STI-X: a novel approach to STI testing in rural and regional Victoria, Australia

Accessing testing for sexually transmissible infections (STI) in regional and rural areas can be challenging for many people. Innovative solutions are necessary to ensure that barriers are minimised for populations who are often disadvantaged by the health system. STI-X, our STI test vending machine brings testing to local communities in areas where accessing a clinical service can be difficult due to extended wait times or where there is concern about privacy. Providing the option of a free, quick and easy STI test aims to reduce the prevalence of STIs and the burden on the primary care system.

"Almost like it was really underground": a qualitative study of women's experiences locating services for unintended pregnancy in a rural Australian health system

Rural women in Australia are more likely than urban women to experience unintended pregnancy, yet little is known about how this issue is managed in a rural health setting. To address this gap, we conducted in-depth interviews with 20 women from rural New South Wales (NSW) about their unintended pregnancy. Participants were asked about accessing healthcare services and what was uniquely rural about their experience. The framework method was used to conduct an inductive thematic analysis. Four themes emerged from the data: (1) fragmented and opaque healthcare pathways, (2) a limited number of willing rural practitioners, (3) small town culture and community ties and (4) interrelated challenges of distance, travel and money. Our findings highlight how pervasive structural issues related to accessibility of health services intersect with small-town culture to create compounding obstacles for rural women, especially those seeking an abortion. This study is relevant to other countries with similar geographies and models of rural healthcare. Our findings point to the necessity for comprehensive reproductive health services including abortion to be an essential - not optional - part of healthcare in rural Australia.

Expanding community pharmacists' scope of practice in relation to contraceptive counselling and referral: a protocol for a pragmatic, stepped-wedge, cluster randomised trial (ALLIANCE)

INTRODUCTION

Improving access to effective contraception has the potential to reduce unintended pregnancy and abortion rates. Community pharmacists could play an expanded role in contraceptive counselling and referral to contraceptive prescribers particularly when women are already attending community pharmacy to obtain emergency contraceptive pills (ECPs) or to have medical abortion (MA) medicines dispensed. The ALLIANCE trial aims to compare the subsequent uptake of effective contraception (hormonal or intrauterine) in women seeking ECP or MA medicines, who receive the ALLIANCE community pharmacy-based intervention with those who do not receive the intervention.

METHODS AND ANALYSIS

ALLIANCE is a stepped-wedge pragmatic cluster randomised trial in Australian community pharmacies. The ALLIANCE intervention involves community pharmacists delivering structured, patient-centred, effectiveness-based contraceptive counselling (and a referral to a contraceptive prescriber where appropriate) to women seeking either ECPs or to have MA medicines dispensed. Women participants will be recruited by participating pharmacists. A total of 37 pharmacies and 1554 participants will be recruited. Pharmacies commence in the control phase and are randomised to transition to the intervention phase at different time points (steps). The primary outcome is the self-reported use of effective contraception at 4 months; secondary outcomes include use of effective contraception and the rate of pregnancies or induced abortions at 12 months. A process and economic evaluation of the trial will also be undertaken.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Monash University Human Research Ethics Committee (#34563). An explanatory statement will be provided and written consent will be obtained from all participants (pharmacy owner, pharmacist and women) before their commencement in the trial. Dissemination will occur through a knowledge exchange workshop, peer-reviewed journal publications, presentations, social media and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622001024730.

What women want from local primary care services for unintended pregnancy in rural Australia: a qualitative study from rural New South Wales

BACKGROUND

Under the generalist model of health care in rural Australia, general practitioners (GPs) are often the first point of contact for women seeking health services for unintended pregnancy, including pregnancy decision-making support and options advice, antenatal or abortion care. Rural women are more likely to experience unintended pregnancy in Australia, yet little is known about how well local rural primary healthcare services currently meet their needs.

METHODS

To address this gap, this qualitative study explores through in-depth semi-structured interviews, the experiences of 20 rural women managing an unintended pregnancy, and their expectations of, and satisfaction with, the quality of care they received. The Framework Method was used to organise data and conduct an inductive thematic analysis.

RESULTS

Three themes related to management of unintended pregnancy in a rural primary care setting were identified: (1) women expect informed and efficient care once services are reached; (2) women desire greater choice and aftercare; and (3) comprehensive reproductive health should be part of rural primary care. Participants indicated an awareness of the limitations of the rural health system, yet a firm expectation that despite access delays, all of their reproductive health needs would be met. Choice, time efficiency, and aftercare were identified as gaps in the current primary care service experience. A desire for greater attention to rural reproductive health, including improved contraception, was also emphasised.

CONCLUSIONS

Rural women with unintended pregnancy experienced gaps in service quality and described a lack of woman-centred care in their local rural health setting. This study offers insight into how rural primary care providers can better support women to make decisions about and reach their preferred services for unintended pregnancy.

Improving rural and regional access to long-acting reversible contraception and medical abortion through nurse-led models of care, task-sharing and telehealth (ORIENT): a protocol for a stepped-wedge pragmatic cluster-randomised controlled trial in Australian general practice

INTRODUCTION

Women living in rural and regional Australia often experience difficulties in accessing long-acting reversible contraception (LARC) and medical abortion services. Nurse-led models of care can improve access to these services but have not been evaluated in Australian general practice. The primary aim of the ORIENT trial (ImprOving Rural and regIonal accEss to long acting reversible contraceptioN and medical abortion through nurse-led models of care, Tasksharing and telehealth) is to assess the effectiveness of a nurse-led model of care in general practice at increasing uptake of LARC and improving access to medical abortion in rural and regional areas.

