Alcohol availability and prevalent Chlamydia trachomatis in young Australians: a multi-level analysis.

Background Prevalence of sexually transmissible infections (STIs) has been associated with availability of alcohol. This paper investigates potential associations between prevalent cases of chlamydia in young people in Australia and the availability of alcohol within their local area, defined as postcode of residence. Methods Alcohol availability was determined at the postcode level using liquor licensing data, classified as total number of licences, number of 'take-away' licences and number of licenses by population. Participant data were drawn from a survey targeting Australians aged 16-29years in rural and regional Australia, capturing demographic details including postcode of residence, indicators of sexual behaviour including condom use and chlamydia test results. Mixed-effects logistic regression was used to examine potential associations between first, alcohol availability and chlamydia, and second, between condom use and chlamydia. Results We found little evidence of associations between alcohol availability and chlamydia in either unadjusted or adjusted models. After adjusting for alcohol availability, we observed significant associations between inconsistent condom use and chlamydia prevalence, whether alcohol availability was measured as total number (adjusted odds ratio (AOR) 2.20; 95% confidence interval (CI) 1.20, 3.70), number of take-away licenses (AOR 2.19; 95% CI1.30, 3.69) or licenses per 1000 population (AOR 2.19; 95% CI 1.30, 3.68). Conclusion Little evidence of association between alcohol availability and chlamydia at the postcode level was found. Further research is required to determine appropriate measures of 'local area' and how characteristics thereof may impact on sexual health.

How rural immersion training influences rural work orientation of medical students: Theory building through realist evaluation.

AIM: To develop theory about how contexts and mechanisms interact to contribute to openness to future rural practice by medical students undertaking immersive rural training. METHODS: A realist evaluation based on RAMESES II protocol. We interviewed 23 students exploring Contexts (C) which were external (place-based) and internal (the student's characteristics), Mechanisms (M) (that drive a response) and Outcomes (O) (openness to rural work). RESULTS: 'Openness to rural work' related to: a desire to live rurally, work in rural medicine, or consider this as a possibility. This was triggered by responses to experience in rural places of an aspirational, intellectual and emotional nature (mechanisms). Students most affected were those with a strong motivation to help others and who value teamwork. Students with clearly envisaged career paths suited to metropolitan areas, or those retaining/prioritising strong social and community ties in metropolitan areas were less likely to commit to future rural work. CONCLUSION: Our theory indicates multi-level stimuli activates openness. Implications are that rural immersion programs could select students with an orientation towards teamwork, without pre-set professional ideation, and with a strong commitment to helping others. Experiencing rural immersion will trigger aspirational, intellectual and emotional responses leading to rural work openness for such students.

A Checklist for Implementing Rural Pathways to Train, Develop and Support Health Workers in Low and Middle-Income Countries.

Background: There is an urgent need to scale up global action on rural workforce development. This World Health Organization-sponsored research aimed to develop a Rural Pathways Checklist. Its purpose was to guide the practical implementation of rural workforce training, development, and support strategies in low and middle-income countries (LMICs). It was intended for any LMICs, stakeholder, health worker, context, or health problem. Method: Multi-methods involved: (1) focus group concept testing; (2) a policy analysis; (3) a scoping review of LMIC literature; (4) consultation with a global Expert Reference Group and; (5) field-testing over an 18-month period. Results: The Checklist included eight actions for implementing rural pathways in LMICs: establishing community needs; policies and partners; exploring existing workers and scope; selecting health workers; education and training; working conditions for recruitment and retention; accreditation and recognition of workers; professional support/up-skilling and; monitoring and evaluation. For each action, a summary of LMICs-specific evidence and prompts was developed to stimulate reflection and learning. To support implementation, rural pathways exemplars from different WHO regions were also compiled. Field-testing showed the Checklist is fit for purpose to guide holistic planning and benchmarking of rural pathways, irrespective of LMICs, stakeholder, or health worker type. Conclusion: The Rural Pathways Checklist provides an agreed global conceptual framework for the practical implementation of "grow your own" strategies in LMICs. It can be applied to scale-up activity for rural workforce training and development in LMICs, where health workers are most limited and health needs are greatest.

The levonorgestrel intrauterine device in Australia: analysis of prescribing data 2008-2012.

