A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities.

BACKGROUND: Medication errors are a leading cause of mortality and morbidity. Clinical pharmacy services provided in hospital can reduce medication errors and medication related harm. However, few rural or remote hospitals in Australia have a clinical pharmacy service. This study will evaluate a virtual clinical pharmacy service (VCPS) provided via telehealth to eight rural and remote hospitals in NSW, Australia. METHODS: A stepped wedge cluster randomised trial design will use routinely collected data from patients' electronic medical records (n = 2080) to evaluate the VCPS at eight facilities. The sequence of steps is randomised, allowing for control of potential confounding temporal trends. Primary outcomes are number of medication reconciliations completed on admission and discharge. Secondary outcomes are length of stay, falls and 28 day readmissions. A cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) will be conducted. The CEA will answer the question of whether the VCPS is more cost-effective compared to treatment as usual; the CBA will consider the rate of return on investing in the VCPS. A patient experience measure (n = 500) and medication adherence questionnaire (n = 100 pre and post) will also be used to identify patient responses to the virtual service. Focus groups will investigate implementation from hospital staff perspectives at each site. Analyses of routine data will comprise generalised linear mixed models. Descriptive statistical analysis will summarise patient experience responses. Differences in medication adherence will be compared using linear regression models. Thematic analysis of focus groups will identify barriers and facilitators to VCPS implementation. DISCUSSION: We aim to demonstrate the effectiveness of virtual pharmacy interventions for rural populations, and inform best practice for using virtual healthcare to improve access to pharmacy services. It is widely recognised that clinical pharmacists are best placed to reduce medication errors. However, pharmacy services are limited in rural and remote hospitals. This project will provide evidence about ways in which the benefits of hospital pharmacists can be maximised utilising telehealth technology. If successful, this project can provide a model for pharmacy delivery in rural and remote locations. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) -ACTRN12619001757101 Prospectively registered on 11 December 2019. Record available from: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378878&isReview=true.

Aboriginal and Torres Strait Islander disability prevalence: making sense of multiple estimates and definitions.

OBJECTIVE: To analyse the multiple sources of statistics on prevalence of disability among Aboriginal and Torres Strait Islander (Indigenous) people in Australia to provide reliable headline estimates. METHODS: Survey documentation and statistics from the Australian Bureau of Statistics (ABS) were collated and comparatively analysed. RESULTS: Two separate concepts are defined by the ABS: 'Disability' and 'Disability and restrictive health conditions'. The former is used in the Survey of Disability, Ageing and Carers (SDAC), the recommended source of disability prevalence estimates. The second is used in surveys to compare people with disability to those without. The 2014-15 National Aboriginal and Torres Strait Islander Survey (NATSISS) used a mix of these definitions, which led to differing prevalence estimates from SDAC estimates. Further, there is confusion in the NATSISS results, with 'disability' frequently replacing 'disability and restrictive health condition'. DISCUSSION: The SDAC should be used for prevalence statistics on disability in the Indigenous population. The ABS should act to clarify or withdraw confusing results from the 2014-15 NATSISS survey. Implications for public health: Official statistics are used to allocate resources; in particular, to and within the National Disability Insurance Scheme. These need to be accurate to ensure Indigenous people's health needs are met.

Physical activity among indigenous Australian children and youth in remote and non-remote areas.

Sport and physical activity (PA) hold particular significance in Australian Indigenous communities, and have the potential to address many of the health and education challenges faced by Indigenous communities. Optimal levels of PA are an important foundation in efforts to build healthy communities and reduce social disadvantage experienced to date. Yet little evidence relating to the current levels of PA within these communities, or the relationship between PA and outcomes, has been available. Drawing on national survey data from the Australian Bureau of Statistics, we examine levels of PA in the Australian Aboriginal and Torres Strait Islander Health Survey 2012-13. These data describe PA levels among Indigenous Australians, aged 5-17 years, in remote and non-remote communities. We also examine the relationship between PA and participation in education and self-reported health among 15-17 year olds. Overall, participation rates appear to be high, with 64-84% of youth reporting at least 60 min of PA on the previous day. A gender gap was also evident, with lower levels of activity among girls. PA decreased with age, particularly at or around the age of puberty. There were no significant associations between PA and either self-reported health or engagement in study. There was a relationship between high PA and low area-level socio-economic status in remote areas, but no association in non-remote areas. The differences between remote and non-remote areas highlight the importance of disaggregated analysis of Indigenous populations and are consistent with qualitative studies identifying locally contextualised factors influential in promoting PA.