METHODS AND ANALYSIS

ORIENT is a stepped-wedge pragmatic cluster-randomised controlled trial. We will enrol 32 general practices (clusters) in rural or regional Australia, that have at least two general practitioners, one practice nurse and one practice manager. The nurse-led model of care (the intervention) will be codesigned with key women's health stakeholders. Clusters will be randomised to implement the model sequentially, with the comparator being usual care. Clusters will receive implementation support through clinical upskilling, educational outreach and engagement in an online community of practice. The primary outcome is the change in the rate of LARC prescribing comparing control and intervention phases; secondary outcomes include change in the rate of medical abortion prescribing and provision of related telehealth services. A within-trial economic analysis will determine the relative costs and benefits of the model on the prescribing rates of LARC and medical abortion compared with usual care. A realist evaluation will provide contextual information regarding model implementation informing considerations for scale-up. Supporting nurses to work to their full scope of practice has the potential to increase LARC and medical abortion access in rural and regional Australia.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Monash University Human Research Ethics Committee (Project ID: 29476). Findings will be disseminated via multiple avenues including a knowledge exchange workshop, policy briefs, conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000086763).

Management of Chlamydia Cases in Australia (MoCCA): protocol for a non-randomised implementation and feasibility trial

INTRODUCTION

The sexually transmitted infection chlamydia can cause significant complications, particularly among people with female reproductive organs. Optimal management includes timely and appropriate treatment, notifying and treating sexual partners, timely retesting for reinfection and detecting complications including pelvic inflammatory disease (PID). In Australia, mainstream primary care (general practice) is where most chlamydia infections are diagnosed, making it a key setting for optimising chlamydia management. High reinfection and low retesting rates suggest partner notification and retesting are not uniformly provided. The Management of Chlamydia Cases in Australia (MoCCA) study seeks to address gaps in chlamydia management in Australian general practice through implementing interventions shown to improve chlamydia management in specialist services. MoCCA will focus on improving retesting, partner management (including patient-delivered partner therapy) and PID diagnosis.

METHODS AND ANALYSIS

MoCCA is a non-randomised implementation and feasibility trial aiming to determine how best to implement interventions to support general practice in delivering best practice chlamydia management. Our method is guided by the Consolidated Framework for Implementation Research and the Normalisation Process Theory. MoCCA interventions include a website, flow charts, fact sheets, mailed specimen kits and autofills to streamline chlamydia consultation documentation. We aim to recruit 20 general practices across three Australian states (Victoria, New South Wales, Queensland) through which we will implement the interventions over 12-18 months. Mixed methods involving qualitative and quantitative data collection and analyses (observation, interviews, surveys) from staff and patients will be undertaken to explore our intervention implementation, acceptability and uptake. Deidentified general practice and laboratory data will be used to measure pre-post chlamydia testing, retesting, reinfection and PID rates, and to estimate MoCCA intervention costs. Our findings will guide scale-up plans for Australian general practice.

ETHICS AND DISSEMINATION

Ethics approval was obtained from The University of Melbourne Human Research Ethics Committee (Ethics ID: 22665). Findings will be disseminated via conference presentations, peer-reviewed publications and study reports.

Co-design of a nurse-led model of care to increase access to medical abortion and contraception in rural and regional general practice: A protocol

PROBLEM

Women in rural and regional Australia experience a number of barriers to accessing sexual and reproductive health care including lack of local services, high costs and misinformation.

SETTING

Nurse-led task-sharing models of care for provision of long-acting reversible contraception (LARC) and early medical abortion (EMA) are one strategy to reduce barriers and improve access to services but have yet to be developed in general practice.

KEY MEASURES FOR IMPROVEMENT

Through a co-design process, we will develop a nurse-led model of care for LARC and EMA provision that can be delivered through face-to-face consultations or via telehealth in rural general practice in Australia.

STRATEGIES FOR CHANGE

A co-design workshop, involving consumers, health professionals (particularly General Practitioners (GPs) and Practice Nurses (PNs)), GP managers and key stakeholders will be conducted to design nurse-led models of care for LARC and EMA including implant insertion by nurses. The workshop will be informed by the 'Experience-Based Co-Design' toolkit and involves participants mapping the patient journey for service provision to inform a new model of care.

EFFECTS OF CHANGE

Recommendations from the workshop will inform a nurse-led model of care for LARC and EMA provision in rural general practice. The model will provide practical guidance for the set-up and delivery of services.

LESSONS LEARNT

Nurses will work to their full scope of practice to increase accessibility of EMA and LARC in rural Australia.

Patient-delivered partner therapy: One option for management of sexual partner(s) of a patient diagnosed with a chlamydia infection

BACKGROUND

Chlamydia is the most commonly diagnosed bacterial sexually transmissible infection (STI) in Australia. Partner management is key to reducing transmission and a cornerstone of best practice chlamydia management. While most patients will opt for telling their partner(s) themselves, patient-delivered partner therapy (PDPT) offers an alternative way to inform and treat partners where usual management is inappropriate or unlikely to be undertaken. Guidelines for PDPT vary across Australia. Recent research found that general practitioners (GP)s want practical guidance for using PDPT in appropriate situations.

