Case Study Handbook
Case Study Handbook
PBHL20009/PBHL20010
2022
Case Study Handbook
PBHL20009
PBHL20010
General Guidelines
Assessment 1 for PBHL20009 and PBHS20010 is the case study. This assessment task is worth 50% of the overall grade for the unit.
The case study is a written assignment in two parts where each part is around 2000 words. It must be completed individually. This assessment will be completed over two units. The first part of the case study will make up Assessment 1 in your first unit of enrolment (either PBHL20009 or PBHL20010) and the second part of the case study will be Assessment 1 in your second unit of enrolment (either PBHL20009 or PBHL20010). Your enrolment in this term will determine which part of the assessment must be completed.
If you are enrolled in PBHL20009 and you have not yet completed PBHL20010, you will complete the first part of the case study.
If you are enrolled in PBHL20010 and you have not yet completed PBHL20009, you will complete the first part of the case study.
If you are enrolled in PBHL20009 and you have successfully completed PBHL20010, you will complete the second part of the case study.
If you are enrolled in PBHL20010 and you have successfully competed PBHL20009, you will complete the second part of the case study.
If you have successfully completed PBHL20009 or PBHL20010 and are completing the second part of the case study this term, your research will need to follow on from your previously submitted first part of the case study. You must continue your research with the same topic as that chosen for the first part of your assignment.
The case study is a major research paper examining the nature, significance, and impacts of a public health concern on a specific community. It is necessary to undertake significant research into the ways your chosen community is affected by the public health concern and how the concern is addressed in this context. You will need to draw on your knowledge of multiple elements of public health thinking and practice in order to develop a structured analysis of current initiatives that are in place that aim to address your chosen topic. These elements could include disease/infection control measures, public policy and planning, stakeholder relationships, cultural context, and systems thinking, among others. It is necessary to apply your examination of relevant research relating to the public health concern in your chosen community to develop your own original discussion of possible initiatives and/or avenues for further research that could address the concern in the future.
Work on your case study should begin without delay. If you are completing the first part of the case study this term, you should choose a topic (see next section, Topics) as soon as possible and begin planning your research. If you are completing the second part of the case study this term, you should begin planning your research in the first two weeks of the term.
Please note that you must achieve a mark of at least 50% on the case study in order to pass the unit.
Topics
Please choose a topic from the list below for your case study. You must advise the Unit Coordinator of your chosen topic by email by the end of week 2.
The topics for the case study are as follows:
Dengue Hemorrhagic Fever in [a community of your choice]
Waste Management in [a community of your choice]
The Aging Population and Its Implications for Public Health in [a community of your choice]
Poor Nutrition and Its Implications for Public Health in [a community of your choice]
Occupational Injuries in [a community of your choice]
Vaccine-Preventable Diseases of Childhood in [a community of your choice]
Maternal and Infant Morbidity and Mortality in [a community of your choice]
Earthquakes/Floods/Fire/Other Natural Disaster in [a community of your choice] N.B. If you choose this topic, you will need to choose and specify a natural disaster that is relevant to your chosen community
Cancer in [a community of your choice]
Access to Healthcare in [a community of your choice]
Water Quality and Its Implications for Public Health in [a community of your choice]
The Relationship Between the Living Environment and Public Health in [a community of your choice]
For each topic on the list above, a community must be specified that is directly affected by the public health concern. Your chosen community should be specified where indicated above, eg. Occupational Injuries in Automotive Machinists; Maternal and Infant Morbidity and Mortality in Australian Immigrants from Non-English Speaking Backgrounds; etc.
If you would like to propose your own topic for the case study, you must seek approval from the Unit Coordinator. If you choose to do so, please submit a topic proposal to the Unit Coordinator by email detailing the specific public health concern and community that you wish to discuss before the end of week 2.
Structure
The case study must be structured with the following sections:
Part 1
Introduction
Population at Risk
Planning Initiatives
Review of Existing Initiatives
Part 2
A Systems Approach to the Case
Risks and Advantages
Expert Assessment
Please note that sections 1 to 4 constitute the first part of the case study. Sections 5 to 7 constitute the second part of the case study. If you are completing the first part of the case study, your paper must include sections 1 to 4 as outlined above.
If you are completing the second part of the case study, you must complete sections 5 to 7 as outlined above. These sections must be added to your previously completed first part of the case study your topic will be the same as in your previously completed first part. Your final submission must include sections 1 to 7 as outlined above in a single document.
Please refer to PBHL20010 Case Study Overview or PBHL20009 Assessment Overview for content overviews for each section of the case study.
Literature
You must conduct significant research into your chosen topic as part of the case study. A review of relevant literature is essential to provide appropriate context and background for your chosen topic, support your original analysis, and place your ideas in the context of current trends in public health research, thinking, and practice. It is essential that all literature used to develop your case study is correctly cited and listed in a reference list according to standard academic formatting practices.
Depending on your chosen topic, you might need to examine literature from a variety of public health perspectives to develop and support your analysis. For example, in addition to a body of scholarly research that directly discusses the impact of your chosen public health concern on the community, you might also refer to literature from related fields such as culture, history, or ethics as well as policy documents, health promotion materials, etc. Please note that there is no number of references that is automatically correct when developing your case study. Instead, it is up to you to consider the research that relates to your chosen public health concern, examine the research as it applies directly and indirectly to your chosen community, and include references to sources that directly reinforce and develop your analysis. It is important to remember that your research must focus on your chosen topic as it impacts one specific community group. As such, it will be necessary to evaluate all literature in the context of the insight that the research gives into the public health concern as how it affects the specific community.
Some important questions to consider when examining the body of literature relating to your chosen topic could be:
What insight does the research give us into the defining characteristics of your chosen community?
What insight does the research give us into what policies/strategies/initiatives are the most relevant to your chosen community, and why?
What does the research show us about how risk is defined and measured in the context of your chosen community?
How has your chosen topic been treated in the past, and how have social/cultural attitudes toward the public health concern changed within your chosen community?
How is the risk associated with your chosen topic currently viewed in the context of public health thinking and practice?