Title X-Funded Health Center Staff Members' Perspectives on Barriers to Insurance Use For Confidential Family Planning Services.

CONTEXT: Under the Affordable Care Act (ACA), the number of patients who have health insurance among those receiving family planning and reproductive health services at Title X-funded health centers has grown. However, billing some patients' insurance for services may be difficult because of Title X's extensive confidentiality protections. Little is known about health centers' experiences in addressing these difficulties. METHODS: Eight focus group discussions were conducted with a convenience sample of 54 Title X-funded health center staff members and state program administrators in January and April 2015. Transcripts were examined through thematic analysis. RESULTS: Participants identified five key barriers to centers' ability to bill patients' health insurance. Insurance providers' policyholder communications (e.g., explanations of benefits or patient portal postings) can threaten confidentiality for patients insured as dependents. Patients and providers are sometimes confused about insurance providers' confidentiality protections; centers are hesitant to bill insurance when protections are unclear. Changes in Medicaid family planning waiver coverage in some states have added to this uncertainty. Health centers can encounter significant administrative burdens when billing insurance while trying to protect patients' confidentiality. Finally, patients sometimes hesitate to use their insurance because of financial or other concerns. CONCLUSIONS: Title X-funded health centers face several barriers to their ability to bill patients' health insurance while maintaining confidentiality protections. As a result, they are likely to continue relying on Title X funds to cover services for some insured patients despite the expansion of health insurance under the ACA.

Men and women with psychosis and the impact of illness-duration on sex-differences: The second Australian national survey of psychosis.

We aimed to examine and compare sex-differences in people receiving treatment for psychotic illnesses in community settings, based on long or short duration of illness; expecting association between longer illness-duration and worse outcomes in women and men. Clinical, demographic and service-use data from the Survey of High Impact Psychosis were analysed by sex and duration of illness (≤5 years; ≥6 years), using independent t-tests, chi-square tests, one-way ANOVA, and Cramer's V. Of the 1825 participants, 47% had schizophrenia, 17.5% bipolar and 16.1% schizo-affective disorders. More women than men had undertaken post-school education, maintained relationships, and been living in their own homes. Women with a shorter-illness-duration showed social functioning equivalent to non-ill women in the general population. Men tended to have an early illness onset, show premorbid dysfunction, be single, show severe disability, and to use illicit substances. Men with a longer-illness-duration were very socially disadvantaged and isolated, often experiencing homelessness and substance use. Men with a short-illness-duration were most likely to be in paid employment, but two-thirds earned less than $AUD500 per fortnight. Men with longer-illness-duration showed most disability, socially and globally. Interventions should be guided by diagnosis, but also by a person's sex and duration of illness.

Long-term effects of lifetime trauma exposure in a rural community sample.

BACKGROUND: This study examines the long-term outcomes of lifetime trauma exposure, including factors that contribute to the development of PTSD, in a sample of rural adults. METHODS: In 623 rural community residents, lifetime trauma exposure, PTSD, other psychiatric disorders and lifetime suicidal ideation were assessed using the World Mental Health Composite International Diagnostic Interview. Logistic regressions were used to examine relationships between potentially traumatic events (PTEs) and lifetime PTSD and other diagnoses. RESULTS: 78.2% of participants reported at least on PTE. Rates were broadly comparable with Australian national data: the most commonly endorsed events were unexpected death of a loved one (43.7%); witnessing injury or death (26.3%); and life-threatening accident (19.3%). While the mean age of the sample was 55 years, the mean age of first trauma exposure was 19 years. The estimated lifetime rate of PTSD was 16.0%. Events with the strongest association with PTSD were physical assault and unexpected death of a loved one. Current functioning was lowest among those with current PTSD, with this group reporting elevated psychological distress, higher mental health service use, a greater number of comorbidities, and lower perceived social support. Respondents with a past PTE but no PTSD history were generally similar in terms of their current wellbeing to those with no lifetime PTE. CONCLUSIONS: PTEs may have diverse psychological and social consequences beyond the development of PTSD. Ensuring that adequate support services are available in rural areas, particularly in the period immediately following a PTE, may reduce the long-term impact of traumatic events.

