Community-based alcohol education intervention (THEATRE) study to reduce harmful effects of alcohol in rural Sri Lanka: design and adaptation of a mixed-methods stepped wedge cluster randomised control trial.

INTRODUCTION: Alcohol consumption is a leading cause of mortality, morbidity and adverse social sequelae in Sri Lanka. Effective community-based, culturally adapted or context-specific interventions are required to minimise these harms. We designed a mixed-methods stepped wedge cluster randomised control trial of a complex alcohol intervention. This paper describes the initial trial protocol and subsequent modifications following COVID-19. METHODS AND ANALYSIS: We aimed to recruit 20 villages (approximately n=4000) in rural Sri Lanka. The proposed intervention consisted of health screening clinics, alcohol brief intervention, participatory drama, film, and public health promotion materials to be delivered over 12 weeks.Following disruptions to the trial resulting from the Easter bombings in 2019, COVID-19 and a national financial crisis, we adapted the study in two main ways. First, the interventions were reconfigured for hybrid delivery. Second, a rolling pre-post study evaluating changes in alcohol use, mental health, social capital and financial stress as the primary outcome and implementation and ex-ante economic analysis as secondary outcomes. ETHICS AND DISSEMINATION: The original study and amendments have been reviewed and granted ethical approval by Rajarata University of Sri Lanka (ERC/2018/21-July 2018 and February 2022) and the University of Sydney (2019/006). Findings will be disseminated locally in collaboration with the community and stakeholders.The new hybrid approach may be more adaptable, scalable and generalisable than the planned intervention. The changes will allow a closer assessment of individual interventions while enabling the evaluation of this discontinuous event through a naturalistic trial design. This may assist other researchers facing similar disruptions to community-based studies. TRIAL REGISTRATION: The trial is registered with the Sri Lanka Clinical Trials Registry; https://slctr.lk/trials/slctr-2018-037.

The risk and protective factors for suicidal burden among 251 763 school-based adolescents in 77 low- and middle-income to high-income countries: assessing global, regional and national variations.

BACKGROUND: Adolescent suicide is a global public health concern and the second leading cause of adolescent death worldwide. This study aimed to estimate the burden of adolescent suicidal behaviours and its association with violence and unintentional injury, psychosocial, protective, lifestyle and food security-related factors amongst school-based adolescents across 77 countries in the six World Health Organization (WHO) regions. METHODS: This study comprised a sample of 251 763 adolescents drawn from the latest Global School-based Student Health Survey of school-based adolescents, aged 11-17 years, across 77 countries. Logistic regression analyses were employed to estimate the adjusted effect of independent factors on adolescent suicidal behaviours. RESULTS: The population-weighted 12-month prevalence of suicidal ideation (SI), suicidal planning (SP) and suicidal attempts (SA) amongst school-based adolescents was 18, 18 and 16%, respectively. Adolescent suicidal behaviours (i.e. SI, SP and SA) were respectively associated with being physically attacked, physical fighting, high levels of anxiety, feeling lonely, being bullied, lack of parental support, poor peer support, not having close friends and high levels of sedentary behaviours. Overall, these associations also extended to the context of food insecurity across regions and country income groups, where the magnitude of association slightly varied from odds ratios of 1.25 times to 3.13. CONCLUSIONS: The burden of school-going adolescent suicidal thoughts, suicide planning and suicide attempts is of particular concern in low-resource countries. Comprehensive suicide prevention programmes for school-going adolescents in LMICs are needed that address socio-cultural inequities related to violence and unintentional injury, social support and psychological factors, protective, and lifestyle-related factors.

Abortion care pathways and service provision for adolescents in high-income countries: A qualitative synthesis of the evidence.