While you must demonstrate knowledge of current trends in the research and the place of your ideas in this context through an examination of relevant literature, it is important to remember that you do not necessarily have to agree with every idea from the literature. This is especially important when completing sections 4 and 7 of the case study you must include your own evaluation of the significance and effectiveness of the initiatives discussed and develop your own analysis of the reasons why these initiatives are successful/unsuccessful. You must also develop your own ideas as to how your chosen public health concern could be better addressed and/or approaches that you think would be beneficial to your chosen community. This means that you do not necessarily have to agree with the conclusions drawn in the literature. Please note, however, that you must objectively discuss and demonstrate your understanding of the research in the context of public health thinking and practice, regardless of how you develop your own original analysis.
Referencing
All source material used to develop your analysis for your case study must be correctly cited in-text. All cited material must be detailed in full in a reference list at the end of your paper. You must not include sources on your reference list that are not cited in-text and vice versa.
Please follow a standard academic referencing style consistently throughout your case study. It is recommended to use the Harvard referencing system. The style guide for Harvard referencing can be found at https://delivery-cqucontenthub.stylelabs.cloud/api/public/content/harvard-referencing-style.pdf?v=306efe7e. Please note that the standard formatting for all resource types is specified in the style guide, and these guidelines must be followed in your case study. There are also instructions for in-text citations, quotations, creating a reference list, and guidelines for paraphrasing and summarizing ideas from the literature, among other useful information.
It is possible to organize and enter your references using a program such as Endnote. If you choose to use Endnote, it is strongly recommended that you check the formatting of all in-text citations and references manually as well to avoid errors in presentation.
It is essential that you appropriately cite all references used to support your discussion in your case study. Academic integrity is a very serious, very important aspect of developing your research, and failure to adhere to an appropriate academic standard in referencing can severely impact your grade.
Style and Formatting
The case study must be presented as an academic research paper. As such, a formal academic writing style is required in the presentation of your assignment. In addition to the structure outlined above, you must maintain a tone that is consistent with the standards of academic research. This includes correct spelling, punctuation, and grammar as well as stylistic elements of language and formatting.
In order to ensure that your case study adheres to an appropriate academic presentation standard, please keep in mind the following basic elements of style and formatting:
Avoid the first person.
Example: Instead of I think health promotion campaigns in languages other than English are effective because... consider expression such as The effectiveness of health promotion campaigns in languages other than English can be observed through...
Avoid the use of impersonal you.
Example: Instead of You can see in Figure 1 above... consider expression such as It can be seen in Figure 1 above that... or Figure 1 above indicates that...
Avoid absolutes and statements of universality. This applies even when discussing ideas that are generally accepted as fact and/or are a part of collective cultural knowledge.
Example: Instead of In his study, Smith (2021) proves that there is a connection between socioeconomic status and the perception of trustworthiness of healthcare practitioners... or Everyone knows smoking causes cancer... consider expression such as Smith (2021) suggests that there is a connection between socioeconomic status and the perception of trustworthiness of healthcare practitioners... and Smoking is widely understood to be a contributing factor to the development of cancer...
Avoid weighted/emotive language. It is important to be aware of the connotations of words and maintain an objective tone, especially when discussing ideas that are commonly associated with a culturally determined emotional response and/or subjective ideals that are based in shared cultural knowledge.
Example: Instead of The tragic destruction caused by the earthquake obviously devastated the surrounding communities... or Lazy people have poor eating habits... consider expression such as The destructive force of the earthquake caused both physical and psychological damage, which can be observed through... and There are many factors that are associated with lifestyle choices such as eating habits, including complex social/perceptual/experiential factors...
Be mindful of the placement of in-text citations. It is essential to make it clear when you are summarizing/paraphrasing ideas from the literature and when you are presenting your own analysis. In-text citations should not be placed where you are expressing your opinion and/or discussing your interpretation/evaluation of ideas, practices, etc. Sentence structure can be instrumental in clarifying how you are using the literature.
Avoid non-standard paragraph structure. There should always be a blank line between paragraphs always press enter twice after the end of a paragraph and before and after a section heading.
As a general rule, the most common word will likely be the best choice and will often result in clearer, more concise expression. While words such as observe, assert, comprehend, etc. have a place in formal academic writing, it can also be perfectly correct to use more common forms such as, see, suggest, and understand. Try to be mindful of clarity in your writing and avoid obscure synonyms and flowery language that can make your intention unclear.
Contact
Any questions or concerns should be addressed to the Unit Coordinator:
Dr. Rebecca Fanany r.fanany@cqu.edu.auFor academic skills support, please refer to the Academic Learning Centre (ALC):
https://www.cqu.edu.au/student-life/academic-learning-centre
PBHL20010
Assessment 1 Case Study Marking Guide
Criterion HD D CR P F
The population at risk for the chosen public health issue is described and discussed
The chosen population group is clearly identified, and the specific public health issue of concern to the group is described, including clear discussion of elements of risk and relevant connections to a broader social/cultural context. Additional stakeholder groups are identified and described where relevant.
8.5-10 The chosen population group is identified and specific public health interests are mentioned but description and discussion of additional factors is incomplete or inaccurate. Connections between the population group and public health impacts are considered but without a clear description of significant social/cultural context.
7-8.4 An attempt has been made to identify the relevant population group but evidence supporting this is incomplete and lacks a clear and precise connection with a specific public health concern. Discussion of determinants is superficial, with no significant consideration of risk or associated stakeholder groups/social and cultural context.
6-6.9 An attempt has been made to identify the relevant population group and associated public health issue but the discussion of determinants is basic, superficial, and/or inaccurate. Relevant contextual factors are not mentioned or are identified but incompletely or inaccurately described with little significant discussion.
5-5.9 Required elements are fully or partially absent. The population of interest is not identified and discussed, a specific public health concern is not clearly identified, determinants are not identified and analysed, and/or the significance of the public health concern to the chosen group is not considered. Discussion contains irrelevant and/or inaccurate elements with no meaningful analysis.
