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EXTENDING COMMUNITY THROUGH COLLABORATIONResearch fellowship helps nurse serve underserved in Australia by Barbara Elisse Najar and Heddy Bishop Hubbard
Sonj Hall, RN, MPH, PhD, spent 2005-06 as a Harkness Fellow with the Agency for Healthcare Research and Quality (AHRQ), a public health service agency in the U.S. Department of Health and Human Services (www.ahrq.gov). Hall is a graduate of The University of Western Australia. Prior to her appointment as a fellow, she was a lecturer in health systems and economics in the School of Population Health at The University of Western Australia. As a registered nurse and health services researcher who has worked internationally, Hall has a particular interest in health care inequalities, which was the subject of her doctoral dissertation. Her focus has been on the effectiveness, quality and equity of health services for various disadvantaged groups, including children with disabilities, frail older adults, people from low socioeconomic groups, those living in rural areas and those without private health insurance. A fervent advocate for transferring research into practice and policy, she has testified before the Australian Parliament’s Senate and advised various governmental and nongovernmental organizations on health care policy. The New York-based Commonwealth Fund sponsors the Harkness Fellowships in Health Care Policy, which focus largely on quality improvement, patient safety and the needs of underserved groups. These fellowships provide a unique opportunity for mid-career health services researchers and practitioners from Australia, New Zealand, the United Kingdom and Germany to spend up to 12 months in the United States conducting original research and working with leading U.S. health policy experts. During this time, they gain in-depth understanding of the U.S. health care system and policy challenges, enhance their methodological skills, and develop valuable contacts and opportunities for ongoing cross-national exchange and collaboration. The program encourages fellows to use their experiences to advocate more effectively for health services upon their return home, a win-win situation for both the host country—the United States—and the fellow’s country of origin. The Commonwealth Fund also offers reciprocal fellowships called Packer Policy Fellowships that enable mid-career U.S. health policy researchers and practitioners, including nurses, to spend up to 10 months in Australia conducting original research and working with leading Australian health policy experts on issues relevant to both countries. Ian Axford Fellowships provide similar opportunities for researchers from outside the United Kingdom to spend time in that country. Hall is one of eight people to receive Harkness Fellowships in
2005-06. She sought the fellowship to learn more about health
care issues in the United States that could be applied to her
homeland. Specifically, she wanted to learn about the role of
advocacy groups in the United States so that she could help shape
access-to-care policy for the four major cancers—lung, colorectal,
breast and prostate—in Western Australia. Her topic of study,
which grew out of her previous research, was the impact that U.S.
and Australian policies have on improving access and quality of
care for people with cancer living in disadvantaged communities. “If everyone had the right to primary and hospital care, you would not see differences, but there are differences,” she explained. “Factors such as patient choice, patient literacy and when to seek help are some factors from the patient side. Providers may have biases, including prejudice toward certain populations such as indigenous groups. Factors such as lack of transportation to medical care are also at play.” Hall stated that there are many things that influence policies affecting care and what can be achieved in a country such as Australia, which is roughly the same size as the United States but has only 20 million people. “You simply can’t put health care everywhere that it’s needed; choices have to be made,” she notes. “Are you going to provide care in the cities and a means to get there, or are you going to localize services? Who has the right to decide? Therefore, the role of advocacy groups, including grass-roots organizations, nonprofit groups, clinical and professional groups, and government agencies can be critical. The confluence of these diverse interests, sometimes competing with one another, can also limit what is achieved.” Hall approached her research project by first conducting a literature search on the role of advocacy groups. Then she used the Delphi method, whereby leaders identify people they believe to be “key informants” from the major health and cancer-care advocacy groups. She interviewed these informants and asked them how they felt they had influenced federal government cancer-care policy. She also employed the “snowball” technique, asking each interviewee for names of other people she should talk to. In all, she conducted 26 interviews that encompassed more than 70 organizations. Although the focus of Hall’s questions was on federal-level policy, she traveled extensively around the United States to visit and interview advocacy groups in their home states. She used the information she gathered to establish a baseline measure of cancer-care policies that influence major U.S. government organizations. Hall is currently in the process of analyzing her data and will make her results available at a future date. Harkness Fellowships help recipients broaden their methods base. An economist and self-described quantitative “numbers-and-database cruncher,” Hall says her fellowship has permitted her to expand into the qualitative realm. “I’ve become better able to analyze policy and policy formation, particularly in terms of evidence-based care,” she says. “I’m learning how policy both incorporates the evidence and also diverges from it. For example, the evidence says that people treated in urban health care centers have much better outcomes, yet this evidence cannot solely dictate where services are provided. “Local services, especially in the huge rural expanses that constitute much of Australia, must be provided irrespective of the evidence. Cost then becomes a driving factor. We must show that services are cost-effective as well as safe and effective. The United States spends about 15 percent of its gross domestic product on health care versus 8 to 10 percent in other developed countries, such as Australia, yet the health outcomes are the same. We cannot afford care that does not make sense.” As a nurse, Hall has a high regard for her profession, so we naturally wanted to know her thoughts about nursing in the United States versus Australia. “It has been gratifying to find the strong and dynamic community of nurses here at AHRQ,” she responds. “I’ve been amazed at the diversity of issues and subjects that AHRQ nurses are tackling, especially in the areas of quality and patient safety. It’s a reflection of how nurses and nursing careers can become more diverse. Nurses do not need to remain in traditional roles, and that is a most inspiring message to take back home. My experience in the United States makes me feel proud and excited to be a nurse. “It would be most unusual to find nurses at such an organization as AHRQ in Australia,” Hall says. “Not many Australian nurses are heading up research teams as principal investigators; there’s definitely an imbalance compared with physicians. Slowly, it is improving, but there is still a long way to go.” She notes that at least half of Harkness Fellows are medical doctors, and there seem to be fewer good nursing applicants for the fellowships. “Only one other nurse has ever won a Harkness Fellowship. I would love it if more nurses were encouraged to apply,” she says. “The lack of nurses in senior positions makes them less apt to feel worthy of such an honor. Of course, it’s also difficult to leave one’s country for a year, particularly when there are families and commitments involved.” Hall observes that it has been “exciting to learn how to focus on qualitative research and to discover how the political system works in the United States—what you consider important and why. It has opened new avenues for me.” With regard to AHRQ, says Hall, it has been “a wonderful setting from which to pursue my research. I’m especially grateful to my mentors—AHRQ’s director, Dr. Carolyn Clancy, and Dr. Ernest Moy. I am looking forward to returning to Australia and the chance to put my new knowledge to use, and I envisage continuing my work with underserved groups and working with Australian advocates more productively to improve health care outcomes.” RNL
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