hearing, difficulty in learning, incomplete use of limbs, breathing difficulty, chronic or recurring pain, or nervous conditions.
Disability is further defined within the ABS in terms of the area of life in which restriction is experienced. Some people may only be restricted in ways that have a minor impact on their lives. Others may be restricted in terms of the type of work they can do, or in terms of learning or schooling activity. Other may be restricted in performing activities that are even more basic in terms of their wellbeing and independence. These latter activities are described by the ABS as 'core activities' and include self-care activities (e.g. bathing, dressing, eating), mobility activities (e.g. moving around home, getting in and out of bed or a chair, using public transport), and communication activities (e.g. understanding and being understood by others).
Another important consideration when classifying disability is the relative severity of a disability. Severity of disability is defined by the ABS in terms of restriction of the core activities mentioned above. A 'profound' restriction exists when a person always needs assistance with core activities. 'Severe' restrictions are defined as those where the person sometimes needs assistance with core activities. Where a person does not need assistance, but has difficulty performing core activities, their level of restriction is seen as 'moderate', and where they have no difficulty performing a core activity, but need to use aids or equipment, they are seen as having a 'mild' restriction.
Core activity restrictions together with restrictions in schooling and employment are referred to as 'specific restrictions' in ABS publications and correspond to the term 'handicap' used in disability surveys prior to 1998. This approach to defining and classifying disability is represented in the diagram below within the context of the total population.
The generalised framework outlined earlier identifies three main kinds of intervention, namely, prevention and health promotion; treatment and care; and, rehabilitation. However, a key area of interest in relation to health intervention, is monitoring the effectiveness, or performance, of intervention activities. The performance of the health system, particularly the performance of health care interventions, is considered in detail within the National Health Performance Framework (NHPF), introduced by the National Health Performance Committee in 2001. The NHPF identifies three main tiers, and several dimensions within each of these, to provide a structure for measuring the performance of the health system. The three tiers are:
The content of the first two tiers of the NHPF relate to matters that have been covered above. The third tier of the framework - health system performance - identifies a range of issues relating to quality of care, equity and context.
In summary, the NHPF proposes that in order to provide high quality interventions, health care services in all settings need to:
It should be noted that the perspective on measuring quality in the NHPF varies from that expressed in the Performance Indicator Frameworks adopted by the Productivity Commission for the ongoing Review of Government Service Provision where quality is identified as a component of effectiveness. For example, in the Commission's framework for public acute care hospitals, quality is indicated by patient satisfaction, misadventures and accreditation (SCRCSSP 2000).
The NHPF also identifies another key goal of the health system as being equity of outcomes. Equity relates to all tiers of the NHPF and can be measured by comparing differentials between population groups of interest (e.g. people of different ages, people living in rural areas, etc.). Under the NHPF, an ultimate goal for the health system is to achieve equal outcomes within each dimension of quality listed above, and for all population groups.
When measuring performance, quality and equity of interventions, a number of contextual elements need to be considered. For example, there are a variety of settings within which interventions take place. These can be health system based (e.g. hospitals, surgeries, health centres, etc.) or community based (e.g. the home, schools, workplaces, etc.). There are also many different types of service providers delivering health services. Again these providers can be working within the health system (e.g. doctors and other health professionals), or operating outside it (e.g. home carers, teachers, employers, etc.). In some instances, a setting, such as a hospital, might also be considered a service provider, as it is an organisational entity with behaviours and characteristics that function at an organisational level. The NHPF can be applied to all settings and service providers.
The following diagram summarises the model that underlies the NHPF and is used for evaluating health system performance. It represents settings and service providers as the context for health system evaluation. It represents quality and equity as key performance goals. It also acknowledges that performance needs to be understood in terms of what health problem is being treated, and what type of intervention is being undertaken (e.g. whether prevention and health promotion, treatment and care, or rehabilitation). The performance model below complements the generalised health framework presented above by elaborating on the relationship between interventions and resources, and provides a structure against which progress towards health system goals might be evaluated.
Direct health transactions
Transactions relating to health can be broadly classified into two types: direct and indirect. Direct health transactions are those where the primary motivation for the transaction is to influence the health of the recipient. Health promotion and ill health prevention initiatives, strategies and programs are direct health transactions, and typically take place between members of the public and government, health service or community organisations. Many direct health transactions revolve around ill health. These include transactions occurring within the core community, where family members care for one another when ill, and transactions within the wider environment (e.g. with health professionals such as general practitioners, chiropractors, pharmacists, optometrists, dentists, counsellors, or with health organisations such as hospitals and nursing homes). Examples of direct health transactions are given in the diagram below.
Indirect health transactions
Indirect health transactions do not have health outcomes as their primary motivation. They take place in all arenas of social concern, and many are associated with the environmental health determinants described above. In other words, many environmental factors (e.g. the social environment) affect the health of individuals via transactions. Some indirect health transactions are relatively closely linked to health, e.g. the provision and preparation of food by parents for children. The intention behind other indirect transactions is even further removed from improving one's health, e.g. attending theatre or films; or from reducing another's health, e.g. home burglary.