0-4.9
Planning elements are discussed and considered
Characteristics of the population of interest are clearly and specifically described and their relevance to the public health concern is discussed. Factors directly affecting the chosen group are described and discussed with an in-depth consideration of relevant contextual concerns, including the relationships between risk and planning and other relevant stakeholder groups. No irrelevant elements or inaccuracies are present, and least two brief examples are given.
8.5-10 Characteristics of the population of interest are outlined and an attempt has been made to discuss their relevance to the public health concern. Factors directly affecting the chosen group are described and discussed with some consideration of relevant contextual concerns. Discussion is mostly accurate but could include some irrelevant elements, and at least two brief examples are given.
7-8.4 Characteristics of the population of interest are mentioned and some indication of their relevance to the public health concern is considered. Some specific factors directly affecting the chosen group are mentioned but discussion of contextual concerns is superficial and/or irrelevant. A brief example is given but discussion of the significance is superficial or incomplete.
6-6.9 Characteristics of the population of interest are mentioned but are incomplete. An attempt to consider their relevance to the public health concern is made but little or no mention of significant factors and a broader context is presented. Examples are absent or unconnected and without meaningful discussion of their significance to the analysis of risk factors, stakeholder roles, and/or the health concerns of the population group.
5-5.9 Some specific characteristics of the population of interest are noted but an indication of their relevance to the public health concern is absent. No connections between significant factors or social/cultural context is presented and examples are absent or irrelevant.
0-4.9
Existing initiatives are reviewed and evaluated
In-depth discussion of current policies, plans, practices, and/or initiatives to address the public health concern is included with clear original analysis of factors impacting effectiveness. Original analysis of alternatives with clear and precise connection to discussion of relevant risks and specific health concerns to the population of interest and social/cultural context is present. The role of relevant stakeholder groups in decision-making is fully discussed. A detailed and accurate consideration of past and current trends in public health thinking and practice is included as relevant.
8.5-10 Some in-depth discussion of current policies, plans, practices, and/or initiatives to address the public health concern is included but original analysis of factors impacting effectiveness is absent or superficial. An attempt has been made to consider alternatives but original analysis is absent or superficial, and lacks a clear connection to discussion of relevant risks and specific health concerns to the population of interest and social/cultural context. The roles of relevant stakeholder groups in decision-making are mentioned. Discussion of past and current trends in public health thinking and practice is irrelevant or incomplete.
7-8.4 Current policies, plans, practices, and/or initiatives to address the public health concern are mentioned but original analysis of factors impacting effectiveness is superficial. Some alternatives are mentioned but original analysis is absent or superficial. Connections between ideas are imprecise and/or unclear, and little meaningful discussion of risk and social/cultural context is present. Decision-making roles are mentioned but discussion is irrelevant or absent, with little or no consideration of past and current trends in public health thinking and practice.
6-6.9 An attempt has been made to identify some policies, plans, practices, and/or initiatives to address the public health concern but original analysis is absent with no meaningful discussion of alternatives. Risk factors are mentioned but consideration of relevant initiatives/measures is incomplete. An attempt has been made to consider aspects of decision-making roles but discussion of the significance of these factors in terms of the population of interest is absent or superficial with no meaningful consideration of past and current trends in public health thinking and practice.
5-5.9 An attempt has been made to identify some policies, plans, practices, and/or initiatives but no original analysis is presented. Identification of alternatives is absent or incomplete with no original analysis and no consideration of risk to the population of interest. The significance of decision-making roles is not considered and no analysis of significant factors in terms of the population of interest or public health thinking and practice is present.
0-4.9
Appropriate use of literature
All literature used is less than 10 years old, comes from high quality sources, addresses the relevant cultural context, and derives from refereed journals or organizations of recognized standing in the field of public health. All original analysis is clearly and appropriately supported and/or reinforced by the literature, and the relevance of all sources is clearly discussed. Assessment format conforms exactly to guidelines.
8.5-10 A majority of literature used is less than 10 years old, comes from high quality sources, addresses the relevant cultural context, and derives from refereed journals or organizations of recognized standing in the field of public health. Original analysis is appropriately supported by the literature but the relevance of some sources is not clear. Assessment format conforms exactly to guidelines.
7-8.4 Some literature used is less than 10 years old, comes from high quality sources, addresses the relevant cultural context, and derives from refereed journals or organizations of recognized standing in the field of public health. Some original analysis may be appropriately supported by the literature but is incomplete and/or imprecise, and material may be quoted/paraphrased with no clear indication of the significance of ideas. Assessment format partially conforms to guidelines, but sections are missing or irrelevant information has been included.
6-6.9 Literature from inappropriate sources has been included, consumer or proprietary material has been used, items that do not address the relevant cultural context have been used, and only a few items derive from refereed journals or organizations of recognized standing in the field of public health. Literature is quoted/paraphrased with no discussion of the significance or ideas or in the context of original analysis. Assessment format mostly conforms to guidelines, but sections are missing or irrelevant information has been included, while required information is omitted.
5-5.9 Literature from inappropriate sources has been used, consumer or proprietary material has been used, items that do not address the relevant cultural context have been used, and use of items from refereed journals or organizations of recognized standing in the field of public health is minimal or non-existent. Guidelines have not been followed and/or part or all of the assessment does not address the assigned topic.
Assessment Fail
Writing style is appropriate and a suitable level of integrity is maintained
All text represents original language and ideas. Material taken from other sources is fully cited in accordance with academic conventions, text is logically coherent, language used is formal and stylistically appropriate. Original analysis and material taken from cited sources is clearly discernible.
8.5-10 All text represents original language and ideas, material taken from other sources is cited, text is generally logically coherent, and language used is formal and stylistically appropriate. Original analysis and material taken from cited sources is discernible but may be unclear at times.
7-8.4 All text represents original language and ideas but a large number of direct quotations have been used and/or large sections of material paraphrased from the literature has been included with no discussion of the significance of the material. Material taken from other sources is cited but contains errors or is incomplete, discussion lacks logical coherence, and an attempt has been made to use language that is formal and stylistically appropriate for a piece of university assessment but language that is unclear, imprecise, and/or stylistically inappropriate may be present. The distinction between original analysis and material taken from cited sources is often unclear.
