"COVID-19 - A Perfect Storm": A Qualitative Exploration of Residential Care Facility Managers Perspectives on the Psychosocial Impacts of COVID-19.

Growing evidence highlights the negative impact of managing the COVID-19 pandemic on the wellbeing of the healthcare workforce, including in the aged care sector. We undertook a qualitative study during the pandemic's third year to explore the psychosocial impacts on nine managers of residential care facilities (RCFs) across metropolitan and rural New South Wales, the largest state in Australia. Four themes were identified: (1) Increased pressure on maintaining aged care services, (2) Increased responsibility on RCF managers, (3) Psychosocial impacts due to accumulating pressures, and (4) Experience of beneficial supports. COVID-19 compounded pre-pandemic sector challenges and added new stressors. While resilient and resourceful, RCF managers experienced workplace stress and burnout, which may affect quality of resident care and impact on staff retention. There is a need for more investment to effectively support staff, and research to identify optimal psychosocial and management supports.

Implementing recommended COVID-19 public health measures in the era of living with COVID-19: Experiences of residential aged care facility managers in New South Wales, Australia.

OBJECTIVES: To understand residential aged care facility (the facility) managers' perspectives on implementing public health measures (the measures) in their facilities in terms of barriers, facilitators and suggestions for improvement, after three years of the COVID-19 pandemic. METHODS: Nine managers of the facilities without an active COVID-19 outbreak across New South Wales, Australia, representing metropolitan and rural locations, diverse facility size and star quality rating were interviewed (April-June 2023) and data qualitatively analysed. RESULTS: Broader policy context, the need to balance the measures with resident well-being, facility-built infrastructure and mask fatigue were reported as barriers to implementation. Workplace policies, cultural embedding and local innovations were reported as facilitators. Suggested strategies included recommending the measures consistent with temporal COVID-19 risk; government agencies improving communication about the measures; mandatory staff vaccination; and simplified reporting requirements. CONCLUSIONS: We recommend that relevant government agencies develop a single source of formalised, endorsed, up-to-date advice for the sector-specific COVID-19 information and communications; streamline outbreak notification and reporting requirements; and improve consultation with the sector.

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia.

OBJECTIVES: To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions. DESIGN: We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting. SETTING: Australian primary care. PARTICIPANTS: Registered physiotherapists who are members of a practice-based research network (n=31). RESULTS: The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application. CONCLUSION: High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

Meaningful coproduction with clinicians: establishing a practice-based research network with physiotherapists in regional Australia.

BACKGROUND: The disconnect between research and clinical practice leads to research evidence that is often not useful for clinical practice. Practice-based research networks are collaborations between researchers and clinicians aimed at coproducing more useful research. Such networks are rare in the physiotherapy field. We aimed to describe (i) clinicians' motivations behind, and enablers to, participating in a network, (ii) the process of network establishment and (iii) research priorities for a practice-based network of physiotherapists in the Hunter Region of New South Wales (NSW), Australia that supports research coproduction. METHODS: We describe the methods and outcomes of the three steps we used to establish the network. Step 1 involved consultation with local opinion leaders and a formative evaluation to understand clinicians' motivations behind, and enablers to, participating in a network. Step 2 involved establishment activities to generate a founding membership group and codesign a governance model. Step 3 involved mapping clinical problems through a workshop guided by systems thinking theory with local stakeholders and prioritizing research areas. RESULTS: Through formative evaluation focus groups, we generated five key motivating themes and three key enablers for physiotherapists' involvement in the network. Establishment activities led to a founding membership group (n = 29, 67% from private practice clinics), a network vision and mission statement, and a joint governance group (9/13 [70%] are private practice clinicians). Our problem-mapping and prioritization process led to three clinically relevant priority research areas with the potential for significant change in practice and patient outcomes. CONCLUSIONS: Clinicians are motivated to break down traditional siloed research generation and collaborate with researchers to solve a wide array of issues with the delivery of care. Practice-based research networks have promise for both researchers and clinicians in the common goal of improving patient outcomes.

