download PDF
full article:
Health justice partnerships (HJPs; also referred to as advocacy health alliances, AHAs, and medical legal partnerships, MLPs) offer an innovative model for integrated health and legal services where health-medical practitioners work collaboratively with legal practitioners, in the same location, to support clients with dual health and legal issues1.
This service model offers new opportunities to assist individuals with limited access to service provision, and who are experiencing complex health, wellbeing and legal issues. Young people may experience a range of elevated health impacts associated with legal issues2,3. Research suggests that young people with multiple legal problems generally try to address these problems without seeking legal advice4. This can trigger additional legal issues and an escalation in the seriousness of the issue.
In regional and remote Australia, health outcomes are poorer than in metropolitan areas5.Barriers to service access for mental health patients in rural and remote communities include distance and financial costs6. As well, availability of services, timeliness of accessing services and acceptability of the service in meeting the needs of consumers can further impact on the health of people in rural and regional areas of Australia7.
There is a growing body of evidence of the benefits of an HJP model to support the health and legal issues for disadvantaged people8-10 including young people and people in rural areas, where legal services are provided in partnership with healthcare providers.
While HJPs have been widely adopted in the USA1,11 and in other developed countries, they are only just becoming established in Australia12,13. A recent review of research into MLPs and its application for clients with mental health issues concluded that MLPs within the Australian context may offer greater opportunities to address the challenges experienced for those living in rural and remote locations1.
To address the legal and health needs of young people in rural and regional Victoria an HJP was established as a partnership between a regional university, a community legal centre and a community health centre (with integration of the service occurring between the latter two organisations).
This HJP was established in a region of approximately 49 000km2 and a population of 227 000 of which approximately 13% of the population are young people, aged 15-24 years14. The region comprises a mix of larger regional service centres, smaller towns and rural localities. The three key objectives associated with this project are to:
- improve, through early intervention, the health and legal outcomes for young people aged 15-25 years through the implementation of an early intervention health justice partnership in the region
- build capacity of agency partners to understand the impact of environmental issues, such as legal problems, on the health and wellbeing of young people in the region, aged 15-25 years
- increase the awareness amongst young people (patient/clients) about the legal resources available in the region and statewide.
Evaluative research is being conducted alongside this program to examine (1) the contribution of the program on outcomes for young people, (2) how the HJP influences the resolution of legal issues - and their impact on health - for young people, and (3) the referral and practice outcomes for partner (and other) organisations. This article reports on the preliminary findings from the HJP during its first 6 months of an 18-month program.
Program overview
The HJP program commenced in mid-2015 and offers legal services (supported by a part-time lawyer and administrative officer) to young people aged up to 25 years. A large community health centre, located in a major regional service centre, was the location for the HJP program delivery. The flexibility of the program ensures that any young person referred to the program can access the service from where they live, or at another location that is convenient and safe.
Referrals to the program are received from partner and external agencies; young people can also self-refer. The main methods for referral include the program website, text messages, and telephone and/or through informal discussions between agency workers and the youth lawyer. HJPs are based on the premise that young people will delay accessing legal services and may not identify that their problem has a legal remedy. Hence, young people are more likely to access other services such as health or housing instead of seeking assistance from a lawyer to resolve their underlying legal issues.
To increase capacity of other agency workers and ensure timeliness of referrals, a legal health check (LHC) was developed. The one-page LHC consists of a series of questions that agency staff and young people can use to identify whether they have a legal problem and the process for referring to the HJP.
Research methods comprised survey data, and secondary data from the partner agencies.
Initial data was collected using surveys with each key stakeholder group (clients of the program, staff at both collaborating agencies). An intake survey and an exit survey were developed for clients. The survey development was informed by the work of Burns et al15, Coumarelos et al4 and Dr Liz Curren (lecturer, Australian National University).
The intake survey comprised questions about demographics, past and current legal issues and whether (and in what ways) the legal issue impacted on health and wellbeing. The exit survey sought input from clients about accessing the HJP program, the resolution of the legal problem and whether they would recommend the program to others. Client surveys were available in hard copy and online (web survey). iPads were made available to enable clients to complete survey online. Both surveys were developed for young people using 'easy English'. Only those young people aged 16-25 years were invited to participate in the evaluation research.