Limited research in high-income countries (HICs) examines adolescent abortion care-seeking pathways. This review aims to examine the pathways and experiences of adolescents when seeking abortion care, and service delivery processes in provision of such care. We undertook a systematic search of the literature to identify relevant studies in HICs (2000-2020). A directed content analysis of qualitative and quantitative studies was conducted. Findings were organised to one or more of three domains of an a priori conceptual framework: context, components of abortion care and access pathway. Thirty-five studies were included. Themes classified to the Context domain included adolescent-specific and restrictive abortion legislation, mostly focused on the United States. Components of abortion care themes included confidentiality, comprehensive care, and abortion procedure. Access pathway themes included delays to access, abortion procedure information, decision-making, clinic operation and environments, and financial and transportation barriers. This review highlights issues affecting access to abortion that are particularly salient for adolescents, including additional legal barriers and challenges receiving care due to their age. Opportunities to enhance abortion access include removing legal barriers, provision of comprehensive care, enhancing the quality of information, and harnessing innovative delivery approaches offered by medical abortion.

Assessing care trajectories of adolescent females seeking early induced abortion in New South Wales: multistage, mixed-methods study protocol.

INTRODUCTION: In Australia, New South Wales (NSW), abortion has recently been removed from the criminal code. Previous research from Australia and other high-income countries has focused on adult women's access to abortion services. This protocol describes a five-stage mixed-methods study to determine the care trajectories and experiences of adolescent females, aged 16-19 years, seeking an early induced abortion in NSW. The aims are to (1) explore the needs and perspectives of adolescent females seeking sexual and reproductive health services in NSW and (2) develop a framework for abortion service provision for adolescents in NSW. METHODS AND ANALYSIS: This study comprises: (1) semistructured qualitative interviews with key informants, individuals with diverse, in-depth experience of providing and/or supporting abortion care in NSW; (2) a cross-sectional online survey of adolescent females residing in NSW; (3) case study interviews with adolescents females who have accessed an abortion service in NSW; (4) a co-design workshop with adolescents who took part in stage 3 to develop relevant knowledge and recommendations and (5) a knowledge dissemination forum with key stakeholders. ETHICS AND DISSEMINATION: Ethics approval has been received from the University of Technology Sydney Human Research Ethics Committee for this study. Data collection commenced in March 2019 and will continue until the end of 2020. This study aims to develop a deep understanding of adolescent abortion care trajectories and experiences of abortion services in NSW. The study will deliver co-produced recommendations to improve adolescent access to abortion information and services.

Models of maternal and child healthcare for African refugees: protocol for an exploratory, mixed-methods study.

INTRODUCTION: There is a paucity of research examining models of maternal and child health (MCH) care for refugees in high-income countries. Attention has focused on tailoring existing healthcare services to meet the needs of this population and ensure accessible high-quality patient-centred care. This protocol reports the methodology of a study designed to identify models of care for African refugees in New South Wales (NSW), Australia, to determine the evidence for these models and the improvements necessary to best meet service needs that can be delivered in line with available resources, organisational readiness and capacity to implement. METHODS AND ANALYSIS: This multiphased, participatory research project will employ an exploratory, mixed-methods design. Preparatory activities involve a situational analysis of current MCH services for African refugees and associated policies and guidelines in NSW. We will consult key health service providers and analyse Australian census and settlement data to identify refugee communities and their relation to healthcare services. Phase 1 will ascertain the MCH care needs of African refugees and appropriate service models using: a Delphi survey with health service managers and providers, a nominal group process with African women refugees and; key informant interviews with senior health service managers. This data will be synthesised to provide insight into appropriate models-of-care that could be implemented. These will be discussed in a stakeholder workshop. Phase 2 will comprise a readiness-to-change survey with a selection of providers to explore the willingness, commitment and efficacy of staff members to adopt such models-of-care. ETHICS AND DISSEMINATION: Ethical approval was granted by NSW Health. Findings will be disseminated to all stakeholders at a knowledge exchange forum to inform the development of a high-quality MCH service delivery model that can be feasibly implemented specifically for African refugee communities. PROSPERO REGISTRATION NUMBER: CRD42018095564.

Understanding the Experiences and Needs of Migrant Women Affected by Female Genital Mutilation Using Maternity Services in Australia.