A qualitative study on COVID-19 pandemic impacts on parental attitudes and intentions for routine adolescent vaccinations: The role of trust.

INTRODUCTION: The COVID-19 pandemic has contributed to declines in routine childhood and adolescent vaccination coverage globally. While the declines in Australia have been less, they are a concern, given steady increases in coverage prior to the pandemic. Given limited evidence on how the experiences of parents during the pandemic affected their attitudes about and intentions towards adolescent vaccinations, with this study we aimed to explore these. METHODS: This was a qualitative study. We invited parents of adolescents eligible for school-based vaccinations in 2021 from metropolitan, regional and rural areas of New South Wales and Victoria (the most affected States) and South Australia (less affected) to half hour-long online semi-structured interviews. We analysed data thematically and applied a conceptual model of trust in vaccination. RESULTS: In July 2022 we interviewed 15 accepting, 4 hesitant and two parents who refused adolescent vaccinations. We identified three themes: 1. Pandemic impacting on professional and personal lives and routine immunisations; 2. Pandemic strengthening preexisting vaccine hesitancy, with perceived lack of clarity in governmental information about vaccination and stigma around non-vaccinating as contributing factors; 3. Pandemic raising awareness of the benefits of COVID-19 and routine vaccinations, with communication campaigns and one's trusted doctor's vaccination recommendations as contributing factors. CONCLUSIONS: For some parents, experiences of poor system readiness and growing distrust towards health and vaccination systems strengthened their pre-existing vaccine hesitancy. We offer recommendations on how trust in the health system and immunisation can be optimised post-pandemic to increase uptake of routine vaccines. These include improving access to vaccination services and clear, timely information about vaccines; supporting immunisation providers in their immunisation consultations; working alongside communities, and building capacity of vaccine champions.

Understanding the factors that influence communication about COVID-19 vaccines with patients: Perspectives of Australian immunisation providers.

Background: COVID-19 immunisation providers have been at the forefront of the pandemic, and their ability to communicate effectively with patients is key to encouraging COVID-19 vaccine acceptance and uptake. This study explored providers' perspectives on the factors influencing communication with patients about COVID-19 vaccines. Methods: We used an explanatory-sequential mixed-methods approach to conduct the study between December 2021 and March 2022. Phase I involved a cross-sectional survey with immunisation providers in New South Wales (n = 341; 189 general practitioners, 118 nurses and 34 pharmacists), followed by Phase II: semi-structured, in-depth qualitative interviews (n = 19; 10 nurses, 9 pharmacists). We generated descriptive results for the survey. We analysed the qualitative data thematically using an inductive approach. Results: Almost half of survey participants reported communicating often with people who were hesitant about COVID-19 vaccines (49 %; 166/341), however, 21 % (71/341) reported inadequate time to address concerns during consultations. Interview participants reported communication challenges, including time constraints, difficulties addressing and eliciting patient concerns, and keeping up to date with changing information. Conversely, interview participants reported that easy access to government information resources, time to learn about COVID-19 vaccines proactively, knowing about and being able to use tailored strategies to support Aboriginal and Torres Strait Islander and CALD patients were helpful when communicating with patients. Conclusions: Immunisation providers play an important role in patient vaccine acceptance and uptake. Our findings indicate that whilst providers were largely confident in their interactions with patients, further communication support would strengthen providers' skills in communicating with patients who have questions and concerns about COVID-19 vaccines.

Describing the evidence-base for research engagement by health care providers and health care organisations: a scoping review.