6-6.9 A large number of direct quotations have been used and/or large sections of material paraphrased from the literature has been included with no discussion of the significance of the material. Material taken from other sources is cited but contains errors or is incomplete and discussion lacks logical coherence. An attempt has been made to use language that is formal and stylistically appropriate for a piece of university assessment but language that is unclear, imprecise, and/or stylistically inappropriate is used significantly. The distinction between original analysis and material taken from cited sources is not clear.
5-5.9 Assessment contains text that has been copied from sources or inadequately paraphrased, citations are incomplete or missing, discussion lacks logical coherence, and/or language that is unclear, imprecise, and/or stylistically inappropriate is used.
Assessment Fail
Assessment 1
Case Study
Suicide in Older People in Australia
PBHL20010
Unit Coordinator: Dr Rebecca Fanany
Laura Palmer
Student ID: 02021901
Introduction
Suicide is a major public health concern in Australia and is the leading cause of death among those aged 15 to 49 years of age (Department of Health and Aged Care 2021a). It is not widely known, however, that the highest risk of suicide by age in Australia is among men aged 85 and over (Suicide Prevention Australia 2022a). Suicide among older people (aged 65 and older) is becoming an increasing concern due to a number of social and cultural factors in Australian society which could impact the likelihood of recognizing risk factors for suicide and attempted suicide while also influencing the likelihood of effective interactions between older people and healthcare/medical personnel (De Leo 2022). Suicide among older people impacts society on a number of levels and, as a growing public health concern, gives insight into the nature of mental health issues and perceptions of these issues within Australian society. This case study examines the significance of these issues and considers the effectiveness of initiatives that are in place to address suicide in older Australians.
Population at Risk
While suicide is statistically more prevalent in Australia among those age 15 to 49 years of age, it is significant that it is the 85+ age group that is at the highest risk as an age-specific group. This suggests that there might be risk factors among the older age group that are not commonly recognized and that could be contributing to a societal trend that places older people outside of the culturally accepted realm that is generally acknowledged as in need of this aspect of mental health support. This is additionally supported by cases of silent suicide that research suggests could account for a significant number of deaths in older people one of the most common forms of silent suicide is voluntary stopping eating and drinking (VSED) (De Leo 2022). VSED as a method of suicide/attempted suicide has been observed for a long time and is almost entirely ignored among medical and legal practitioners alike (Pope 2017), as opposed to a more commonly recognized method such as medical aid in dying (MAID). Unlike the more overt MAID, VSED deaths are extremely rarely registered as suicides (De Leo 2022). This further suggests that suicide among older people could be even more prevalent than is apparent through statistical analysis alone.
Among those aged 85 and over, men are the most at risk of suicide but it is significant that age distribution of suicide deaths is similar among men and women (Australian Institute of Health and Welfare 2022b). This suggests that risk factors for suicide that are similar among both genders but that there could be other factors that are significant in determining the response to those risks in Australian society. Some of the significant risk factors for suicide include bereavement, social isolation, loss of independence due to physical injury/illness, sensory loss or impairment, chronic pain, chronic physical and/or mental illness, and financial difficulties (Life in Mind 2022). These risk factors are likely to be prevalent in both genders, but it is possible that they may affect men and women differently. Cultural background, for example, might be a significant factor in determining how men and women in Australia respond to pain or chronic illness and how they perceive the severity of illness. Differing attitudes toward the acceptability of seeking medical treatment could lead men and women to experience chronic illness as more or less severe and disturbing to normal functioning within their established social roles. Similarly, men and women in Australia might perceive physical injury and/or disability as more or less acceptable due to underlying cultural perceptions that could, in turn, impact the experience of severity of a loss of independence. These cultural factors could be especially true in the case of the Australian indigenous community, which is at high risk for suicide across age groups (AIHW 2022a). Canuto et. al (2018) noted that both intrinsic and extrinsic cultural barriers exist that influence the ability and willingness of Aboriginal and Torres Strait Islander men to seek primary health care services, including personal discomfort, fear, lack of knowledge, shame, long waiting times, and culturally inappropriate staff. These factors could be significant in affecting the risk of suicide in the older indigenous population as well as potentially influencing attitudes of health care providers toward those at risk.
Physical and/or mental illness is likely one of the most significant risk factors for suicide in older persons in Australia. While factors such as social isolation, financial stress, or loss of purpose are significant risk factors, research suggests that illness is a major determinant in risk of suicide. In a study of typologies of persons who died by suicide, Clapperton et. al (2020) found that physical illness and mood disorders were prevalent in those aged 65+ to a significantly greater extent than situational stressors. They note that illness and depression are often linked, their findings suggest that suffering from physical and/or mental illness could be a more significant factor leading to suicide in older people than outside influences. It is worth noting, however, that there could be a number of related social and cultural factors that contribute to this finding, however, which were beyond the scope of the authors research. A lack of interpersonal support through family and other social networks, for example, could be a key factor in determining the extent to which physical and mental illness affects older people.
The effect of an absence of interpersonal relationships is also especially significant when considering the older community as life changes in old age in particular, retirement and transitioning from employment to retirement can trigger or intensify mental health issues that can lead to an increased risk of suicide. Page et. al (2020) observed a connection between suicide and attempted suicide and unemployment in older people, with a greater risk observed in those who were not working (but not retired) and those who retired involuntarily. The authors also noted that the presence of social relationships, and especially married or de facto relationships, was significant in reducing the risk in these groups. This is suggestive not only of the importance of a sense of purpose in older people and especially men that is often achieved through employment that continues into old age, but also highlights the interconnectedness of risk factors that impact older people in Australia.