Aboriginal and Torres Strait Islander community governance of health research: Turning principles into practice.

PROBLEM: Gaps exist in researchers' understanding of the 'practice' of community governance in relation to research with Aboriginal and Torres Strait Islander peoples. DESIGN: We examine Aboriginal community governance of two rural NSW research projects by applying principles-based criteria from two independent sources. SETTING: One research project possessed a strong Aboriginal community governance structure and evaluated a 2-year healthy lifestyle program for children; the other was a 5-year cohort study examining factors influencing the mental health and well-being of participants. KEY MEASURES FOR IMPROVEMENT: The National Health and Medical Research Council of Australia's 'Values and ethics: guidelines for ethical conduct in Aboriginal and Torres Strait Islander research' and 'Ten principles relevant to health research among Indigenous Australian populations' described by experts in the field. STRATEGIES FOR CHANGE: Adopt community-based participatory research constructs. Develop clear governance structures and procedures at the beginning of the study and allow sufficient time for their establishment. Capacity-building must be a key component of the research. Ensure sufficient resources to enable community engagement, conduct of research governance procedures, capacity-building and results dissemination. EFFECTS OF CHANGE: The implementation of governance structures and procedures ensures research addresses the priorities of the participating Aboriginal and Torres Strait Islander communities, minimises risks and improves outcomes for the communities. LESSONS LEARNT: Principles-based Aboriginal and Torres Strait Islander community governance of research is very achievable. Next steps include developing a comprehensive evidence base for appropriate governance structures and procedures, and consolidating a suite of practical guides for structuring clear governance in health research.

Self-reported contacts for mental health problems by rural residents: predicted service needs, facilitators and barriers.

BACKGROUND: Rural and remote Australians face a range of barriers to mental health care, potentially limiting the extent to which current services and support networks may provide assistance. This paper examines self-reported mental health problems and contacts during the last 12 months, and explores cross-sectional associations between potential facilitators/barriers and professional and non-professional help-seeking, while taking into account expected associations with socio-demographic and health-related factors. METHODS: During the 3-year follow-up of the Australian Rural Mental Health Study (ARMHS) a self-report survey was completed by adult rural residents (N = 1,231; 61% female; 77% married; 22% remote location; mean age = 59 years), which examined socio-demographic characteristics, current health status factors, predicted service needs, self-reported professional and non-professional contacts for mental health problems in the last 12 months, other aspects of help-seeking, and perceived barriers. RESULTS: Professional contacts for mental health problems were reported by 18% of the sample (including 14% reporting General Practitioner contacts), while non-professional contacts were reported by 16% (including 14% reporting discussions with family/friends). Perceived barriers to health care fell under the domains of structural (e.g., costs, distance), attitudinal (e.g., stigma concerns, confidentiality), and time commitments. Participants with 12-month mental health problems who reported their needs as met had the highest levels of service use. Hierarchical logistic regressions revealed a dose-response relationship between the level of predicted need and the likelihood of reporting professional and non-professional contacts, together with associations with socio-demographic characteristics (e.g., gender, relationships, and financial circumstances), suicidal ideation, and attitudinal factors, but not geographical remoteness. CONCLUSIONS: Rates of self-reported mental health problems were consistent with baseline findings, including higher rural contact rates with General Practitioners. Structural barriers displayed mixed associations with help-seeking, while attitudinal barriers were consistently associated with lower service contacts. Developing appropriate interventions that address perceptions of mental illness and attitudes towards help-seeking is likely to be vital in optimising treatment access and mental health outcomes in rural areas.

Determinants of suicidal ideation and suicide attempts: parallel cross-sectional analyses examining geographical location.