OBJECTIVE

The aim of this article is to provide an overview of the process of offering PDPT and note the challenges GPs may face in its provision.

DISCUSSION

PDPT is one option for partner management when sexual partner(s) are unlikely or unable to seek timely care themselves. However, there are challenges to the use of PDPT in general practice. The provision of clear guidelines is an essential step to promote its appropriate use.

Love during lockdown: findings from an online survey examining the impact of COVID-19 on the sexual health of people living in Australia

INTRODUCTION

Australia recorded its first case of COVID-19 in late January 2020. On 22P March 2020, amid increasing daily case numbers, the Australian Government implemented lockdown restrictions to help 'flatten the curve'. Our study aimed to understand the impact of lockdown restrictions on sexual and reproductive health. Here we focus on sexual practices.

METHODS

An online survey was open from the 23PP April 2020 to 11P May 2020. Participants were recruited online via social media and other networks and were asked to report on their sexual practices in 2019 and during lockdown. Logistic regression was used to calculate the difference (diff) (including 95% CIs) in the proportion of sex practices between time periods.

RESULTS

Of the 1187 who commenced the survey, 965 (81.3%) completed it. Overall, 70% were female and 66.3% were aged 18-29 years. Most (53.5%) reported less sex during lockdown than in 2019. Compared with 2019, participants were more likely to report sex with a spouse (35.3% vs 41.7%; diff=6.4%; 95% CI 3.6 to 9.2) and less likely to report sex with a girl/boyfriend (45.1% vs 41.8%; diff=-3.3%; 95% CI -7.0 to -0.4) or with casual hook-up (31.4% vs 7.8%; 95% CI -26.9 to -19.8). Solo sex activities increased; 14.6% (123/840) reported using sex toys more often and 26.0% (218/838) reported masturbating more often. Dating app use decreased during lockdown compared with 2019 (42.1% vs 27.3%; diff= -14.8%; 95% CI -17.6 to -11.9). Using dating apps for chatting/texting (89.8% vs 94.5%; diff=4.7%; 95% CI 1.0 to 8.5) and for setting up virtual dates (2.6% vs 17.2%; diff=14.6%; 95% CI 10.1 to 19.2) increased during lockdown.

CONCLUSION

Although significant declines in sexual activity during lockdown were reported, people did not completely stop engaging in sexual activities, highlighting the importance of ensuring availability of normal sexual and reproductive health services during global emergencies.

Patient delivered partner therapy for chlamydia infection is used by some general practitioners, but more support is needed to increase uptake: findings from a mixed-methods study

OBJECTIVES

Patient-delivered partner therapy (PDPT) describes the giving of a prescription or antibiotics by an index case with chlamydia to their sexual partners. PDPT has been associated with higher numbers of partners receiving treatment. In Australia, general practitioners (GPs) previously expressed negative views about PDPT. Health authority guidance for PDPT has since been provided in some areas. We investigated recent use and perceptions of PDPT for chlamydia among GPs in Australia.

METHODS

In 2019, we conducted an online survey comprising multiple-choice and open-ended questions to investigate GPs' chlamydia management practices, including PDPT. Logistic regression identified factors associated with ever offering PDPT. A directed content analysis of free-text data explored GPs' perceptions towards PDPT.

RESULTS

The survey received responses from 323 GPs; 85.8% (n=277) answered PDPT-focused questions, providing 628 free-text comments. Over half (53.4%) reported never offering PDPT, while 36.5% sometimes and 10.1% often offered PDPT. GPs more likely to offer PDPT were aged ≥55 years (adjusted OR (AOR) 2.9, 95% CI 1.4 to 5.8), worked in non-metropolitan areas (AOR 2.5, 95% CI 1.5 to 4.4) and jurisdictions with health authority PDPT guidance (AOR 2.3, 95% CI 1.4 to 3.9). Qualitative data demonstrated that many GPs recognised PDPT's potential to treat harder to engage partners but expressed hesitancy to offer PDPT because they considered partners attending for care as best practice. GPs emphasised a case-by-case approach that considered patient and partner circumstances to determine PDPT suitability. To alleviate medicolegal concerns, many GPs indicated a need for professional and health authority guidance that PDPT is permissible. They also desired practical resources to support its use.

CONCLUSION

GPs appear to accept the place of PDPT as targeted to those who may otherwise not access testing or treatment. Availability of health authority guidance appears to have supported some GPs to incorporate PDPT into their practice.

Contraceptive use and pregnancy plans among women of reproductive age during the first Australian COVID-19 lockdown: findings from an online survey

PURPOSE

Australia introduced 'lockdown' measures to control COVID-19 on 22 March 2020 which continued for a period of two months. We aimed to investigate the impact this had on sexual and reproductive health (SRH).