Online surveys were also used to collect data from staff at the two partner organisations in which the service is integrated. Staff surveys sought to capture reflections about the HJP program, how it is informing staff practice and their observations about the impact of the program on clients.
All surveys comprised a range of response options which included a combination of open-ended questions, close-ended questions and Likert scale responses. Survey responses were analysed, where appropriate, using thematic and quantitative techniques.
Secondary data collected by one of the partner agencies were also examined. This data (quantitative) is being used to provide an overview of all clients who accessed the service providing details about (de-identified) client demographics and information about legal issues for which young people sought advice through this program. Further analysis of this data occurred at the end of the program, in late 2016.
All clients referred to the HJP were invited to participate in the research. Staff across both partner agencies received emails inviting them to participate in the research.
Ethics approval
Ethics approval for this research was granted by Federation University Australia Human Research Ethics Committee (approval number A15-061).
Insights from the secondary data
Program uptake: Secondary data reveals that 57 clients were referred to the HJP program in the first 6 months of operation with 52 clients entering the program (41 new clients and 11 repeat clients). Clients came from a broad geographic area: four clients resided in rural areas with populations of 3000 or less (based on postcodes) and clients were from predominantly disadvantaged backgrounds including Aboriginal and Torres Strait Islanders (n=5), clients with a disability (n=18) and clients with low incomes (n=47). Six clients were aged less than 18 years; the remainder were all between 18 and 26 years.
Health and legal issues of young people: The secondary data indicate that the young people referred to the program were experiencing a range of legal issues ranging from theft, tenancy issues, credit debt, traffic infringements, drug trafficking, assault and property damage.
Insights from the evaluation research
The intake survey was completed by 15 young people, with most (n=13) indicating that their legal problem was very important to them and was affecting how supported they felt (80%), their stress levels (73%), concentration (73%), sleep (73%), their overall feelings of wellness (73%) and their confidence (60%). Furthermore, three clients commented that the legal problem was affecting their lives in other ways including their ability to drive their car (whether this was because of the type of legal problem or due to health reasons brought on by the legal problem is uncertain), financial pressures, and 'feeling left in the dark about things'.
The majority of survey clients (n=11) had their legal issue for more than 1 month; some young people (n=5) had had their legal issue for more than 6 months.
Staff reflections: Seven staff (a total of 27 staff from two service areas: youth services and alcohol and other drug) from the partner organisations completed surveys, with most (n=5) observing positive outcomes for their clients following referral to the HJP. When asked to describe the outcomes they had observed, three staff commented that their clients had resumed normal levels of daily functioning, with two being less anxious or worried. Staff also commented that the integrated HJP model was building staff capacity, increasing their knowledge about legal issues and the impact of legal issues on the health and wellbeing of their clients.
Learnings so far: The preliminary data suggest that the program is starting to meet its objectives; referrals to the program are occurring and young people are identifying links between their legal issues and their health and wellbeing. Data suggest that the integrated model is also having a positive impact on the knowledge and work practices of staff from the partner agency.
Client participation in this research indicates that approximately one-third of all referred clients have participated in this research and completed intake surveys. Completion rates of the exit surveys, however, have been low (only one exit survey has been completed). An amendment to the method for capturing research data is currently under way to encourage greater participation from clients.
Preliminary research findings are consistent with the published literature supporting the benefits of an HJP model on health and legal issues for disadvantaged young people8-10 living in rural and regional areas1,7. Survey data will continue to be collected for the remainder of the program with methods of data collection expanded to include interviews with clients, and with staff from the two participating agencies. Staff from external agencies that have referred clients to the HJP will also be asked to contribute insights about the HJP through a survey and interview to further triangulate the data being collected.
The findings from this first stage of research into the establishment of an HJP to address the health and legal needs of young people in regional Victoria are promising. They suggest that the aims for establishing the HJP are being met, with young people - many from disadvantaged backgrounds (and from a broad geographic spread) - being referred to and accessing the program. Clients and staff have also identified an understanding of the impact of legal issues on the health of young people. Continued research across the timeline of this HJP program will offer veracity for these initial findings and provide deeper insights about the program and of the implementation of an HJP for youth in regional areas of Australia.
