Department of Rural Health, The University of Melbourne, 49 Graham St Shepparton, Vic, 3630, Australia.
School of Public Health and Social Work, Queensland University of Technology, Kelvin Grove Campus, Kelvin Grove, Brisbane, Qld, 4059, Australia.
Soc Sci Med. 2021 Nov;289:114449. doi: 10.1016/j.socscimed.2021.114449. Epub 2021 Oct 1.
Across the globe, people are not equitably included or respected by health services. This results in some people being 'hardly reached' and having less access to safe and appropriate care. While some health services have adopted specific agendas to increase inclusion, these services can struggle to implement such strategies because the underlying reasons for exclusion have not been addressed. This calls for preparation prior to implementation of inclusion approaches that deconstructs discourses and practices of exclusion. This paper presents a pre-inclusion framework that seeks to deconstruct exclusion in health services. Authors developed this framework from action research in four 'mainstream' regional health services in southeast Australia over five years. Research identified dominant discourses of exclusion among staff in these services. The study also identified common experiences of residents hardly reached by these services. Following, a range of change activities were undertaken within these services to deconstruct exclusion. Researchers also kept journals, reflected on their impact, and identified lessons learned from trying to deconstruct exclusion. Triangulating these analyses, researchers developed an interdisciplinary framework that weaves together Foucauldian theory on power/discourse with continuous quality improvement processes to embed cultural humility and voices of the hardly reached in health care. The framework outlines five foundational concepts (power as productive, deconstruction, use of continuous quality improvement processes, cultural humility and voices of service users), followed by six principles (a journey, expect resistance, whole of service approach, make visible the reasons for change, we are all cultural beings and people centred care) and six actions undertaken within health services (commitment, assessment of exclusion, action plans, structural change, reflective discussions and engagement). Until such approaches to deconstruct exclusion are implemented, inclusive agendas are likely to be ineffective.
在全球范围内，人们并没有被医疗服务平等地接纳或尊重。这导致一些人难以被触及，他们获得安全和适当的护理的机会也较少。虽然一些医疗服务机构已经采取了具体的方案来提高包容性，但这些服务机构可能难以实施这些策略，因为没有解决导致排斥的根本原因。这就需要在实施包容方法之前进行准备，以解构排斥的话语和实践。本文提出了一个预包容框架，旨在解构医疗服务中的排斥。作者在五年的时间里，在澳大利亚东南部的四个“主流”地区卫生服务机构进行了行动研究，从而开发了这个框架。研究发现，这些服务机构的工作人员中存在着排斥的主导话语。研究还发现了这些服务机构中难以被触及的居民的共同经历。随后，在这些服务机构中开展了一系列变革活动，以解构排斥。研究人员还撰写了日记，反思了他们的影响，并从试图解构排斥中吸取了经验教训。通过对这些分析进行三角剖分，研究人员开发了一个跨学科框架，将福柯关于权力/话语的理论与持续质量改进过程编织在一起，以将文化谦逊和服务对象的声音嵌入到医疗保健中。该框架概述了五个基础概念（权力是生产性的、解构、使用持续质量改进过程、文化谦逊和服务对象的声音），然后是六个原则（旅程、预期阻力、整体服务方法、使变革的原因可见、我们都是文化的存在和以人为中心的护理）和六个在卫生服务机构中采取的行动（承诺、排斥评估、行动计划、结构变革、反思性讨论和参与）。在实施解构排斥的方法之前，包容性议程可能不会有效。