MATERIALS AND METHODS

Australians aged 18+ were eligible to participate in an online survey from 23 April to 11 May 2020. We report on the experiences of 518 female participants aged <50 years. Pregnancy intentions and contraceptive use were analysed using descriptive statistics. Odds ratios and 95% confidence intervals were calculated to investigate difficulty accessing SRH products and services. Qualitative data were analysed using conventional content analysis.

RESULTS

Most participants were aged 18-24 years, and indicated they were trying to avoid pregnancy. The oral contraceptive pill was the most common single method used however nearly 20% reported they were not using contraception. Women who were employed had less trouble accessing contraception during lockdown. Participants reported delaying childbearing or deciding to remain childfree due to COVID-19.

CONCLUSION

COVID-19 lockdown impacted the SRH of Australian women. Findings highlight the importance of continued access to SRH services and products during global emergencies.

'It's literally giving them a solution in their hands': the views of young Australians towards patient-delivered partner therapy for treating chlamydia

OBJECTIVES

Patient-delivered partner therapy (PDPT) is a method for providing antibiotic treatment for the sexual partners of an index patient with an STI by means of a prescription or medication that the index patient gives to their sexual partner(s). Qualitative research regarding barriers and enablers to PDPT has largely focused on the views of healthcare providers. In this study, we sought to investigate the views of young people (as potential health consumers) regarding PDPT for chlamydia.

METHODS

Semi-structured telephone interviews were conducted with young Australian men and women. Participants were asked to provide their views regarding PDPT from the perspective of both an index patient and partner. Purposive and snowball sampling was used. Data were analysed thematically.

RESULTS

We interviewed 22 people (13 women, 9 men) aged 18-30 years, 15 of whom had previously been tested for chlamydia. Despite none having previous knowledge of or experience using PDPT, all viewed it positively and thought it should be widely available. Participants reported that they would be willing to give PDPT to their sexual partners in situations where trust and comfort had been established, regardless of the relationship type. Protecting their partners' privacy was essential, with participants expressing reluctance to provide their partners' contact details to a doctor without consent. Beyond logistical benefits, PDPT was viewed as a facilitator to partner notification conversations by offering partners a potential solution. However, most interviewees indicated a preference to consult with a healthcare provider (GP or pharmacist) before taking PDPT medication. Participants indicated that legitimacy of information when navigating a chlamydia diagnosis was crucial and was preferably offered by healthcare providers.

CONCLUSIONS

Though PDPT is unlikely to fully replace partners' interactions with healthcare providers, it may facilitate partner notification conversations and provide partners greater choice on how, when and where they are treated.

Using electronic communication technologies for improving syphilis partner notification in Chile: healthcare providers' perspectives - a qualitative case study

Background Partner notification (PN) in Australia has been studied and improved in recent decades. International researchers have highlighted the use of electronic communication technologies to assist PN (Internet partner notification or IPN). Using the Australian experience as an example, the aim of this study is to explore clinicians' perspectives on the use of specialised websites, such as Let them know, to facilitate PN in the Chilean context.

METHODS

Semi-structured interviews were conducted with healthcare providers (HCPs) in 14 primary health care centres and six sexual health units located at two regional Health Services, as well as with key informants from different backgrounds. Interviews were transcribed verbatim and QSR International's NVivo 11 PRO Software was used for cross-case thematic analysis, which followed an inductive approach. Selected quotes were translated from Spanish to English. Codes and themes were reviewed by the research team.

RESULTS

Most participants were unaware of IPN and demonstrated interest. Many agreed this could be a feasible strategy considering the high use of mobile technologies and the Internet in Chile. Participants' primary concerns around this approach were confidentiality, privacy and efficacy, given the local cultural context. The use of a counsellor to offer professional support and guidance was identified as essential to strengthen PN in Chile.

CONCLUSION

The use of IPN could be an alternative PN strategy for Chile. However, the involvement of local staff and further research to explore patients' perceptions and preferences will be essential in tailoring interventions.

What do young women living in regional and rural Victoria say about chlamydia testing? A qualitative study

Background Chlamydia trachomatis is the most commonly notified sexually transmissible infection in Australia, with almost 100000 cases diagnosed in 2018. Chlamydia is easy to diagnose and treat, but infections are underdiagnosed. Eighty per cent of chlamydia cases are asymptomatic. Without testing, infections will remain undetected. Several barriers to testing have been identified in previous research, including cost, privacy concerns for young rural people, knowledge gaps, embarrassment and stigma. The aim of this study was to investigate young regional and rural women's understanding of chlamydia and factors that may prevent or delay testing.

METHODS

Semistructured interviews were conducted with 11 women aged between 18 and 30 years residing in north-east Victoria, Australia. Interviews were transcribed verbatim and analysed thematically.

RESULTS

Themes were grouped under four categories: (1) chlamydia and stigma; (2) the application of stigma to self and others; (3) factors affecting testing; and (4) knowledge. A chlamydia infection was associated with stigma. The young women in this study anticipated self-stigma in relation to a positive diagnosis, but resisted stigmatising others. Increased knowledge about chlamydia prevalence was associated with reduced self-stigma. The most consistent factor affecting testing decisions was personal risk assessment. Knowledge gaps about symptoms, testing and treatment were also identified, with participants not always accessing information from reputable sources.