One of the key risk factors in older people in Australia could also be the need to live in a nursing home or other aged care facility. It has been observed that almost half of all nursing home residents suffer from depression (Murphy et al. 2018). This could suggest a significantly increased risk for suicide among older people in nursing homes due to existing mental health conditions. It is worth noting, however, that the controlled environment of a nursing home with the constant presence of medical and care personnel could limit the ability and means for residents to attempt suicide (Murphy et al. 2018). In order to better understand this aspect of social context in relation to suicide in older people, the authors studied the incidence of suicide in nursing homes across all Australian states and territories through a retrospective analysis of mortality data among nursing home residents. They found that more men than women died by suicide, which coincides with known statistics among the general population. It was also found, however, that suicide was more common among younger residents in the under 65 age group and there were fewer suicides overall compared to the general population. This could be due to the environment or possible underreporting within the context of nursing homes. Similarly, while the most at risk group displayed a lower incidence of suicides, the authors note that there could be other contributing factors, including physical limitations in the 85+ age group and a greater likelihood of death from natural causes. (Murphy et al. 2018). This research is significant in the consideration of suicide in older people as a public health concern in Australia as it demonstrates an overall lack of understanding of the underlying social and experiential factors that contribute to suicide risk in older people while also highlighting the very real potential for suicide deaths in older people to be overlooked or misidentified, even in a controlled, highly supervised environment such as a nursing home.
While the perceived loss of independence associated with residence in a nursing home is an important risk factor to consider, it is also significant that living in rural areas has been found to be a strong risk factor for suicide in older Australians. Inadequate access to healthcare and untreated mental illness, often stemming from bereavement, the stress of chronic illness, and financial or other situational stressors have been identified as risk factors for suicide in older people living rural areas (Fitzpatrick et al. 2021). Interestingly, underlying mental illness was not necessarily a precipitating factor in suicide or attempted suicide in older people in rural areas, however; perceptual and experiential elements of personal significance, eg. worry about a house/farm or a desire to control the time and manner of death, appeared to be of greater importance (Fitzpatrick et al. 2021). These findings are important indicators that there are a number of similarities in risk factors for suicide in older people in both rural and urban areas and further suggests that there are complex interrelationships between physical and mental health, social roles, and perceptual experience that are significant in contributing to the risk of suicide in this community.
Planning Initiatives
Much of the research indicates that social isolation and a loss of purpose could be at the root of many of the social and experiential issues faced by older adults at risk of suicide in Australia. A lack of support is likely one of the most significant factors, especially in Australia, where it is a common cultural practice for adult children and other extended family members to live separately with relatively limited contact. Opportunities for meaningful social interaction in old age are often limited, especially due to deaths in family and friendship circles, with the social network available to older people often decreasing rapidly as age increases. Access to healthcare, including mental health care, is not always possible, but it is worth noting also that willingness to access medical treatment could also be an important factor trust in medical personnel and healthcare services could be a determinant of the extent to which older people access available services. While it is beyond the scope of this study, this could be especially important in the case of Australians from diverse cultural backgrounds. More research into this aspect of culture and risk of suicide in older people is necessary to determine the extent to which cultural considerations impact the choice to access healthcare services for older people at risk of suicide in Australia.
Social isolation is especially significant due to the potential for mental illness to develop or intensify, especially depression and related conditions, due to the absence of a social network. But it is also an important factor because of the potential for signs of suicidal ideation to be missed in the absence of close social relationships. The possibility of the presence of undiagnosed or untreated mental health issues is also significant in this context, but it is worth noting that social and experiential factors that trigger or contribute to mental illness in this context must be addressed in order for this risk to be reduced (Fitzpatrick et al. 2021). Nonetheless, the effects of social isolation on the community are multifaceted and are potentially also significant in the phenomenon of silent suicide mentioned above. Attitudes of healthcare personnel toward older people are especially important in this context, especially for those living in assisted living facilities of various kinds, such as nursing homes. The potential for suicide and suicidal ideation to be missed even in contexts where older people are in constant contact with medical or other healthcare workers suggests that there is a need for training within the healthcare system as well as more effective public health initiatives in Australia to address suicide in older people.
The research also suggests that a loss of purpose is one of the most significant factors contributing to suicide risk in older people. The effects of life changes such as retirement and the impact of anxiety over significant personal experiences or settings as noted in the research above suggests that changes in social role and the perception of relevance of experience are major triggers for suicidal ideation and significantly increase suicide risk in older people. As noted with the effects of social isolation, these factors are complex and interrelated; the loss of a loved one, for example, can result in the sudden loss of the main source of support while also drastically changing social and financial circumstances. Similarly, retirement can result in the loss of a significant activity that brings social connection but also could bring financial stress along with the perception of a drastic change or removal of an important social and cultural role. It is significant the research indicates that older people who retired voluntarily or who were not a part of the workforce did not show an increased risk of suicide (Page et al. 2020). This suggests that it is the perception of negative change and/or lack of preparedness for major life changes based on personally significant social/cultural ideals that is the significant factor in increasing the risk of suicide in older people.
Chronic illness could be the most important risk factor in older people in Australia. As noted above, chronic pain, illness, or disability is one of the most prevalent risk factors in older people who die by suicide and has been noted in various contexts to be a more significant risk factor than mental illness. As with social changes, there is a connection between chronic illness and other risk factors, with the perception of physical disability differing based on personal experience and cultural factors as noted above. The phenomenon of silent suicide is likely also connected with the prevalence of chronic illness in older people at risk of suicide and suicidal ideation, especially with VSED often ignored or implicitly encouraged by healthcare personnel (Pope 2017). Factors such as inability to access healthcare, inaccessibility of appropriate treatment options, and desire for control over the experience of illness and death are also significant in this context, and could be factors that change the perception and experience of health and healthcare in older people, in turn resulting in suicidal ideation.
The above risk factors are indicative of the aspects of the perception and experience of older people in Australia that are potentially the most useful to consider in planning initiatives to address suicide risk. The main elements of risk that appear to impact older people are based in major changes in social role. While this effect is the clearest in the effects of social isolation and a loss of purpose, the extreme mental health impacts of chronic illness can also be seen to be rooted in an intense shift in the perceptual experience of the self due to physical change and debilitation. While physical symptoms, especially pain, can be upsetting and difficult to manage, it is worth noting that experiences of illness are not unique to old age, nor do all older people experience mental health issues as a result of illness. The research suggests that it is this often unwelcome shift in the personal experience of the self and societal interactions, eg. loss of family relationships, loss of professional status, etc. As such, health promotion activities aimed at reducing the risk of suicide in older people should be targeted at addressing this underlying perceptual need to maintain a societal role in older people. This includes facilitating the perception of self in individuals that is similar to that experienced in early life or that allows for an easier transition into a new stage of life. It is worth noting that certain aspects of the life experience of older people can be difficult to address through external means, eg. pain management for sufferers of chronic illness could be possible but it is not possible to directly address the loss of friends and/or family due to death in old age. Health promotion activities and initiatives targeted at older people should instead aim to provide physical and experiential opportunities to the older community that enhance the perception of choice, independence, and inclusion that are often removed due to the drastic life changes that come with old age.