BACKGROUND: Unplanned pregnancy is a significant problem in Australia. Local data pertaining to use of the levonorgestrel-releasing intra-uterine device (LNG-IUD), and associated factors are limited. The aim of this analysis was to calculate prescribing rates of the LNG-IUD in Australia, including trends in prescribing and associations with socio-demographic factors, in order to increase understanding regarding potential use. METHODS: We examined prescriptions for the LNG-IUD recorded in the national Pharmaceutical Benefits Scheme (PBS) from 2008 to 2012. Prescribing trends were examined according to patient age, remoteness of residential location, and proximity to relevant specialist health services. Associations between these factors and prescription rates were examined using poisson regression. Analyses were stratified by 5-year age-groups. RESULTS: Age-adjusted prescription rates rose from 11.50 per 1000 women aged 15-49 (95% CI: 11.41-11.59) in 2008 to 15.95 (95% CI:15.85-16.01) in 2012. Prescription rates increased most among 15-19-year-olds but remain very low at 2.76 per 1000 women (95% CI: 2.52-3.01). Absolute increases in prescriptions were greatest among 40-44-year-olds, rising from 16.73 per 1000 women in 2008 (95% CI: 16.12-17.34) to 23.77 in 2012 (95% CI: 22.58-24.29). Rates increased significantly within all geographical locations (p < 0.01). Non-metropolitan location was significantly associated with increased prescribing rates, the association diminishing with increasing age groups. CONCLUSIONS: Prescription of LNG-IUD in Australia is very low, especially among young women and those in major cities. Service providers and young women may benefit from targeted education outlining use of the LNG-IUD, strengthened training and referral pathways. Disparities in prescription according to location require further investigation.

Prescription rates of the contraceptive implant in Australia 2008-2012: impact of patient age and area of residence.

UNLABELLED: Background Long-acting reversible contraceptives are an effective means of preventing unwanted pregnancies and associated negative consequences. The Sexual Health and Family Planning Association of Australia has called for efforts to address barriers to the uptake of long-acting reversible contraceptives (LARCs) in Australia, where LARC uptake is thought to be low, though comprehensive data describing use and associated factors is scarce. The aims of this study were to describe patterns of prescriptions for the etonogestrel-releasing subdermal implant (SDI) in Australia, 2008-2012, and associated factors. METHODS: Records of prescriptions written through Australia's Pharmaceutical Benefits Scheme from 2008 to 2012 were obtained, including patient age and geographic location. Direct, age-standardised rates (ASR) of prescriptions were calculated for each year and location, with multivariate analysis used to examine associations between prescription rates and patient age, location and proximity to family planning clinics (FPC) or Aboriginal Medical Services (AMS). RESULTS: ASR of prescriptions rose ~6% per year (OR 1.06, 95%CI: 1.05-1.06) from 13.05 per 1000 (2008) to 15.76 per 1000 (2012; P<0.01). Rates were highest among 15- to 19-year-olds, increasing from 20.81 (2008) to 29.09 per 1000 (2012: P<0.01) and lowest among 45- to 49-year-olds, increasing from 3.37 to 3.73 per 1000 (P<0.01). ASR by location were significantly higher in regional than metropolitan areas. CONCLUSIONS: This is the first analysis of SDI prescriptions across all ages and regions of Australia. Uptake of SDI in Australia is increasing but remains low. Significant associations were found between prescription rates and patient age and residence in regional/remote areas.

Actual availability of general practice appointments for mildly ill children.

OBJECTIVE: To determine actual availability and cost of general practitioner appointments for children with conditions of low acuity and low urgency, from the perspective of the child's family. DESIGN, PARTICIPANTS AND SETTING: A "secret shopper" method, whereby research assistants posing as parents seeking appointments for mildly ill children telephoned a random sample of 225 general practice clinics within three Melbourne Medicare Local catchments, which included urban, suburban and regional areas; the study was conducted between 1 August and 30 September 2014. MAIN OUTCOME MEASURES: Availability of same-day appointments and time until appointment; bulk-billing status of the clinic and/or the potential cost of an appointment. RESULTS: High availability of appointments was found in all three catchment areas (range, 72%-81% of clinics contacted). About half (49%) had appointments available within 4 hours. Between 72% and 80% of clinics contacted in the three Medicare Local catchment areas offered bulk-billing for paediatric appointments. CONCLUSION: There is extensive same-day new-patient GP appointment availability for mildly ill children in the catchment areas of Melbourne studied. Further, as most of the available appointments are in clinics that bulk bill, financial access should not affect this availability. Increased paediatric presentations to emergency departments are not likely to be the result of limited GP availability. These findings provide an important base for developing data-driven policy approaches to the development and use of primary care.

Co-payments and parental decision-making: A cross-sectional survey of the impact on general practice and emergency department presentations.