CONCLUSION

Chlamydia testing was viewed as a positive activity among this cohort. However, there is considerable perceived stigma about being diagnosed with an infection. Interventions that communicate prevalence, reduce stigma and provide factual information about testing and risk are still needed. Clinicians have an opportunity to convey this information at consultation. Health promotion workers should continue to develop and run campaigns at a community level to encourage regular screening.

Sexually transmissible infections, partner notification and intimate relationships: a qualitative study exploring the perspectives of general practitioners and people with a recent chlamydia infection

Background Individuals diagnosed with a chlamydia infection are advised to notify their sexual partners from the previous 6 months so that they too can get tested and treated as appropriate. Partner notification is an essential component of chlamydia management, helping to prevent ongoing transmission and repeat infection in the index case. However, partner notification can be challenging, particularly in circumstances where a relationship has ended or transmission has occurred beyond the primary relationship.

METHODS

In this study we use data from 43 semistructured interviews with general practitioners (GPs) and people with a recent diagnosis of chlamydia. The interviews examined experiences of chlamydia case management in the general practice context. Here, we focus specifically on the effect of a chlamydia infection on intimate relationships in the context of the consultation and beyond.?

RESULTS

A chlamydia infection can have significant consequences for intimate relationships. Although GPs reported speaking to their patients about the importance of partner notification and participants with a recent chlamydia infection reported notifying their sexual partners, both would appreciate further support to engage in these conversations.

CONCLUSIONS

Conversations with patients should go beyond simply informing them of the need to notify their sexual partners from the previous 6 months, and should provide information about why partner notification is important and discuss strategies for informing partners, particularly for those in ongoing relationships. Ensuring GPs have the training and support to engage in these conversations with confidence is vital.

Patient-delivered partner therapy for chlamydia in Australia: can it become part of routine care?

Background Patient-delivered partner therapy (PDPT) is a method for an index patient to give treatment for genital chlamydia to their sexual partner(s) directly. In Australia, PDPT is considered suitable for heterosexual partners of men and women, but is not uniformly endorsed. We explored the policy environment for PDPT in Australia and considered how PDPT might become a routine option.

METHODS

Structured interviews were conducted with 10 key informants (KIs) representing six of eight Australian jurisdictions and documents relevant to PDPT were appraised. Interview transcripts and documents were analysed together, drawing on KIs' understanding of their jurisdiction to explore our research topics, namely the current context for PDPT, challenges, and actions needed for PDPT to become routine.

RESULTS

PDPT was allowable in three jurisdictions (Victoria, New South Wales, Northern Territory) where State governments have formally supported PDPT. In three jurisdictions (Western Australia, Australian Capital Territory, Tasmania), KIs viewed PDPT as potentially allowable under relevant prescribing regulations; however, no guidance was available. Concern about antimicrobial stewardship precluded PDPT inclusion in the South Australian strategy. For Queensland, KIs viewed PDPT as not allowable under current prescribing regulations and, although a Medicine and Poisons Act was passed in 2019, it is unclear if PDPT will be possible under new regulations. Clarifying the doctor-partner treating relationship and clinical guidance within a care standard were viewed as crucial for PDPT uptake, irrespective of regulatory contexts.

CONCLUSION

Endorsement and guidance are essential so doctors can confidently and routinely offer PDPT in respect to professional standards and regulatory requirements.

Medical termination of pregnancy service delivery in the context of decentralization: social and structural influences

Background

Medical termination of pregnancy (MToP) is a safe and acceptable abortion option. Depending on country context, MToP can be administered by general practitioners and mid-level healthcare providers in the first and second trimesters of pregnancy. Like other high-income countries, a range of social and structural barriers to MToP service provision exist in Australia. To counter some of these barriers, geographic decentralization of MToP was undertaken in rural Victoria, Australia, through training service providers about MToP to increase service delivery opportunities. The aim of this study was to investigate the factors that enabled and challenged the decentralization process.

Methods

Face-to-face and telephone interviews were undertaken between April and June 2016 with a purposeful sample of six training providers and 13 general practitioners (GP) and nurse training participants. Study participants were asked about their perceptions of motivations, enablers and challenges to MToP provision. A published conceptual framework of synergies between decentralization and service delivery was used to analyse the study findings.

Results

Three key themes emerged from the study findings. First, the effort to decentralize MToP was primarily supported by motivations related to making service access more equitable as well as the willingness of training providers to devolve their informal power, in the form of MToP medical expertise, to training participants. Next, the enablers for MToP decentralization included changes in the regulatory environment relating to decriminalization of abortion and availability of required medication, formation of partnerships to deliver training, provision of MToP clinical resources and local collegial support. Finally, challenges to MToP decentralization were few but significant. These included a lack of a state-wide strategy for service provision, provider concerns about coping with service demand, and provider stigma in the form of perceived negative community or collegial attitudes. These were significant enough to create caution for GPs and nurses considering service provision.

Conclusions

Decentralization concepts offer an innovative way for reframing and tackling issues associated with improving MToP service delivery. There is scope for more research about MToP decentralization in other country contexts. These findings are important for informing future rural MToP service expansion efforts that improve equity in service access.

The impact of a chlamydia education program on practice nurse's knowledge and attitudes in relation to chlamydia testing: a cross-sectional survey

Background We aimed to determine the impact of a chlamydia (Chlamydia trachomatis) education program on the knowledge of and attitudes towards chlamydia testing of practice nurses (PNs).