Review of Existing Initiatives
Existing initiatives addressing suicide and suicide risk in older adults in Australia center on materials promoting awareness and information on available healthcare services. A number of organizations exist that conduct research into suicide and suicide risk in Australia. Some of the most notable include Beyond Blue, the Black Dog Institute, Suicide Prevention Australia, and Lifeline Australia. These NGOs provide extensive resources on suicide as a societal issue and public health concern in Australia but all these organizations take a broad approach to suicide and suicide risk without any particular focus or emphasis on specific risk factors such as age. With the exception of services for youth communities, eg. Kids Helpline, there are no targeted services, communities, or resources that are specifically for older communities outside of health promotion resources focusing on awareness.
While it is beyond the scope of this paper to examine each organization providing support services to older adults at risk of suicide, it is worth considering the resources presented by some of the most representative organizations in Australia. The Black Dog Institute is an independent organization affiliated with the University of Sydney. The organization provides primarily research based services with a focus on mental health issues in the community at large, with emphasis on a number of areas deemed to be of social and cultural significance, such as digital innovation, lived experience, youth, mental health in workplace settings, and suicide prevention (Black Dog Institute 2022a). Suicide Prevention Australia is a member-based organization focused on research-based policy and strategic planning centering on suicide prevention initiatives. Their work focuses on building stakeholder relationships and influence policy planning through research (Suicide Prevention Australia 2022b).
It is significant that the organizations mentioned above present information through involved websites, many of which include resources for multiple mental health concerns. In the case of the Black Dog Institute and Suicide Prevention Australia, the resources include various phone helplines for individuals experiencing suicidal thoughts or who are seeking support for mental health concerns (Black Dog Institute 2022b; Suicide Prevention Australia 2022c). As primarily research-focused organizations, the support services for the older community are limited, as are health promotion information and resources specifically targeting the older, at risk population.
Beyond Blue is a well known independent organization providing information, services, and support throughout Australia. Their work centers on promoting mental health, providing information and resources, and suicide prevention. It is significant that one of the key goals of Beyond Blue is to disseminate information to the community at large and reduce stigma associated with mental health issues, including suicide, by providing accessible resources not only to individuals and online, but also in community spaces, workplace settings, and educational settings (Beyond Blue 2022a). Unlike the institutions discussed above which focus on strategic planning through research, Beyond Blue can be seen to be a more directly accessible community organization it is likely that the availability of materials through public and community spaces gives Beyond Blue a more prevalent position in shared cultural consciousness within the community, which, in turn, suggests that services aimed at reducing suicide and supporting those at risk might be more widely utilized. One of the ways that Beyond Blue aims to address suicide in older adults specifically is through the provision of training in supporting sufferers of depression and anxiety and managing these conditions. The organization also provides published resources for family, friends, and healthcare personnel detailing signs of mental illness and suicidal ideation and supportive strategies for addressing these concerns within the broad social network of older communities (Beyond Blue 2022b). This emphasis on practical strategies and the presentation of information that is accessible throughout the community is indicative of the broad approach to suicide prevention in older communities taken by the organization, where suicide risk is approached from the perspective of both providing support to those at risk as well as guiding and informing the social networks around them.
The Australian government also has initiatives in place to address suicide in the community. A number of independent organizations targeting at risk population groups are funded by the government, including Beyond Blue, Kids Helpline, the Suicide Callback Service, Lifeline, and the National Suicide and Self-Harm Monitoring Service. Research into suicide prevention is also funded through government grants and research is supported by the Suicide Prevention Research Fund. Collaborative planning is also a focus of government initiatives, including with organizations in Australia and internationally. Strategies such as the National Suicide Prevention Strategy, National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, Fifth National Mental Health and Suicide Prevention Plan, and National mental Health and Wellbeing Pandemic Response Plan are also in place to raise awareness of suicide risk and support those impacted by suicide and formalize the commitment of government at the state and national levels to suicide prevention research and planning throughout Australia (DHAC 2021b).
While the Australian government has committed considerable resources, including financial resources, to research and policy development focusing on suicide prevention, it is worth noting that there is a lack of information specifically targeted at the older, at risk population available through the Australian government online resources. Much of the information available on the suicide prevention page of the Department of Health and Aged Care website relates to policy documents that are not relevant in most subsections of the community and specific information about support services is limited to links to the websites of independent organizations such as those discussed above. While this is not necessarily inconsistent with the role of government as an authority outside of the domain of the everyday experience of the general population, including the aged population, it is significant that access to resources for specific population subgroups is not easily gained through the government website.
It can be seen through an examination of representative sources of information and support services that online resources represent the primary mode of dissemination of materials targeting at risk populations and the community affected by suicide in older adults in Australia. This is significant in that it is likely that older Australians who are in need of physical and/or mental health support might not necessarily seek out online resources, nor are all members of the community automatically able to access information and services online. It is likely that the broad approach taken by Beyond Blue, who targets both at risk communities and those directly and indirectly affected by suicide within those communities, and who provides both information and practical strategies through real-life settings, would be the most effective in influencing at risk community groups. Even in light of these differences in approach, however, it is significant that initiatives tend to focus on the general population, youth, and indigenous communities. While these aspects of strategic development are essential in the context of the Australian cultural context, it is also the case that the older community remains one of the most at risk population subgroups and, as such, requires policy development that takes the specific risks and social/cultural experiences of that subgroup into account.