BACKGROUND: Co-payments for medical services have been a controversial topic in Australia. OBJECTIVE: The aim of this study was to assess parents' perspectives on the potential impact of co-payments for general practice and emergency department (ED) services for children. METHODS: A cross-sectional survey was conducted between May and November 2014 in the EDs of four metropolitan hospitals in Melbourne. The participants were 1531 parents of children presenting with lower urgency conditions. The outcome measures were the potential impact of a $7 general practice co-payment or a $7 ED co-payment on the use of services for children. RESULTS: Seventy-three per cent (n = 1089) of parents reported that a $7 general practice co-payment would not increase their use of EDs for lower urgency problems for their children. Increased use was associated with younger parent or guardian age and lower household income. Ninety per cent (n = 1343) reported that a $7 ED co-payment would not have an impact on ED attendance. Impact was associated with younger parent or guardian age and lower income. DISCUSSION: For most parents presenting to an ED with their child, a $7 general practice or ED co-payment is unlikely to affect health service use, although significant differences in response were found according to parent or guardian age and household income.

Income inequality and Neisseria gonorrhoeae notifications in females: a country-level analysis.

UNLABELLED: Background Patterns of population susceptibility to sexually transmissible infections may be influenced by various social determinants of health, however these receive relatively little attention. Income inequality is one such determinant that has been linked to a number of poor health outcomes. The objective of this analysis was to determine whether there is an association between income inequality and Neisseria gonorrhoeae notification rates when measured at the country level. METHODS: Gini coefficients, gonorrhoea notification rates among women, per capita gross domestic product and approximate size of female population were obtained for 11 countries of the OECD. Linear regression was used to measure the association between income inequality and gonorrhoea notification rates, using generalised estimation equations (GEE) to control for the non-independence of repeat measures from particular countries. RESULTS: A total of 36 observations from 11 countries were included. Gini coefficients ranged from 0.21 to 0.38 and gonorrhoea notifications from 0.7 to 153 per 100000 females. Significant associations were found between country-level income inequality and gonorrhoea notification rates among women (b=17.79 (95% CI: 10.64, 24.94, P<0.01). CONCLUSIONS: Significant associations were found, highlighting the importance of acknowledging and accounting for social determinants of sexual health and suggesting that further research in this arena may be fruitful.

Chlamydia prevalence in young attenders of rural and regional primary care services in Australia: a cross-sectional survey.

OBJECTIVE: To estimate chlamydia prevalence among 16-29-year-olds attending general practice clinics in Australia. DESIGN, PARTICIPANTS AND SETTING: A cross-sectional survey was conducted from May 2010 to December 2012. Sexually experienced 16-29-year-olds were recruited from 134 general practice clinics in 54 rural and regional towns in four states and in nine metropolitan clinics (consecutive patients were invited to participate). Participants completed a questionnaire and were tested for chlamydia. MAIN OUTCOME MEASURE: Chlamydia prevalence. RESULTS: Of 4284 participants, 197 tested positive for chlamydia (4.6%; 95% CI, 3.9%-5.3%). Prevalence was similar in men (5.2% [65/1257]; 95% CI, 3.9%-6.4%) and women (4.4% [132/3027]; 95% CI, 3.5%-5.2%) (P = 0.25) and high in those reporting genital symptoms or a partner with a sexually transmissible infection (STI) - 17.0% in men (8/47; 95% CI, 2.8%-31.2%); 9.5% in women (16/169; 95% CI, 5.1%-13.8%). Nearly three-quarters of cases (73.4% [130/177]) were diagnosed in asymptomatic patients attending for non-sexual health reasons, and 83.8% of all participants (3258/3890) had attended for non-sexual health reasons. Prevalence was slightly higher in participants from rural and regional areas (4.8% [179/3724]; 95% CI, 4.0%-5.6%) than those from metropolitan areas (3.1% [17/548]; 95% CI, 1.5%-4.7%) (P = 0.08). In multivariable analysis, increasing partner numbers in previous 12 months (adjusted odds ratio [AOR] for three or more partners, 5.11 [95% CI, 2.35-11.08]), chlamydia diagnosis in previous 12 months (AOR, 4.35 [95% CI, 1.52-12.41]) and inconsistent condom use with most recent partner (AOR, 2.90 [95% CI, 1.31-6.40]) were significantly associated with chlamydia in men. In women, increasing partner numbers in previous 12 months (AOR for two partners, 2.59 [95% CI, 1.59-4.23]; AOR for three or more partners, 3.58 [95% CI, 2.26-5.68]), chlamydia diagnosis in previous 12 months (AOR, 3.13 [95% CI, 1.62-6.06]) and age (AOR for 25-29-year-olds, 0.23 [95% CI, 0.12-0.44]) were associated with chlamydia. CONCLUSIONS: Chlamydia prevalence is similar in young men and women attending general practice. Testing only those with genital symptoms or a partner with an STI would have missed three-quarters of cases. Most men and women are amenable to being tested in general practice, even in rural and regional areas.