BACKGROUND: Having a research-engaged health and medical workforce is associated with improvements in clinical outcomes for patients. As such, there has been significant government investment internationally to support health care organisations and services to increase staff engagement with research. OBJECTIVES: This scoping review sought to provide an overview of the literature describing strategies employed to increase research engagement by health care providers and organisations, and to undertake a qualitative analysis to generate a list of research engagement strategies. METHODS: A scoping review using systematic search strategies was undertaken to locate peer-review publications and grey literature related to research engagement by health care providers and organisations. Research engagement was defined as a 'deliberate set of intellectual and practical activities undertaken by health care staff and organisations to conduct research'. A database search of electronic records was performed with no limit on publication date. Publications were included regardless of study type (excluding systematic reviews) and categorised as either databased (presenting data or new analysis of existing data) and non-databased (no new data or analyses). Databased publications were further classified according to study type, study design and setting. A qualitative synthesis using a Framework Approach was undertaken with all studies that described a strategy to improve research engagement. RESULTS: A total of 152 publications were included in this study with 54% categorised as non-databased. Of the databased articles, the majority (72%) were descriptive studies describing prevalence of correlates of research engagement, 17 (25%) described intervention studies where only two were controlled studies. The following research engagement strategies were identified: i) dual skilled team/staff, ii) resources or physical infrastructure, iii) incentives, iv) leadership support of research, v) education/training, vi) networks, vii) forming partnerships or collaborations and viii) overall leadership structure of entity. CONCLUSIONS: The literature on research engagement is primarily opinion-based and descriptive in nature. To provide the evidence needed to inform strategies, this needs to progress beyond descriptive to more rigorous well-designed intervention research.

COVID-19 vaccination acceptance among older adults: A qualitative study in New South Wales, Australia.

Objectives: The COVID-19 pandemic has had a severe impact on people across the world, particularly older adults who have a higher risk of death and health complications. We aimed to explore older adults' intention towards COVID-19 vaccination and factors that influenced their motivation to get vaccinated. Study design: A qualitative study was conducted in New South Wales, Australia (April 2021), involving interviews with older adults (aged 70 years and older). Methods: In-depth interviews were carried out with 14 older adults on their perceptions around COVID-19 vaccination. The COVID-19 vaccination program had just commenced at the time of data collection. We thematically analysed interviews and organised the themes within the Behavioural and Social Drivers of Vaccination (BeSD) Framework. Results: We found that most participants were accepting of COVID-19 vaccination. Participants' motivation to get vaccinated was influenced by the way they thought and felt about COVID-19 disease and vaccination (including perceptions of vaccine safety, effectiveness, benefits, COVID-19 disease risk, and vaccine brand preferences) and social influences (including healthcare provider recommendation, and influential others). The uptake of COVID-19 vaccination was also mediated by practical issues such as access and affordability. Conclusions: Efforts to increase COVID-19 vaccination acceptance in this population should focus on highlighting the benefits of vaccination. Support should be given to immunisation providers to enhance efforts to discuss and recommend vaccination to this high-risk group.

Physiotherapists' opinions, barriers, and enablers to providing evidence-based care: a mixed-methods study.

BACKGROUND: Physiotherapists deliver evidence-based guideline recommended treatments only half of the time to patients with musculoskeletal conditions. Physiotherapists' behaviour in clinical practice are influenced by many cognitive, social, and environmental factors including time and financial pressures. Many initiatives aimed at improving physiotherapists' uptake of evidence-based care have failed to appreciate the context involved in clinical decisions and clinical practice. Therefore, we aimed to describe: i) opinions toward evidence; ii) how evidence is accessed; iii) factors influencing evidence access; iv) factors influencing evidence application, for physiotherapists working in regional areas. METHODS: We used a mixed-methods study with online survey and focus groups. We included registered physiotherapists in the survey and physiotherapists practising in regional New South Wales in the focus groups. Quantitative and qualitative data were used to inform all research objectives. We used eight domains of the Transtheoretical Domains Framework to design survey questions. We analysed quantitative and qualitative data in parallel, then integrated both sources through by developing a matrix while considering the Transtheoretical Domains Framework domains to generate themes. RESULTS: Fifty-seven physiotherapists participated in the study (survey only n = 41; focus group only n = 8; both survey and focus group n = 8). Participants reported that evidence was important, but they also considered patient expectations, colleagues' treatment choices, and business demands in clinical decision making. Physiotherapists reported they access evidence on average 30 minutes or less per week. Competing demands like business administration tasks are barriers to accessing evidence. Participants reported that patient expectations were a major barrier to applying evidence in practice. Environmental and systemic factors, like funding structures or incentives for evidence-based care, and social factors, like lacking or having a culture of accountability and mentorship, were reported as both barriers and enablers to evidence application. CONCLUSIONS: This study provides context to physiotherapists' opinion, access, and application of evidence in clinical practice. Physiotherapists' provision of evidence-based care may be improved by enhancing structural support from workplaces to access and apply evidence and exploring discrepancies between physiotherapists' perceptions of patient expectations and actual patient expectations.