METHODS

A cross-sectional survey was conducted at baseline and 6-12 months following recruitment with PNs in the Australian Chlamydia Control Effectiveness Pilot. Likert scales were analysed as continuous variables (scores), and t-tests were used to assess changes in mean scores between survey rounds and groups.

RESULTS

Of the 72 PNs who completed both surveys, 42 received education. Epidemiology knowledge scores increased significantly between surveys in the education group (P<0.01), with change in knowledge being greater in the education group compared with the non-education group (P<0.01). Knowledge of recommended testing scenarios (P=0.01) and retesting following treatment (P<0.01) increased in the education group. Attitudes to testing scores improved over time in the education group (P=0.03), with PNs more likely to want increased involvement in chlamydia testing (P<0.01). Change in overall attitude scores towards testing between surveys was higher in the education group (P=0.05). Barriers to chlamydia testing scores also increased in the education group (P=0.03), with change in barriers greater in the education vs the non-education group (P=0.03).

CONCLUSION

The education program led to improved knowledge and attitudes to chlamydia, and could be made available to PNs working in general practice. Future analyses will determine if the education program plus other initiatives can increase testing rates.

Facilitators of community participation in an Aboriginal sexual health promotion initiative

INTRODUCTION

Community participation is a collaborative process aimed at achieving community-identified outcomes. However, approaches to community participation within Aboriginal health promotion initiatives have been inconsistent and not well documented. Smart and Deadly was a community-led initiative to develop sexual health promotion resources with young Aboriginal people in regional Victoria, Australia. The principles of community-centred practice, authentic participatory processes and respect for the local cultural context guided the initiative. The aim of this article is to report factors that facilitated community participation undertaken in the Smart and Deadly initiative to inform future projects and provide further evidence in demonstrating the value of such approaches.

METHODS

A summative evaluation of the Smart and Deadly initiative was undertaken approximately 2 years after the initiative ended. Five focus groups and 13 interviews were conducted with a purposive sample of 32 participants who were involved with Smart and Deadly in one of the following ways: project participant, stakeholder or project partner, or project developer or designer. A deductive content analysis was undertaken and themes were compared to the YARN model, which was specifically created for planning and evaluating community participation strategies relating to Aboriginal sexual health promotion.

RESULTS

A number of factors that facilitated community participation approaches used in Smart and Deadly were identified. The overarching theme was that trust was the foundation upon which the facilitators of community participation ensued. These facilitators were cultural safety and cultural literacy, community control, and legacy and sustainability. Whilst the YARN model was highly productive in identifying these facilitators of community participation, the model did not have provision for the element of trust between workers and community. Given the importance of trust between the project team and the Aboriginal community in the Smart and Deadly initiative, a suggested revision to the YARN model is that trust is included as the basis upon which YARN model factors are predicated.

CONCLUSIONS

Adding trust to the YARN model as a basis upon which YARN model factors are grounded assists future Aboriginal health promotion projects in ensuring community participation approaches are more likely to be acceptable to the Aboriginal community.

Opt-Out Referral of Men Who Have Sex With Men Newly Diagnosed With HIV to Partner Notification Officers: Results and Yield of Sexual Partners Being Contacted

BACKGROUND

Given its potential for reducing the proportion of people with human immunodeficiency virus (HIV) unaware of their diagnosis, partner notification for HIV has been underutilized. This study aimed to determine if the implementation of opt-out referral of men who have sex with men, newly diagnosed with HIV, to partner notification officers (PNO) increased the proportion of sexual partners notified.

METHODS

In April 2013, all individuals newly diagnosed with HIV at the Melbourne Sexual Health Centre, Australia were referred to Department of Health PNO to facilitate partner notification. The number of sexual partners reported by men and the proportion contacted in the 12 months before (opt-in period) and after (opt-out period) this policy change were determined through review of the clinical PNO records.

RESULTS

Overall, 111 men were diagnosed with HIV during the study period. Compared with men in the opt-in period (n = 51), men in the opt-out period (n = 60) were significantly more likely to accept assistance from the PNO (12 [24%] vs 51 [85%]; P < 0.001). A significantly higher proportion of reported partners were notified with opt-out referral (85/185, 45.9%; 95% confidence interval, 38.6-53.4) compared with opt-in referral (31/252, 12.3%; 95% confidence interval, 8.5-17.0) (P < 0.001).

DISCUSSION

Opt-out referral to PNO was associated with a substantially higher proportion of partners at risk of HIV being contacted.