BACKGROUND: Suicide death rates in Australia are higher in rural than urban communities however the contributors to this difference remain unclear. Geographical differences in suicidal ideation and attempts were explored using two datasets encompassing urban and rural community residents to examine associations between socioeconomic, demographic and mental health factors. Differing patterns of association between psychiatric disorder and suicidal ideation and attempts as geographical remoteness increased were investigated. METHODS: Parallel cross-sectional analyses were undertaken using data from the 2007 National Survey of Mental Health and Wellbeing (2007-NSMHWB, n = 8,463), under-representative of remote and very remote residents, and selected participants from the Australian Rural Mental Health Study (ARMHS, n = 634), over-representative of remote and very remote residents. Uniform measures of suicidal ideation and attempts and mental disorder using the World Mental Health Composite International Diagnostic Interview (WMH-CIDI-3.0) were used in both datasets. Geographic region was classified into major cities, inner regional and other. A series of logistic regressions were undertaken for the outcomes of 12-month and lifetime suicidal ideation and lifetime suicide attempts, adjusting for age, gender and psychological distress. A sub-analysis of the ARMHS sample was undertaken with additional variables not available in the 2007-NSMHWB dataset. RESULTS: Rates and determinants of suicidal ideation and suicide attempts across geographical region were similar. Psychiatric disorder was the main determinant of 12-month and lifetime suicidal ideation and lifetime suicide attempts across all geographical regions. For lifetime suicidal ideation and attempts, marital status, employment status, perceived financial adversity and mental health service use were also important determinants. In the ARMHS sub-analysis, higher optimism and better perceived infrastructure and service accessibility tended to be associated with a lower likelihood of lifetime suicidal ideation, when age, gender, psychological distress, marital status and mental health service use were taken into account. CONCLUSIONS: Rates and determinants of suicidal ideation and attempts did not differ according to geographical location. Psychiatric disorder, current distress, employment and financial adversity remain important factors associated with suicidal ideation and attempts across all regions in Australia. Regional characteristics that influence availability of services and lower personal optimism may also be associated with suicidal ideation in rural communities.

Factors associated with reported service use for mental health problems by residents of rural and remote communities: cross-sectional findings from a baseline survey.

BACKGROUND: The patterns of health service use by rural and remote residents are poorly understood and under-represented in national surveys. This paper examines professional and non-professional service use for mental health problems in rural and remote communities in Australia. METHODS: A stratified random sample of adults was drawn from non-metropolitan regions of New South Wales, Australia as part of a longitudinal population-based cohort. One-quarter (27.7%) of the respondents were from remote or very remote regions. The socio-demographic, health status and service utilization (professional and non-professional) characteristics of 2150 community dwelling residents are described. Hierarchical logistic regressions were used to identify cross-sectional associations between socio-demographic, health status and professional and non-professional health service utilization variables. RESULTS: The overall rate of professional contacts for mental health problems during the previous 12 months (17%) in this rural population exceeded the national rate (11.9%). Rates for psychologists and psychiatrists were similar but rates for GPs were higher (12% vs. 8.1%). Non-professional contact rates were 12%. Higher levels of help seeking were associated with the absence of a partner, poorer finances, severity of mental health problems, and higher levels of adversity. Remoteness was associated with lower utilization of non-professional support. A Provisional Service Need Index was devised, and it demonstrated a broad dose-response relationship between severity of mental health problems and the likelihood of seeking any professional or non-professional help. Nevertheless, 47% of those with estimated high service need had no contact with professional services. CONCLUSIONS: An examination of self-reported patterns of professional and non-professional service use for mental health problems in a rural community cohort revealed relatively higher rates of general practitioner attendance for such problems compared with data from metropolitan centres. Using a measure of Provisional Service Need those with greater needs were more likely to access specialist services, even in remote regions, although a substantial proportion of those with the highest service need sought no professional help. Geographic and financial barriers to service use were identified and perception of service adequacy was relatively low, especially among those with the highest levels of distress and greatest adversity.

Unintentional injury, psychological distress and depressive symptoms: is there an association for rural Australians?