"I'm scared that if I have the vaccine, it's going to make my lung condition worse, not better." COVID-19 vaccine acceptance in adults with underlying health conditions - A qualitative investigation.

Background: Sustained uptake of COVID-19 vaccines, including booster doses, will continue to be key to minimising morbidity and mortality caused by COVID-19. Because hesitancy can affect people's motivation to get vaccinated, understanding and addressing factors influencing acceptance is critical to achieving high uptake. This is especially the case for adults with underlying health conditions, who are at increased risk of severe illness from COVID-19. The aim of this study was to investigate barriers and facilitators of COVID-19 vaccine acceptance in adults with underlying health conditions during the initial rollout of COVID-19 vaccines in Australia. Methods: We conducted semi-structured, qualitative interviews with 15 adults with underlying health conditions in New South Wales (NSW) in April 2021, focusing on their previous vaccination experiences and feelings about COVID-19 vaccination. We categorised participants as accepting, hesitant or refusing. We analysed interviews thematically, informed by the World Health Organization (WHO) Behavioural and Social Drivers of Vaccination framework. Results: Most (12/15) participants were hesitant about COVID-19 vaccination. Barriers to COVID-19 vaccine acceptance included concerns about vaccine safety and effectiveness; heightened perceptions of risk regarding the vaccines; low perceptions of COVID-19 risk; and negative social influences. Facilitators included perceived benefits of vaccination and positive social influences. Conclusions: For some adults with underlying health conditions, perceptions of heightened vulnerability to COVID-19 vaccine side effects contributed to vaccine hesitancy during the initial rollout of COVID-19 vaccines. We recommend supporting GPs and specialists to proactively reach out and recommend COVID-19 vaccination to this population; encouraging chronic disease organisations to act as trusted advocates of COVID-19 vaccination; and actively communicating evolving knowledge about vaccine safety.

The role of leadership among a Congolese community in Australia in response to the COVID-19 pandemic: a narrative study.

Objective: Community leadership enhances collective action in times of uncertainty, such as during the coronavirus disease (COVID-19) pandemic. This study explores the role of leadership related to the COVID-19 response and information sharing among a newly emerging Congolese community in the Hunter New England region of Australia. Methods: Semi-structured qualitative inquiry was used to interview four participants who were identified as being influential leaders of the local Congolese community. The findings of this study were part of a larger exploration of COVID-19 messaging among emerging culturally and linguistically diverse (CALD) communities. Two interviewers independently analysed the transcribed data before pairing their findings. Narrative analysis was employed. Results: Two major themes were identified: leadership as an assigned and trusted role, and leadership as a continuous responsibility. Several categories were identified within these themes, such as mutual connection, education level, multilingual ability and networking. Discussion: The Congolese community leaders reported feeling responsible and confident in their ability to proactively contribute to the local COVID-19 response by enhancing communication within the community. By partnering with and learning from respected leaders in CALD communities, government health services have the opportunity to improve how current public health messaging is developed.

"Every interaction you have should be an opportunity to discuss and offer influenza vaccination". Health service perspectives on influenza vaccination promotion and delivery to Aboriginal families living in New South Wales, Australia.