Female genital mutilation (FGM) is a cultural practice defined as the partial or total removal of the external female genitalia for non-therapeutic reasons. Changing patterns of migration in Australia and other high-income countries has meant that maternity care providers and health systems are caring for more pregnant women affected by this practice. The aim of the study was to identify strategies to inform culturally safe and quality woman-centred maternity care for women affected by FGM who have migrated to Australia. An Appreciative Inquiry approach was used to engage women with FGM. We conducted 23 semi-structured interviews and three focus group discussions. There were four themes identified: (1) appreciating the best in their experiences; (2) achieving their dreams; (3) planning together; and (4) acting, modifying, improving and sustaining. Women could articulate their health and cultural needs, but they were not engaged in all aspects of their maternity care or considered active partners. Partnering and involving women in the design and delivery of their maternity care would improve quality care. A conceptual model, underpinned by women's cultural values and physical, emotional needs, is presented as a framework to guide maternity services.

Adolescent abortion in 11 high-income countries including Australia: towards the establishment of a minimum data set.

OBJECTIVE: A major public health challenge in Australia is the lack of national adolescent abortion data. This descriptive study identifies, collates and describes publicly available adolescent abortion data in high-income countries including Australia, to describe trends over 10 years and provide recommendations for strengthening data collection. METHODS: Data were extracted from publicly available government sources that met inclusion criteria. All relevant adolescent abortion data from 2007 to 2017 were extracted from datasets and analysed. RESULTS: Eleven high-income countries were included. Incidence data for the adolescent population were available for all countries and states. Incidence of adolescent abortion over 10 years shows a downward trend in all countries. Gestational age at time of abortion was the second-most available variable. The level and type of data across all countries varied; there was a lack of age range standardisation and aggregation of gestational weeks differed, making comparisons difficult. CONCLUSION: A minimum data set of standardised abortion information will enable appropriate adolescent abortion policies and services to be developed that are informed by high quality, up-to-date intelligence. Implications for public health: Availability of data affects government's ability to adequately monitor national adolescent health outcomes and plan and evaluate appropriate reproductive health policy and services.

The Emergency Department Response to Women Experiencing Intimate Partner Violence: Insights From Interviews With Clinicians in Australia.

BACKGROUND AND OBJECTIVES: Emergency departments (EDs) are essential providers of compassionate, immediate treatment and referral for women experiencing intimate partner violence (IPV). IPV, largely perpetrated by men against women, exerts a substantial burden on the health systems and economies of all nations. There is little known about how staff in Australian EDs respond to the challenges such violence generates. We therefore examined the clinical team response to women experiencing IPV in two large Australian metropolitan hospital EDs. METHODS: We undertook qualitative semistructured interviews and focus group discussions with 35 social workers, nurses, and doctors. Transcripts were recorded and transcribed verbatim. We analyzed the data thematically. We first undertook line-by-line coding and organized content into descriptive categories. Latent and manifest patterns were identified across the data and mapped to key themes in negotiation with all authors. RESULTS: Respondents emphasized challenges identifying IPV resulting from professional uncertainty or discomfort and women's fear of the ramifications of disclosure. Emergency clinicians routinely referred women to social workers after medical treatment and described effective collaboration across professions. Social workers outlined difficulties coordinating care with health and community agencies. Staff highlighted challenges maintaining nonjudgmental attitudes and managing their own feelings-especially clinicians who had personally experienced violence. CONCLUSIONS: Emergency departments can provide caring environments for women experiencing IPV. Effective interprofessional teamwork across nursing, medical, and social work professionals may mitigate the need for formal screening tools. Supportive workforce environments can improve staff understanding, reduce stigma, enhance appropriate treatment, and counsel health professionals experiencing violence. However, staff training and advocacy and referral relationships with local programs require strengthening. A connected multisystems-level response is required to coordinate and resource services for all affected by violence.

Experiences of women with cardiac disease in pregnancy: a systematic review and metasynthesis.