PURPOSE: To investigate the association between unintentional injury and mental health in Australian rural communities. METHODS: Using cross-sectional baseline data for a longitudinal study from randomly selected adults in nonmetropolitan Australia, we fitted logistic regression models for the outcomes of domestic or public setting injury and injury in high-risk settings, using prior depression and demographic factors. OR and 99% CI were reported and also calculated for current mental health including psychological distress, depressive symptoms and risky alcohol consumption, comparing those injured with those not. FINDINGS: Of 2,639 participants who completed the injury component, 364 (13.8%) reported injury requiring treatment from a doctor or a hospitalization in the previous 12 months. Of those requiring treatment or hospitalization, 147 (40.4%) reported being injured in a domestic or public setting and 207 (56.9%) in a high-risk setting. The most common types and mechanisms of injury were sprains and strains, and falls, trips and slips, respectively. Preinjury depression was independently associated with unintentional injury in a domestic or public setting. Being injured in this setting was associated with double the odds of experiencing current depressive symptoms. The likelihood of a high-risk setting injury was significantly associated with male gender. High-risk setting injury was associated with current psychological distress and higher levels of alcohol usage. CONCLUSIONS: This study supports the hypothesis that pre-existing depression is associated with unintentional injury in a rural sample and indicates the important role of prior depression in management of injury, given the high rate of injury in rural communities. Mechanisms by which prior depression increases likelihood of unintentional injury will be further investigated using longitudinal data.

Individual and district-level predictors of alcohol use: cross sectional findings from a rural mental health survey in Australia.

BACKGROUND: Excessive alcohol use is a significant problem in rural and remote Australia. The factors contributing to patterns of alcohol use have not been adequately explained, yet the geographic variation in rates suggests a potential contribution of district-level factors, such as socio-economic disadvantage, rates of population change, environmental adversity, and remoteness from services/population centres. This paper aims to investigate individual-level and district-level predictors of alcohol use in a sample of rural adults. METHODS: Using baseline survey data (N = 1,981) from the population-based Australian Rural Mental Health Study of community dwelling residents randomly selected from the Australia electoral roll, hierarchal logistic regression models were fitted for three outcomes: 1) at-risk alcohol use, indicated by Alcohol Use Disorders Identification Test scores ≥8; 2) high alcohol consumption (> 40 drinks per month); and 3) lifetime consequences of alcohol use. Predictor variables included demographic factors, pre-dispositional factors, recent difficulties and support, mental health, rural exposure and district-level contextual factors. RESULTS: Gender, age, marital status, and personality made the largest contribution to at-risk alcohol use. Five or more adverse life events in the past 12 months were also independently associated with at-risk alcohol use (Adjusted Odds Ratio [AOR] 3.3, 99%CI 1.2, 8.9). When these individual-level factors were controlled for, at-risk alcohol use was associated with having spent a lower proportion of time living in a rural district (AOR 1.7, 99%CI 1.3, 2.9). Higher alcohol consumption per month was associated with higher district-level socio-economic ranking, indicating less disadvantage (AOR 1.2, 99%CI 1.02, 1.4). Rural exposure and district-level contextual factors were not significantly associated with lifetime consequences of alcohol use. CONCLUSIONS: Although recent attention has been directed towards the potential adverse health effects of district or community level adversity across rural regions, our study found relatively few district-level factors contributing to at-risk alcohol consumption after controlling for individual-level factors. Population-based prevention strategies may be most beneficial in rural areas with a higher socio-economic ranking, while individual attention should be focused towards rural residents with multiple recent adverse life events, and people who have spent less time residing in a rural area.

Determinants of mental health and well-being within rural and remote communities.

BACKGROUND: The individual and contextual factors influencing current mental health and well-being within rural communities are poorly understood. METHODS: A stratified random sample of adults was drawn from non-metropolitan regions of NSW, Australia. One-quarter (27.7%) of the 2,639 respondents were from remote/very remote regions. An aggregate measure of current well-being was derived from levels of distress and related impairment (Kessler-10 LM), self-reported overall physical and mental health, functioning, satisfaction with relationships, and satisfaction with life. Multivariate methods investigated the contributions to current well-being of demographic/dispositional factors, recent events and social support, individual exposure to rural adversity, and district/neighbourhood level characteristics. RESULTS: Respondents from very remote regions tended to be younger and have lower education. Univariate associations were detected between well being and exposure to rural adversity (greater drought-related worry, lower perceived service and support availability, greater number of years living in the current district). Multivariate analysis (n = 2,462) accounted for 41% of the variance in well-being scores. The major contributing variables were dispositional factors (trait neuroticism, marital status), recent adverse events and indices of social support. However, no additional effects were detected for district-level variables (drought severity, regional socioeconomic categorisation, population change). Similar associations were detected using the K-10 alone as the outcome measure. CONCLUSIONS: The chief determinants of current well being were those reflecting individual level attributes and perceptions, rather than district-level rural characteristics. This has implications for strategies to promote well being within rural communities through enhancing community connectedness and combating social isolation in the face of major adversities such as drought.