INTRODUCTION: There is little research to understand reasons for suboptimal influenza vaccination uptake among Aboriginal people of different ages in Australia. This study aimed to better understand the communication needs and preferences of Aboriginal families (Phase 2) in New South Wales, Australia, and their health service providers (Phase 1), to inform future interventions to improve influenza immunisation coverage in Aboriginal communities. This paper reports from Phase 1 of the study. MATERIAL AND METHODS: Aboriginal and non-Aboriginal researchers designed and conducted the study, with cultural governance provided by Aboriginal health care professionals and other community members working within health departments or community healthcare settings across Australia. In Phase 1 we conducted interviews and focus groups with 18 Aboriginal immunisation providers and mainstream immunisation co-ordinators from three geographic areas in New South Wales. We used group-based thematic analysis with a cultural lens and sought participants' feedback prior to finalising results. RESULTS: We identified four themes, framed as opportunities for improvement: better supporting Aboriginal Medical Services as providers of influenza vaccinations; improving the accessibility and appropriateness of mainstream services for Aboriginal families; improving health providers' knowledge of Aboriginal people' influenza risk and their willingness to recommend vaccination; and engaging communities to design influenza vaccination resources. CONCLUSIONS: To achieve optimal influenza vaccination coverage, all health services must take responsibility for providing culturally responsive clinical care to Aboriginal families. We suggest that, where possible, mainstream services incorporate elements of the family-centred and broader model of health used by Aboriginal Medical Services. This includes creating a welcoming environment, appropriately identifying and getting to know Aboriginal patients, taking a preventative approach, and opportunistically offering and strongly encouraging influenza vaccination to the individual and their family.

Structural and social inequities contribute to pockets of low childhood immunisation in New South Wales, Australia.

Introduction: Childhood immunisation is a safe and effective way to protect children and communities from serious diseases. In Australia childhood immunisation is generally well accepted with high coverage rates however pockets of low coverage exist. Authors conducted five previous studies in New South Wales which found socio-economic disadvantage, gender inequity, health service access barriers and under-utilisation of immunisation data, rather than ideological opposition, contributed to children's incomplete vaccination. Material and Methods: Common findings across those five studies were identified. Additional literature was reviewed using a number of lenses, underpinned by a social determinants of health framework. Results: The lensed approach allowed further exploration of the impact of financial stress, poor mental health, drug and alcohol problems, domestic violence, assumed gender roles, lack of culturally acceptable health care for Indigenous families, geography and changes to immunisation policies on families and how this may have contributed to pockets of low immunisation coverage. Social and structural inequities were revealed. These often contributed to conflicting priorities that meant children's immunisations fell behind. Discussion: Strategies to address inequities may include reorientation of existing community based child health services to include flexible options such as drop in clinics, outreach services, home visiting and ensuring Indigenous families have access to culturally safe and acceptable services. Assistance with transport would further improve access to services. Better use of immunisation data can aid in the identification of pockets of low coverage and monitor and evaluate service effectiveness. Conclusions: Greater awareness of social and structural barriers and their impact on families can inform the design of tailored strategies that address the needs of disadvantaged children and families. Without efforts to overcome the inequities that contribute to low immunisation coverage, the status quo persists, leaving children and communities at risk of vaccine preventable diseases.

The Impact of Public Health Restrictions in Residential Aged Care on Residents, Families, and Staff During COVID-19: Getting the Balance Right.

Outbreaks of COVID-19 in a small number of aged care facilities in Australia had devastating mortality ratios. Strict infection control measures were implemented with little time to adapt. This study explored the views and experiences of residents, families, and care providers about the preparation for COVID-19 and identified areas for improvement. Twenty-one individual interviews were conducted. Using interpretative phenomenological analysis, we found rapid changes to visiting and activities, with physical and emotional impact. Some participants coped using personal resources. Family and residents valued the empathy and quality care provided, despite the overburdened workforce. Good leadership supported implementation of public health advice, but the severity of measures should be proportionate to local risk. Better pandemic planning that includes clear responsibilities, training, and evaluation is important. Consultation with residents, family, and health workers throughout a pandemic will help identify those most at risk of social isolation and physical decline and develop strategies to minimize their impact. The rights and welfare of residents must be respected at all times.