A Systems Approach to the Case
While the most overt impact of suicide in older people is to the aged community itself, there are a number of associated societal effects. Deaths by suicide can be the result of the culmination of the effects of diagnosed or undiagnosed mental illness resulting from a number of social and cultural factors described above. When suicide occurs in older communities, there can be a subsequent impact triggering mental health issues in adjacent communities. This could be due to the extreme emotional impact of suicide as well as the stigma associated with death by suicide in Australian culture. This further indicates that high rates of suicide in one age group in this case, older adults aged over 65 can subsequently trigger mental health issues stemming from guilt, trauma, shock, and grief throughout the community.
Suicide contagion is a factor that has not been researched in depth in older communities but that could be significant in considering the systemic impacts of suicide in older people. Suicide contagion refers to the clustering of suicides or attempted suicides after an individual suicide or presentation of suicidal behavior (Headspace 2015). The nature of suicide contagion has been examined in detail, especially in relation to the effects of media reporting and social media, especially in young people (see, for example, Ortiz and Khin Khin (2018), Hill et al. (2020), and Edwards et al. (2020)). The full impact of suicide contagion is not completely understood but research suggests that health impacts of suicide deaths potentially affect a large number of surrounding people, including many who may not be directly or overtly related (Maple & Sanford 2020). While the potential for this contagion to spread in younger age groups has been examined to some extent, there is little research that considers this effect in the context of older adults. While the media, including social media, represents a clear means for both official and unofficial reports of suicide/suicidal behavior to be disseminated throughout the population, it is likely that older adults do not make use of social media to such a great extent. There are, however, significant means available to older people for exposure to suicides and suicidal behavior to spread. One scenario for this aspect of systemic effect on older people is likely to occur within the context of aged care facilities. Because of the closeness of residents in assisted living facilities of various kinds, as well as the tendency for suicidal ideation to be overlooked as in the case of VSED, the possibility of suicide contagion among older people could be a hidden public health concern. While suicide contagion as a specific phenomenon has not been studied in detail in this context, research suggests that the impacts of suicide death go beyond the immediate contacts of the victim and include first responders, members of the community, colleagues, and acquaintances. In the case of older people, the systemic impact of suicide could include indirect mental health effects on the community at large and, in the case of hidden suicide, could include an immediate social circle (family and/or friends) and medical personnel who may be witnesses or participants in suicidal behavior.
It is significant that there are strong ethical implications associated with suicide in older adults. The most overt representation of this is in the context of medically assisted suicide and VSED. Chronic illness is noted as a main risk factor for suicide in older people, suggesting that the involvement of medical personnel goes beyond assisted suicide and also impacts the nature of experience, perception, and mental health leading to suicidal ideation. The negative mental health impacts of living with pain and physical debilitation are extremely significant in this context and the effects in triggering suicidal behavior in older people could suggest that the medical establishment is not equipped to address the physical impacts of illness in old age or the associated mental health effects.
The ethics surrounding suicide in older people additionally complicate the nature of research into suicide risk and its effects. While initiatives for researching and addressing suicide in older people is often conducted by government organizations or NGOs that are peripherally associated with the government as noted above, but there is no official guideline for approaching the ethical impacts of suicide research and prevention strategies. The perceptual trend that is common in Australian culture of older people as inherently vulnerable creates avenues for coercion and exploitation in the context of research requiring direct contact with older people who have attempted suicide. The authors interviews with older survivors of suicide attempts suggests that the coercive nature and distress caused by research methods into suicide could be a factor limiting the insight gained by research into the particular risk factors affecting the older community. Additionally, they note a need for ethical policy makers to consider age-specific factors specifically within the context of studies could impact and create vulnerability within the older community (Deuter & Jaworski 2017). The ethical implications of research requiring direct contact with the community at risk are indicative of the need for a broad, interdisciplinary approach to the development of initiatives and further illustrate the involvement of multiple societal and institutional stakeholders.
It is worth noting the economic implications of suicide in older people in considering the systemic effects of suicide in older people. This could be especially significant in the case of effects on the immediate social networks surrounding older communities and especially in rural areas. As noted above, risk of suicide in older people is high in rural Australia and financial factors can be significant in this context. For older people with family or community ties, the financial impacts of sudden death by suicide could be severe but, even in those without these connections, there is a societal impact associated with property, debt, and a significant loss to the community and industry in rural communities. In the case of the complicated ethical considerations affecting medical and healthcare personnel, limited resources could be a factor that severely limits the nature of care that is possible in facilities for older, at risk communities. In the case of research into suicide and the development of initiatives, there is not only an economic factor that underlies the activities of governmental and non-governmental organizations, but also the additional complicating factor of potentially conflicting interests of the stakeholders involved. Research approaching the issue from a health/medical perspective that focuses on physical and mental wellbeing, for example, might not be in line with government initiatives concerned with the economic impacts of diminishing populations in rural areas.
Risks and Advantages
One of the main risks associated with initiatives aimed at addressing risk of suicide in older adults comes from the media through which strategies are presented. As noted above, most materials targeted at older people are presented through online informational websites. There are a number of barriers that could prevent members of the aged population from accessing available information due to limited ability to access technology, including physical limitations, lack of knowledge and/or confidence to use technology, and a lack of trust in online health services (Wilson et al. 2021). E-health services and informational materials presented through online media that are intended to be accessed by members of the older, at risk community might be perceived as irrelevant, untrustworthy, or inaccessible for these reasons. Accessibility is itself a serious issue in considering the risk to the older population in Australia as well as many older adults lack the willingness and/or knowledge to access information and cultivate an online presence as is common among younger age groups. Research suggests that just over half (52%) of older adults suffering from chronic disease utilize online resources in Australia and 68% of those access health information online (Burns et al. 2018). As chronic illness is a risk factor for suicide as discussed above, it is likely that the proportion of the older, at risk community that accesses online health services is quite low in light of these figures. This further suggests that there is a great risk that available services are being underutilized by at risk members of the community.