An Expert Group on Health Classifications was established in 2000 (as a sub-committee of NHIMG) to review the range of health classifications used in Australia. The initiative arose from the need to collect high quality and consistent information across the different forms of care and treatment that health service consumers receive in all settings. The Expert Group includes an independent Chair and representatives of the National Health Information Management Group (NHIMG), the National Community Services Information Management Group (NCSIMG), the Australian Institute of Health and Welfare (AIHW), the Australian Bureau of Statistics (ABS), and the Department of Health and Aged Care (DHAC), as well as experts in specific classifications (some of which are described in the following paragraphs). The Group is tasked with achieving agreement, by June 2002, upon national classifications systems for all sectors where health information is collected in Australia. The review will take into account the structures of major health frameworks such as the Conceptual Framework of Health and the National Health Performance Framework outlined on pages 100 and 101.
Countries provide input to the development of international health classifications via WHO Collaborating Centres established for this purpose. AIHW is the Australian Collaborating Centre, and represents the Western Pacific region; with two National Centres for Classification in Health (NCCH) playing key roles. One NCCH provides expert advice on mortality classifications and the other is responsible for morbidity classifications.
Diseases and related health problems
The most commonly used health classification in Australia is the International Statistical Classification of Diseases and Related Health Problems (ICD). As a statistical classification, it is designed to encompass the entire range of morbid conditions within a manageable number of categories. Periodic revisions of the ICD have been coordinated by the World Health Organisation (WHO) since the sixth revision in 1948, when the original focus on causes of death was expanded to include non-fatal diseases. The current version is the Tenth Revision of ICD (ICD-10) and has been introduced into Australia over the last few years.
Causes of death
To classify causes of death, ABS uses the ICD (ICD-10 since 1998), and applies the WHO concept of underlying cause of death. This is defined as the disease or injury initiating the train of morbid events leading directly to death. Classification is based on textual descriptions of the conditions, diseases and injuries reported on the Medical Certificate of Cause of Death (generally provided by an attending physician or coroner, depending on the circumstances of the death). Since 1997, the ABS has coded and retained, not only the underlying cause of death, but all causes and conditions reported on the death certificate.
Diagnosed conditions and injuries
To classify diagnosed morbidity within settings such as hospitals, more detail is required in some cases than is allowed for by the ICD. The National Centre for Health Classifications (NCCH) in Sydney has developed the ICD-10-AM (Australian Modification) for use in clinical settings. (The equivalent version of ICD-9 was known as ICD-9-CM - Clinical Modification). Editions of ICD-10-AM are endorsed by NHIMG with the third edition being planned for implementation in July 2002.
Functioning and disability
In 2001, the WHO endorsed a revision of the classification system used for disability related concepts. In this process, the International Classification of Functioning, Disability and Health (ICF) replaced the International Classification of Impairment, Disability and Handicap (ICIDH). The ICF classifies how well people function across three elements of a healthy life: body functions and structures; ability to perform day-to-day activities; and ability to participate in the social domain. Problems in these areas are now referred to as: impairments; activity limitations; and participation restrictions respectively. ICF also identifies environmental and personal factors in recognition of the impact, positive or negative, that these factors can have on an individual's ability to function. The 1998 ABS Survey of Disability, Ageing and Carers used a definition of functioning and disability based on the draft ICF to ensure the data would be consistent with the new international classification system.
Self reported health problems
When individuals are asked to describe their health problems or symptoms, they are generally not capable of providing information which could be coded accurately or precisely to a classification system designed for clinical detail. Hence, a range of classifications have been developed to handle this level of health knowledge. The ABS has adopted the International Classification of Primary Care, second revision, (ICPC2) to code conditions and injuries reported by respondents in their National Health Surveys. The ICPC was designed to code a patient's reason for encounter with health services. It is also used in the Bettering the Evaluation and Care of Health (BEACH) Project, which includes an annual survey of general practitioners.
As injuries are a result of external causes such as accidents or violence, many of them are potentially preventable. Hence, they are a focus of policy and programs aimed at reducing the disability and premature mortality associated with injuries in the community. For each injury, information is required on a range of elements including the event leading to the injury, the nature of the injury received, what the person was doing at the time, and where the event occurred. Information is also needed on whether the injury was the result of a deliberate action or was an accident. Hence, experts in this field have been developing an International Classification of External Causes of Injury (ICECI) in close collaboration with the committees and processes which manage the ICD. Although not yet an official WHO classification, it is envisaged the ICECI will play a role in the collection and dissemination of injury statistics in Australia at some time in the future.
Clinical diagnoses of mental disorders are generally coded to either the ICD-10, the Classification of Mental and Behavioural Disorders; or the Diagnostic and Statistical Manual of Mental Disorders - 4th edition (DSM-IV). Information collected in the 1997 ABS Survey of Mental Health and Wellbeing was coded to both classifications. In this case, coding to a classification designed for diagnostic data was possible for self-reported mental health data, as clinical diagnoses of mental disorders are largely based on the emotions, thoughts and behaviours described by individuals, rather than on physical examinations undertaken by health professionals.