A matched comparison study of hepatitis C treatment outcomes in the prison and community setting, and an analysis of the impact of prison release or transfer during therapy

Prisoners are a priority group for hepatitis C (HCV) treatment. Although treatment durations will become shorter using directly acting antivirals (DAAs), nearly half of prison sentences in Scotland are too short to allow completion of DAA therapy prior to release. The purpose of this study was to compare treatment outcomes between prison- and community-based patients and to examine the impact of prison release or transfer during therapy. A national database was used to compare treatment outcomes between prison treatment initiates and a matched community sample. Additional data were collected to investigate the impact of release or transfer on treatment outcomes. Treatment-naïve patients infected with genotype 1/2/3/4 and treated between 2009 and 2012 were eligible for inclusion. 291 prison initiates were matched with 1137 community initiates: SVRs were 61% (95% CI 55%-66%) and 63% (95% CI 60%-66%), respectively. Odds of achieving a SVR were not significantly associated with prisoner status (P=.33). SVRs were 74% (95% CI 65%-81%), 59% (95% CI 42%-75%) and 45% (95% CI 29%-62%) among those not released or transferred, transferred during treatment, or released during treatment, respectively. Odds of achieving a SVR were significantly associated with release (P<.01), but not transfer (P=.18). Prison-based HCV treatment achieves similar outcomes to community-based treatment, with those not released or transferred during treatment doing particularly well. Transfer or release during therapy should be avoided whenever possible, using anticipatory planning and medical holds where appropriate.

Socio-demographic and structural barriers to being tested for chlamydia in general practice

OBJECTIVES

To investigate socio-demographic and structural factors associated with not providing a specimen for chlamydia testing following a request by a general practitioner.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional analysis of chlamydia testing data for men and women aged 16-29 years attending general practice clinics participating in a cluster randomised controlled trial evaluating the effectiveness of a chlamydia testing intervention. The study period was the 2013 calendar year.

OUTCOME

The proportion of chlamydia test requests for which the patient did not provide a specimen for testing.

RESULTS

During the study period, there were 13 225 chlamydia test requests, for which a chlamydia test was not performed in 2545 instances (19.2%; 95% CI, 16.5-22.3%). Multivariate analysis indicated that the odds for not undertaking a requested test were higher for men (adjusted odds ratio [aOR], 1.4; 95% CI, 1.3-1.6), those aged 16-19 years (aOR, 1.3; 95% CI, 1.1-1.4), those living in areas of greater socio-economic disadvantage (aOR, 1.2; 95% CI, 1.1-1.4 for each additional quintile of Index of Relative Socio-economic Disadvantage), and those attending clinics without on-site pathology collection (aOR, 1.4; 95% CI, 1.0-1.9).

CONCLUSION

One in five young people did not submit a specimen for chlamydia testing despite their GP requesting it. This highlights the need for clinics to establish systems which ensure that men and those aged 16-19 years undertake chlamydia tests requested by a GP.

Understanding the low uptake of long-acting reversible contraception by young women in Australia: a qualitative study

Background

Australia has high rates of teenage pregnancy compared with many Western countries. Long-acting reversible contraception (LARC) offers an effective method to help decrease unintended pregnancies; however, current uptake remains low. The aim of this study was to investigate barriers to LARC use by young women in Australia.

Methods

Healthcare professionals were recruited through publicly available sources and snowball sampling to complete an interview about young women’s access to and use of LARC. The sample consisted of general practitioners, nurses, medical directors of reproductive and sexual health organisations, a sexual health educator, and health advocates. In addition, four focus groups about LARC were conducted with young women (aged 17–25 years) recruited via health organisations and a university. The data were analysed thematically.

Results

Fifteen healthcare professionals were interviewed and four focus groups were conducted with 27 young women. Shared barriers identified included norms, misconceptions, bodily consequences, and LARC access issues. An additional barrier identified by young women was a perceived lack of control over hormones entering the body from LARC devices. Healthcare professionals also raised as a barrier limited confidence and support in LARC insertions. Strategies identified to increase contraceptive knowledge and access included increasing nurses’ role in contraceptive provision and education, improving sex education in schools, and educating parents.

Conclusions

Challenges remain for young women to be able to make informed choices about contraception and easily access services. More research is needed around innovative approaches to increase LARC knowledge and access, including examining the role of nurses in enhancing young women’s reproductive health.

Rate of repeat diagnoses in men who have sex with men for Chlamydia trachomatis and Neisseria gonorrhoeae: a retrospective cohort study

Background Sexually transmissible infections (STIs) have increased rapidly among men who have sex with men (MSM). One of the most effective strategies to control STIs is partner notification. Inadequate partner notification may be associated with high rates of repeat diagnoses with STIs. The aim of this study is to estimate and compare the rate of chlamydia and gonorrhoea infection following primary infection to the overall clinic rate. Methods: A retrospective cohort analysis of MSM attending the Melbourne Sexual Health Clinic was conducted. For both infections, the overall incidence and that following diagnosis and treatment was calculated. Results: Of the 13053 MSM, the incidence of diagnoses for chlamydia and gonorrhoea was 8.5 (95% CI: 8.2–8.9) and 6.2 (95% CI: 5.9–6.5) per 100 person-years, respectively. Seventy per cent of chlamydia and 64% of gonorrhoea cases were retested at 10–365 days after diagnosis and treatment. Following diagnosis and treatment of chlamydia, the rate ratio in these individuals in the first quarter was 16- and 8-fold higher for chlamydia and gonorrhoea, respectively, compared with the background incidence of diagnoses. Similarly, following diagnosis and treatment of gonorrhoea, the rate ratio in these individuals in the first quarter was 18- and 10-fold higher for gonorrhoea and chlamydia, respectively. Conclusions: These data suggest that approximately half of MSM who test positive for chlamydia or gonorrhoea within 90 days after an initial infection represent contact with either a previous sexual partner or member of the same sexual network, the remainder representing the particularly high STI risk for these MSM.