Another significant risk is the focus on training of medical personnel without consideration of social and cultural factors impacting at risk communities. As discussed above, research into the underlying risk factors contributing to suicidal ideation in older adults suggests that mental illness is frequently a symptom of an underlying physical or emotional trigger for suicidal ideation, as opposed to the initial trigger. There is a strong risk that training initiatives targeting medical personnel who work with older adults who are diagnosed or deemed at risk for mental illness will contribute to the hidden suicide phenomenon that has been noted especially among sufferers of chronic illness. While mental illness and mental health issues among older adults in Australia is a significant aspect of the complex issue of suicide risk, research indicates that the perception of change and/or loss connected to personally significant symbols (including property, mementos, etc. as well as relationships) and life events are more significant primary triggers for suicidal ideation in older adults than the presence of mental illness. There is, then, a risk that medicalization of initiatives and strategies could overlook communities that are most at risk and drastically reduce in effectiveness in encouraging at risk communities to seek social or medical assistance.
It is worth noting, however, that there are advantages to training programs that aim to facilitate the recognition of suicidal behavior and ideation and subsequent provision of treatment/assistance by healthcare workers. The most notable advantage is in increasing the likelihood of that suicidal ideation will be recognized in the first place suicidal behavior is often preceded by presentation at a healthcare provider up to a month before a suicide attempt takes place. This contact with healthcare services often relates to unrelated physical or mental health complaints although, in the case of older adults, commonly recognized warning signs indicating suicidal ideation can be subtle or hidden (Fry et al. 2019). The authors note the importance of the role of emergency personnel in recognizing these warning signs in older adults, but this further suggests that there is a significant risk of suicidal behavior and/or ideation to be overlooked outside of emergency treatment or contexts where older, at risk adults might be hospitalized. Training, then, could play an important role in the context of aged care, and especially outpatient facilities and service providers outside of a healthcare setting, especially when combined with training in cultural awareness and mental health first aid.
Expert Assessment
It can be seen from the above discussion that there are significant gaps in the strategic planning associated with suicide prevention in older adults in Australia, especially in terms of the development of resources and services that aim to address the underlying perceptual experience that often leads to suicidal ideation, as opposed to generalized mental health support. While there is a place for this type of initiative, the research indicates that mental health issues are rarely the initial primary trigger for suicidal ideation in older adults, further suggesting that general support services will not be the most effective for this population subgroup. Instead of presenting information and promoting helpline services, many of which are likely inaccessible or undesirable to large subsections of the older community, a focus on services that address the specific elements of perceptual experience that lead to suicidal ideation in older adults is necessary.
As noted above, experiences of loss are a major risk factor for suicide in older adults. This loss could be tangible, eg. death of loved ones, or intangible and experiential, eg. loss of purpose. Research suggests that supportive services that aid older suicide attempters in finding internal purpose provide significant protective factors against further suicidal behavior. This could include personally significant perceptual and experiential purpose, such as religious fulfilment and understanding, or meaningful activities, including hobbies such as music, knitting, writing, etc (Deuter et al. 2020). It is significant that participation in meaningful activities that include a community or group element, eg. writing groups, music lessons/ensembles, etc., were found to significantly improve the experience of self in suicide attempters and drastically reduce or eliminate the likelihood of further attempts. This suggests that the aspect of loss that is one of the most significant risk factors in older adults, i.e. loss of loved ones who constituted the social support network of members of the aged population, can be alleviated through support in finding and establishing even a small social connection in the context of a personally meaningful activity or interest. Initiatives that aim to provide avenues for the exploration of meaningful activities, then, would be instrumental in addressing suicide risk in older adults, eg. through the funding and establishment of community centers that provide activities through lessons, groups, or clubs.
The issue of chronic illness as a risk factor is arguably the hardest to address as it is not always possible to address the symptoms of illness that are the most psychologically difficult to accept when medical interventions fail or are exhausted. While it is possible that easier access to palliative care and treatments for older sufferers of chronic illness would contribute to easing the physical and mental toll illness often takes in the aged population, this is not always possible outside of in-patient facilities and can create additional issues in sufferers, such as side effects and/or debilitation from medication and the exacerbation of the sense of loss due to a reliance on healthcare services or personnel that is one of the most significant risk factors in and of itself. One strategy that might work to alleviate some of the mental health impacts of chronic illness that could lead to suicidal ideation could include support in reframing the self-experience of sufferers to better integrate a physical state altered by illness into their perceptual framework. As with the concept of internal purpose mentioned above, this kind of psychological support might be more effective than initiatives aimed at addressing generalized anxiety and depressive disorders due to the focus on developing an internal understanding that could provide a sense of agency in sufferers that would give a sense of psychological independence from illness, even in those who are physically dependent due to debilitation.
A loss of purpose can be one of the most difficult risk factors to address due to the fact that many members of the aged population lack social connections. While the research into external purpose through non-human contact among older adults is limited, there is an indication that pets can be a motivating factor in older adults experiencing suicidal ideation (Young et al. 2020). While the research suggests that the perception of being needed, depended on, and responsible for an animal could be a protective factor for older, at risk adults, it is worth noting that there are significant ethical considerations associated with promoting this kind of strategy for suicide prevention. It is not always the case that sufferers of physical or mental illness would have the ability to care and provide for the needs of an animal, especially outside of structured settings, such as aged care or assisted living facilities. Nonetheless, the provision of opportunities to interact with animals could be an effective strategy for addressing suicidal ideation in the aged population, although more research is necessary to determine the most beneficial and ethical way to facilitate this in this context.
Due to the complicated and multifaceted nature of risk factors contributing to suicide risk in the aged population in Australia, it is necessary to approach strategic planning and policy making from the experiential perspective of the older adult community. While there are complicating factors associated with the implementation of the strategies mentioned above, most notably in the certain practical aspects and the high level of training that would be required by facilitators and aged care personnel, these strategies are illustrative of the need for real life initiatives with a basis in the experiential knowledge specific to the older Australian community. Because of this, regardless of the direction policymaking might take at the organizational level in the future, significant research is necessary into the cultural knowledge and experience that is the most significant to this population subgroup. Understanding the perceptual basis that forms the lens through which older adults experience the life changes, including in the sense of self, of old age is necessary to maximize the effectiveness of any initiatives that are aimed at this community in the future.
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