OBJECTIVE: Cardiac disease in pregnancy is a leading cause of maternal death in high-income countries. Evidence-based guidelines to assist in planning and managing the healthcare of affected women is lacking. The objective of this research was to produce the first qualitative metasynthesis of the experiences of pregnant women with existing or acquired cardiac disease to inform improved healthcare services. METHOD: We conducted a systematic search of peer-reviewed publications in five databases to investigate the decision-making processes, supportive strategies and healthcare experiences of pregnant women with existing or acquired cardiac disease, or of affected women contemplating pregnancy. Identified publications were screened for duplication and eligibility against selection criteria, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We then undertook a thematic analysis of the data relating to women's experiences extracted from each publication to inform new healthcare practices and communication. RESULTS: Eleven studies from six countries were included in our meta-synthesis. Four themes were revealed. Women with congenital and acquired heart disease identified situations where they had either taken charge of decision-making, lacked control or experienced emotional uncertainty when making decisions. Some women were risk aware and determined to take care of themselves in pregnancy while others downplayed the risks. Women with heart disease acknowledged the importance of specific social support measures during pregnancy and after child birth, and reported a spectrum of healthcare experiences. CONCLUSIONS: There is a lack of integrated and tailored healthcare services and information for women with cardiac disease in pregnancy. The experiences of women synthesised in this research has the potential to inform new evidence-based guidelines to support the decision-making needs of women with cardiac disease in pregnancy. Shared decision-making must consider communication across the clinical team. However, coordinated care is challenging due to the different specialists involved and the limited clinical evidence concerning effective approaches to managing such complex care.

Medical termination of pregnancy in general practice in Australia: a descriptive-interpretive qualitative study.

BACKGROUND: Australian Government approval in 2012 for the use of mifepristone and misoprostol for medical termination of pregnancy (MTOP) allows general practitioners (GPs) to provide early gestation abortion in primary care settings. However, uptake of the MTOP provision by GPs appears to be low and the reasons for this have been unclear. This study investigated the provision of and referral for MTOP by GPs. METHODS: We undertook descriptive-interpretive qualitative research and selected participants for diversity using a matrix. Twenty-eight semi-structured interviews and one focus group (N = 4), were conducted with 32 GPs (8 MTOP providers, 24 non MTOP providers) in New South Wales, Australia. Interviews were recorded and transcribed verbatim. A framework to examine access to abortion services was used to develop the interview questions and emergent themes identified thematically. RESULTS: Three main themes emerged: scope of practice; MTOP demand, care and referral; and workforce needs. Many GPs saw abortion as beyond the scope of their practice (i.e. a service others provide in specialist private clinics). Some GPs had religious or moral objections; others regarded MTOP provision as complicated and difficult. While some GPs expressed interest in MTOP provision they were concerned about stigma and the impact it may have on perceptions of their practice and the views of colleagues. Despite a reported variance in demand most MTOP providers were busy but felt isolated. Difficulties in referral to a local public hospital in the case of complications or the provision of surgical abortion were noted. CONCLUSIONS: Exploring the factors which affect access to MTOP in general practice settings provides insights to assist the future planning and delivery of reproductive health services. This research identifies the need for support to increase the number of MTOP GP providers and for GPs who are currently providing MTOP. Alongside these actions provision in the public sector is required. In addition, formalised referral pathways to the public sector are required to ensure timely care in the case of complications or the provision of surgical options. Leadership and coordination across the health sector is needed to facilitate integrated abortion care particularly for rural and low income women.

Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies.

BACKGROUND: This study aimed to reveal nurses' experiences and perceptions of turnover in Australian hospitals and identify strategies to improve retention, performance and job satisfaction. Nursing turnover is a serious issue that can compromise patient safety, increase health care costs and impact on staff morale. A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories. METHOD: A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories. RESULTS: Key factors affecting nursing turnover were limited career opportunities; poor support; a lack of recognition; and negative staff attitudes. The nursing working environment is characterised by inappropriate skill-mix and inadequate patient-staff ratios; a lack of overseas qualified nurses with appropriate skills; low involvement in decision-making processes; and increased patient demands. These issues impacted upon heavy workloads and stress levels with nurses feeling undervalued and disempowered. Nurses described supportive strategies: improving performance appraisals, responsive preceptorship and flexible employment options. CONCLUSION: Nursing turnover is influenced by the experiences of nurses. Positive steps can be made towards improving workplace conditions and ensuring nurse retention. Improving performance management and work design are strategies that nurse managers could harness to reduce turnover.