Mental health and well-being within rural communities: the Australian rural mental health study.

OBJECTIVE: This paper outlines the methods and baseline data from a multisite cohort study of the determinants and outcomes of mental health and well-being within rural and remote communities. METHODS: A stratified random sample of adults was drawn in non-metropolitan New South Wales using the Australian Electoral Roll, with the aim of recruiting all adult members of each household. Surveys assessed psychological symptoms, physical health and mental disorders, along with individual-, family/household- and community-level characteristics. A stratified subsample completed a telephone-administered World Mental Health-Composite International Diagnostic Interview (World Mental Health-3.0). Proxy measures of child health and well-being were obtained. Follow up of this sample will be undertaken at one, three and five years. RESULTS: A total of 2639 individuals were recruited (1879 households), with 28% from remote/very remote regions. A significant relationship was found between recent distress (Kessler-10 scores), age and remoteness, with a linear reduction of Kessler-10 scores with age and the lowest mean scores in remote regions. CONCLUSIONS: Existing rurality categories cannot address the diverse socio-cultural, economic and environmental characteristics of non-metropolitan regions. While it has limitations, the dataset will enable a fine-grained examination of geographic, household and community factors and provide a unique longitudinal dataset over a five-year period.

Distress among rural residents: does employment and occupation make a difference?

OBJECTIVE: This study investigates the relationship between levels of mental health and well-being (in terms of self-reported levels of distress) with employment and occupational status of rural residents, to better inform the provision of mental health services to those in greatest need in rural communities. METHOD: A stratified random sample of community residents in rural and remote New South Wales with over-sampling of remote areas as first stage of a cohort study. Psychological distress was measured using Kessler-10, inclusive of additional items addressing functional impairment (days out of role). Occupational data were classified using Australian and New Zealand Standard Classification of Occupations categories. RESULTS: A total of 2639 adults participated in this baseline phase. Among them, 57% were in paid employment, 30% had retired from the workforce, 6% were permanently unable to work and 2% were unemployed. The highest levels of distress and functional impairment were reported in those permanently unable to work and the unemployed group with rates of 'caseness' (likely mental health disorder) varying from 57% to 69%, compared with 34% of farmers and farm managers and 29% of health workers (P < 0.01). CONCLUSION: The rural unemployed suffer considerable psychological distress and 'disability', yet they are not the target of specific mental health promotion and prevention programs, which are often occasioned by rural adversity, such as drought, and delivered through work-based pathways. Policy-makers and health service providers need to consider the needs of the rural unemployed and those permanently unable to work and how they might be addressed.

Ethyl 2-[[2-(3-nitrophenyl)-5-phenyl-1H-imidazol-4-yl]sulfanyl]acetate: synthesis via a microwave-mediated combinatorial chemistry approach.

The orange title compound, C(19)H(17)N(3)O(4)S, can be synthesized either via microwave-mediated combinatorial chemistry strategies or conventional synthetic procedures. The phenyl and meta-nitrophenyl C(6) rings are essentially coplanar with the central imidazolyl ring, with interplanar angles of 0.87 (5) and 0.97 (4), respectively, resulting in optimum conjugation (SCH(2) moiety included); lambda(max) = 281 nm in CH(3)CN. The principal intermolecular interactions are N(imid)-H...O(nitro) and N(imid)-H...O[double bond]C [N...O = 3.058 (2) and 3.432 (3) A, and N-H...O = 128 and 153, respectively]. The closest H.S distance is an intramolecular C-H...S contact, with H...S = 2.54 A and C-H...S = 136.