Establishing a clinic for young people in a rural setting: a community initiative to meet the needs of rural adolescents

This paper describes the establishment and evaluation of a rural clinic for young people. A conceptual approach to community development was used to establish the clinic in a small north Victorian rural health service, with qualitative methods used to evaluate services. Study participants were members of an operational committee and advisory committee for the establishment of the rural clinic for young people. The clinic was evaluated against the World Health Organization framework for the development of youth-friendly services. With robust community support, the clinic was established and is operational. Most consultations have been for sexual and mental health. Qualitative evaluation identifies that not all the World Health Organization benchmarks have been met, but this is hampered predominantly by financial constraints. In conclusion, establishing clinic for young people in a small rural setting can be achieved with community support and the development of referral pathways.

Social workers' perspectives on the psychosocial needs of families during critical illness

This article reports the needs of relatives whose family member is unexpectedly admitted to an Intensive Care Unit. The Critical Care Family Needs Inventory (CCFNI) was used to measure and rank a series of need statements by family members (n = 25) and social workers (n = 42). Comparative analysis reveals that there were need statements that showed a significant difference in mean scores. Minor differences in both the rank order of individual need statements and the five-factor analysis categories were found. Implications for clinical social work practice are discussed.

The right thing to do: patients' views and experiences of telling partners about chlamydia

BACKGROUND

Partner notification for patients diagnosed with chlamydia is a strategy recommended to interrupt transmission of infection, and patients are commonly encouraged by health practitioners to contact their sexual partners themselves. Few studies, however, have ascertained the psychosocial impact of the chlamydia diagnosis and its effect on partner notification.

METHODS

In-depth telephone interviews were conducted with 25 women and 15 men aged 18-55 years, diagnosed with chlamydia from clinics in Victoria, Australian Capital Territory and Queensland. Reactions to chlamydia diagnosis, as well as reasons for, and feelings about, telling their sexual partners about this infection were explored.

RESULTS

Common reactions to initial diagnosis were surprise, shock and shame. The majority of both men and women saw partner notification as a social duty. Some cited concerns about their own health and the health of others as a reason for telling partners and ex-partners about the diagnosis. An infrequent reason offered for partner notification was to confront a partner to clarify fidelity. Reasons for not contacting a partner were typically fear of reaction or a lack of contact details. Although participants reported sexual partners exhibiting a variety of reactions when told of the diagnosis, results showed that for almost everyone, the experience of notifying their partner was better than they had expected.

CONCLUSIONS

Findings suggested that partner notification by people diagnosed with chlamydia is achievable but that many require support from their health practitioner to achieve the skills and confidence necessary during this difficult time.

The impact of immigration on the burden of HIV infection in Victoria, Australia

Background: Accurate estimates of the number of people diagnosed and living with HIV infection within a health jurisdiction provide the basis for planning of clinical service provision. Case reporting of new diagnoses does not account for inwards and outwards migration of people with HIV infection, thereby providing an inaccurate basis for planning. Methods: The Victorian passive surveillance system records all cases of HIV diagnosed in Victoria and distinguishes between new Victorian diagnoses (cases whose first ever HIV diagnosis was in Victoria) and cases previously diagnosed interstate and overseas. In order to gain an understanding of the impact of population movement on the burden of HIV infection in Victoria, we compared the characteristics of people first diagnosed in Victoria with those previously diagnosed elsewhere. Results: Between 1994 and 2007 there were 3111 HIV notifications in Victoria, including 212 (7%) ‘interstate diagnoses’ and 124 (4%) ‘overseas diagnoses’. The proportion of cases diagnosed outside Victoria increased from 6.4% between 1994 and 2000 to 13.8% between 2001 and 2007. Compared with ‘new diagnoses’, a larger proportion of ‘interstate diagnoses’ reported male-to-male sex as their HIV exposure, were Australian-born and diagnosed in Victoria at a general practice specialising in gay men’s health. Compared with ‘new diagnoses’, a larger proportion of ‘overseas diagnoses’ were female, reported heterosexual contact as their HIV exposure, and were diagnosed in Victoria at a sexual health clinic. Conclusions: Between 1994 and 2007 more than 10% of Victorian HIV diagnoses were among people previously diagnosed elsewhere. Characteristics of both interstate and overseas diagnoses differed from new diagnoses. Service planning needs to be responsive to the characteristics of people moving to Victoria with previously diagnosed HIV infection.

Molecular analysis of human immunodeficiency virus strains associated with a case of criminal transmission of the virus

An investigation was done of the evidence for transmission of human immunodeficiency virus (HIV) from an HIV-positive man to several male and female sex contacts. Phylogenetic analysis of sequences from the gag and env genes showed a close relationship between the predominant virus strains from the source and 2 contacts. However, the likelihood that a female contact was infected by the source could not be determined, despite contact tracing indicating that this may have occurred. One male, shown by contact tracing and molecular evidence to have been infected by the source, subsequently transmitted HIV to his female sex partner. HIV sequence from a plasma sample used as a control in the phylogenetic analysis contained env and gag sequences that were closely related to those from the source. An epidemiologic link between these 2 individuals was subsequently confirmed by contact tracing.