Task shifting and sharing in maternal and reproductive health in low-income countries: a narrative synthesis of current evidence.

Reducing maternal mortality and providing universal access to reproductive health in resource poor settings has been severely constrained by a shortage of health workers required to deliver interventions. The aim of this article is to determine evidence to optimize health worker roles through task shifting/sharing to address Millennium Development Goal 5 and reduce maternal mortality and provide universal access to reproductive health. A narrative synthesis of peer-reviewed literature from 2000 to 2011 was undertaken with retrieved documents assessed using an inclusion/exclusion criterion and quality appraisal guided by critical assessment tools. Concepts were analysed thematically. The analysis identified a focus on clinical tasks (the delivery of obstetric surgery, anaesthesia and abortion) that were shifted to and/or shared with doctors, non-physician clinicians, nurses and midwives. Findings indicate that shifting and sharing these tasks may increase access to and availability of maternal and reproductive health (MRH) services without compromising performance or patient outcomes and may be cost effective. However, a number of issues and barriers were identified with health workers calling for improved in-service training, supervision, career progression and incentive packages to better support their practice. Collaborative approaches involving community members and health workers at all levels have the potential to deliver MRH interventions effectively if accompanied by ongoing investment in the health care system.

How does the mining industry contribute to sexual and reproductive health in developing countries? A narrative synthesis of current evidence to inform practice.

AIMS AND OBJECTIVES: To explore client and provider experiences and related health outcomes of sexual and reproductive health interventions that have been led by or that have involved mining companies. BACKGROUND: Miners, and those living in communities surrounding mines in developing countries, are a vulnerable population with a high sexual and reproductive health burden. People in these communities require specific healthcare services although the exact delivery needs are unclear. There are no systematic reviews of evidence to guide delivery of sexual and reproductive health interventions to best address the needs of men and women in mining communities. DESIGN: A narrative synthesis. METHODS: A search of peer-reviewed literature from 2000-2012 was undertaken with retrieved documents assessed using an inclusion/exclusion criterion and quality appraisal guided by critical assessment tools. Concepts were analysed thematically. RESULTS: A desire for HIV testing and treatment was associated with the recognition of personal vulnerability, but this was affected by fear of stigma. Regular on-site services facilitated access to voluntary counselling and testing and HIV care, but concerns for confidentiality were a serious barrier. The provision of HIV and sexually transmitted infection clinical and promotive services revealed mixed health outcomes. Recommended service improvements included rapid HIV testing, the integration of sexual and reproductive health into regular health services also available to family members and culturally competent, ethical, providers who are better supported to involve consumers in health promotion. CONCLUSION: There is a need for research to better inform health interventions so that they build on local cultural norms and values and address social needs. A holistic approach to sexual and reproductive health beyond a focus on HIV may better engage community members, mining companies and governments in healthcare delivery. RELEVANCE TO CLINICAL PRACTICE: Nurses may require appropriate workplace support and incentives to deliver sexual and reproductive health interventions in developing mining contexts where task shifting exists.

Eye health services for Aboriginal people in the western region of NSW, 2010.

AIM: To assess the availability, accessibility and uptake of eye health services for Aboriginal people in western NSW in 2010. METHODS: The use of document review, observational visits, key stakeholder consultation and service data reviews, including number of cataract operations performed, to determine regional service availability and use. RESULTS: Aboriginal people in western NSW have a lower uptake of tertiary eye health services, with cataract surgery rates of 1750 per million for Aboriginal people and 9702 per million for non-Aboriginal people. Public ophthalmology clinics increase access to tertiary services for Aboriginal people. CONCLUSION: Eye health services are not equally available and accessible for Aboriginal people in western NSW. Increasing the availability of culturally competent public ophthalmology clinics may increase access to tertiary ophthalmology services for Aboriginal people. The report of the review was published online, and outlines a list of recommendations.