Telecommunications as a means to access health information: an exploratory study of migrants in australia.

BACKGROUND: Health policies increasingly promote e-health developments (e.g., consumers' access to online health information) to engage patients in their health care. In order to make these developments available for culturally and socially diverse communities, not only do Internet accessibility, literacy and e-health literacy need to be taken into account, but consumers' preferences and information seeking behaviours for accessing health information have also to be understood. These considerations are crucial when designing major new health policy directions, especially for migration destination countries with culturally diverse populations, such as Australia. The aim of this study was to examine how people from a culturally and linguistically diverse (CALD) community use telecommunications (phone, mobile, Internet) to access health information. DESIGN AND METHODS: A case study was conducted using a questionnaire exploring the use of telecommunications to access health information among CALD people. The study was carried out at a community health centre in a socially and economically disadvantaged area of Melbourne, a city of 4 million people with a large CALD and migrant population. Questionnaires were translated into three languages and interpreters were provided. Fifty-nine questionnaires were completed by users of the community health centre. RESULTS: Most of the CALD participants did not have access to the Internet at home and very few reported using telecommunications to access health information. CONCLUSIONS: The findings of the study suggest that telecommunications are not necessarily perceived to be an important channel for accessing health information by members of the CALD community.

Stigma and sex work from the perspective of female sex workers in Hong Kong.

While the stigma surrounding sex work is both well documented and easily recognised, few studies examine stigma in this context from the perspective of the sex workers themselves. In this article we report on a study using a modified grounded theory approach to analyse a series of semi-structured interviews with 49 female sex workers in Hong Kong, in order to examine the ways in which this group experiences and negotiates the stigma which arises from their employment in the sex industry. Sex workers in Hong Kong were subject to various stigmatising forces in their daily lives in their interactions with the public, the police and their families. These processes could have a negative impact on the sex workers' health, both through obvious manifestations such as physical or verbal abuse and through more subtle processes such as those which generated or perpetuated vulnerability and those which compelled the sex workers to conceal their identities and withdraw themselves from social networks. These findings are situated in the context of broader research surrounding sex work, drawing attention to the consequences of stigma on health and their interaction with health-service providers, before briefly discussing possible means of overcoming stigma-related barriers to providing adequate healthcare for this marginalised group.

"One country, two systems": Sociopolitical implications for female migrant sex workers in Hong Kong.

BACKGROUND: Under the "two countries, one system" policy implemented by China to manage the return of Hong Kong's sovereignty, Hong Kong has maintained a comparatively prosperous economy within the Asian region. This has resulted in an environment which fosters migration from the mainland to Hong Kong, due largely to proximity, higher earning potential, common language, and a relaxing of border control measures. However not all mainland China citizens are equally able to access these new migration schemes and indeed a number of women such as sex workers are either migrating and/or working illegally and without occupational, legal and health protection within Hong Kong. DISCUSSION: Female migrant sex workers are exposed to a number of significant threats to their health, however their illegal status contributes to even greater vulnerability. The prevailing discourses which view these women as either "trafficked women" or as "illegal immigrants" do not adequately account for the complex situations which result in such women's employment in Hong Kong's sex industry. Rather, their position can best be understood within the broader frameworks provided by migration literature and the concept of "structural violence". This allows for a greater understanding of the socio-political issues which are systematically denying migrant sex workers adequate access to health care and other opportunities for social advancement. When these issues are taken into account, it becomes clear that the current relevant legislation regarding both immigration and sex work is perpetuating the marginalised and vulnerable status of migrant sex workers. Unless changes are made, structural barriers will remain in place which impede the ability of migrant sex workers to manage their own health needs and status. CONCLUSION: Female migrant sex workers in Hong Kong are extremely vulnerable to a number of occupational health and safety hazards which have significantly detrimental effects on their health. These risks can best be understood within a broad framework of socio-political factors contributing to their vulnerability. Ensuring that migrant sex workers have adequate support for their health and legal rights requires require structural interventions such as decriminalisation and providing open and inclusive access to health service to counteract such factors.