Factors contributing to the sharing of COVID-19 health information amongst refugee communities in a regional area of Australia: a qualitative study.

BACKGROUND: The COVID-19 pandemic has had a disproportionate impact on culturally and linguistically diverse (CALD) groups worldwide. Newly emerging CALD populations formed by recently arrived refugees are predisposed to even greater health disadvantages due to complexities of the refugee experience. The aim of this study was to explore how culture, refugee experiences and existing relationships shaped what COVID-19 messages were listened to and shared during the early-mid phases of the pandemic. The work focused on three newly emerging refugee groups in the Hunter New England region, Australia: Afghan, Congolese and Syrian communities. METHODS: Qualitative, semi-structured interviews were conducted to explore the experiences and stories of 15 adult community members, nine influential members and six service providers. All community members arrived in Australia on or after January 2014. Interpreter-assisted interviews were conducted with small groups or individuals, audio-recorded and transcribed verbatim in English. Three levels of thematic data analysis were employed to uncover the important issues and experiences of the participants. RESULTS: Three key themes and several subthemes were identified. The themes were: 1) Experience as a refugee uniquely influences COVID-19 message communication; 2) Refugee groups use diverse practices when accessing and sharing COVID-19 messages; and 3) Official government messages could be improved by listening and tailoring to community needs. CONCLUSIONS: Effective health messaging relies on reaching communities in a culturally acceptable and meaningful way. Official COVID-19 messages can be tailored to engage newly emerging communities by improving the quality of the content, delivery and format whilst working collaboratively with communities and trusted service providers. Further mutual research is needed to understand emerging communities' viewpoints. The use of culturally informed approaches is recommended.

Ezidi voices: The communication of COVID-19 information amongst a refugee community in rural Australia- a qualitative study.

BACKGROUND: There is growing evidence that government health information related to COVID-19 has failed to adequately reach culturally and linguistically diverse (CALD) populations in Australia. Refugees are a unique sub-set of the CALD communities and are subject to numerous barriers preventing adequate health care, both pre- and post-migration. The barriers are accentuated during emergencies, such as a pandemic, as a result of an intersection of various social and economic inequalities. The recently resettled Ezidi refugee community in a regional area of Australia is an example of a community sitting at the intersection of various inequities and thus at greater risk from COVID-19. The purpose of this study is to describe the experiences of the Ezidi in a regional area with COVID-19 information and how this has been communicated to and shared within this group; what barriers the community may experience in accessing COVID-19 information; and how the government-led COVID-19 information communication could be improved. METHODS: This qualitative study was designed to explore the perceptions and views of the Ezidi and service providers regarding COVID-19 messaging. Multicultural and Refugee Health staff facilitated interviews with four local service providers and ten Ezidi community members, including seven influential leaders. Thematic analysis was employed across individual, pair and group data analysis. Similar categories were grouped into themes. RESULTS: The main findings of the study are: the refugee experience influences the communication of COVID-19 messages; cultural, social and gender norms influence responses to COVID-19; trusted individuals and service providers are key in communities' uptake of COVID-19 messages; currently available governmental COVID-19 information resources and sharing strategies were found unhelpful and inappropriate; COVID-19 communiqués and message delivery for this regional minority refugee community can be improved. CONCLUSION: The recently resettled Ezidi community, and likely other similar communities, would benefit from tailored engagement by government organisations, as well as settlement services to improve the communication of COVID-19 health information and reduce related inequities.

Perspectives of emergency department clinicians on the challenges of addressing low back pain in the emergency setting: A qualitative study.