Acknowledgements
Funding for this project was received from the Victorian Legal Services Board grants. Thanks also to Dr Liz Curren (lecturer, Australian National University) for sharing insights about her work in evaluating the HJP at the Advocacy and Rights Centre Bendigo, Victoria.
References
1. Speldewinde CA, Parsons I. Medical-legal partnerships: the role of mental health providers and legal authorities in the development of a coordinated approach to supporting mental health clients' legal needs in regional and rural settings. Rural and Remote Health (Online) 2015; 15: 3387. Available: www.rrh.org.au (Accessed 23 March 2016).
2. Macourt D. Youth and the law: the impact of legal problems on young people. Updating Justice 2014; 38.
3. Pleasence P, Balmer NJ, Hagel A. Health inequality and access to justice: young people, mental health and legal issues. Available: http://www.thelegaleducationfoundation.org/wp-content/uploads/2015/12/SDYPMH_report.pdf (Accessed 23 March 2016).
4. Coumarelos C, Macourt D, People J, McDonald HM, Wei Z, Iriana R, et al. Legal Australia-wide survey legal need in Victoria, access to justice and legal needs. Volume 14. Sydney: Law and Justice Foundation of NSW, 2012.
5. Vines R. Equity in health and wellbeing: why does regional, rural and remote Australia matter? InPsych 2011; 33 (5).
6. Perkins D, Fuller J, Kelly BJ, Lewin TJ, Fitzgerald M, Coleman C, et al. Factors associated with reported service use for mental health problems by residents in rural and remote communities: cross sectional findings from a baseline survey. BMC Health Services Research 2013; 13: 157. https://doi.org/10.1186/1472-6963-13-157
7. Russell DJ, Humphreys JS, Ward B, Chisholm M, Buykx P, McGrail M, et al. Helping policy-makers address rural health access problems. Australian Journal of Rural Health 2013; 21: 61-71. https://doi.org/10.1111/ajr.12023
8. Klein KD, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children - outcomes from a successful partnership between professionals. Journal of Health Care for the Poor and Underserved 2013; 24(3): 1063-1073. https://doi.org/10.1353/hpu.2013.0147
9. Beck AF, Klein MD, Schaffzin JK, Tallent V, Gillam M, Kahn RS. Identifying and treating a substandard housing cluster using a medical-legal partnership. Pediatrics 2012; 130(5): 831-838. https://doi.org/10.1542/peds.2012-0769
10. Beeson T, McCallister BD, Regenstein M. Making the case for medical-legal partnerships: the review of evidence. (Online) 2013. Available: http://medical-legalpartnership.org/wp-content/uploads/2014/03/Medical-Legal-Partnership-Literature-Review-February-2013.pdf (Accessed 23 March 2016).
11. Atkins D, Heller SM, DeBartolo E, Sandel, M. Medical-legal partnership and health start: integrating civil legal aid services into public advocacy. Journal of Legal Medicine 2014; 35(1): 195-209. https://doi.org/10.1080/01947648.2014.885333
12. Noble P. Advocacy health alliances: better health through medical-legal partnerships. Final report. (Online) 2012. Available: http://www.justiceconnect.org.au/sites/default/files/Better Health Through MedicalLegal Partnership.pdf (Accessed 23 March 2016).
13. Gyorki L. Breaking down the silos: overcoming the practical and ethical barriers of integrating legal assistance into a healthcare setting. Report to the Winston Churchill Memorial Trust of Australia. (Online) 2013. Available: https://www.churchilltrust.com.au/media/fellows/Breaking_down_the_silos_L_Gyorki_2013.pdf (Accessed 23 March 2016).
14. Victoria Government Department of Health and Human Services. 2013 Local government area profiles. (Online) 2014. Available: http://www.health.vic.gov.au/modelling/planning/lga.htm (Accessed 23 March 2016).
15. Burns S, Graham K, MacKeith J. The outcomes star. London: London Housing Foundation and Triangle Consulting, 2006.