OBJECTIVE: To identify and explore ED clinician perspectives on: (i) why patients with low back pain (LBP) present to the ED and are admitted into hospital from ED; (ii) barriers and enablers they face when providing care to patients with LBP; and (iii) strategies to improve the care of patients with LBP, and associated care processes, in the ED. METHODS: We undertook a qualitative exploratory study with ED clinicians (medical officers, nurses and physiotherapists) at a tertiary-level public hospital in New South Wales, Australia, using focus groups and individual interviews. We used thematic analysis to synthesise participant responses to answer the predefined research questions. RESULTS: Twenty-one clinicians participated (two individual interviews, 19 focus groups). Perceptions about better access to the ED and advanced care within ED were thought to drive presentations to the ED for LBP. Barriers and enablers to optimal patient care included patient-, clinician- and service-level factors. The main strategies to improve care included a department LBP pathway, modernised patient and clinician resources, better follow-up options post-discharge and improved communication between ED and primary care. CONCLUSION: We identified a range of targets to improve LBP management in ED. Clinicians perceived internal and external factors to the ED as influences of ED presentation and hospital admission. Clinicians also reported that patient-, clinician- and service-level barriers and enablers influenced patient management in ED. Strategies suggested by clinicians included improved follow-up options, access to resources and an 'LBP pathway' to support decision making.

'Immunisation, I haven't had a problem, but once again the transport, making an appointment, the time that you waste and all of those things are an issue'-Understanding childhood under-immunisation in Mid North Coast New South Wales, Australia.

OBJECTIVES: This study aimed to understand the reasons for childhood under-immunisation in Kempsey, New South Wales, among First Nations and non-First Nations families, and potential strategies to improve coverage. DESIGN: The World Health Organization's Tailoring Immunization Programmes guide was employed. Tailoring Immunization Programmes uses social science, qualitative research methods and community participation and is underpinned by the Capabilities Opportunities Motivations-Behaviors (COM-B) theoretical model of behaviour change. A cultural lens was applied throughout the study design. Using a thematic analysis, factors found to influence childhood under-immunisation were loosely mapped against COM-B framework. SETTING: Face-to-face interviews and focus groups conducted in locations and at times convenient to participants were audio-recorded and transcribed verbatim. PARTICIPANTS: Fifty-six participants (25 First Nations and 13 non-First Nations mothers and grandmothers, and 18 health service providers) took part in the study (July-October 2019). RESULTS: Four themes were identified: (a) parents are supportive of immunisation and effective reminders would make it easier to prioritise it (b) services could be more accessible for families (c) addressing workforce shortages could improve access to immunisation services and (d) addressing entrenched racism in the community will help build cultural safety in health services. While parents in Kempsey were supportive of immunisation, resourceful and resilient, many struggled to overcome entrenched structural and cultural barriers to accessing services. This was particularly difficult for First Nations, socially disadvantaged and single mums. CONCLUSIONS: Public health services can provide more support to those mothers and grandmothers who need it most, to ensure they are able to access immunisation services without delay.

"To Protect Myself, My Friends, Family, Workmates and Patients and to Play My Part": COVID-19 Vaccination Perceptions among Health and Aged Care Workers in New South Wales, Australia.

The 2019 coronavirus disease (COVID-19) pandemic has globally caused widespread disruption, morbidity and mortality. The uptake of COVID-19 vaccination is critical for minimising further impacts of the pandemic. Health and aged care workers (HACWs) play a central role in public confidence in vaccines and are one of the priority groups for COVID-19 vaccination in Australia. Qualitative phone interviews with 19 HACWs aged 21-50 years old from New South Wales, Australia, were conducted, and the data were analysed thematically in order to understand the factors influencing HACWs' acceptance of COVID-19 vaccination. We found that HACWs reported a continuum of COVID-19 vaccination intentions with 12 enthusiastically accepting and 7 hesitant. Using the Behavioral and Social Drivers of COVID-19 Vaccination (BeSD) Framework, we found that participants' acceptance of vaccination was primarily driven by their perceptions of COVID-19 vaccination (such as safety, risk and benefits) and by the information sources, people and norms they trusted. Informed by study findings, we propose several communication strategies which may be helpful in addressing HACWs vaccination acceptance. We note however that as the pandemic continues, further studies with HACWs from diverse backgrounds are needed in order to provide accurate data on diverse motivational and practical drivers of evolving perceptions and attitudes towards vaccination.