'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.

Tailoring immunisation programs in Lismore, New South Wales - we want our children to be healthy and grow well, and immunisation really helps.

INTRODUCTION: In 2018 in the Australian town of Lismore, New South Wales, 175 children were overdue for scheduled vaccinations, 11% of them being Aboriginal and/or Torres Strait Islander (2018). This study aimed to gain a deeper understanding of the reasons for low coverage. METHODS: Aboriginal and non-Aboriginal parents, carers and health service providers were invited to take part in semi-structured interviews and focus groups. Open-ended questions were asked about immunisation barriers and enablers, and what strategies may be effective in improving coverage in Lismore. RESULTS: A total of 35 participants took part. Six themes were developed: childhood immunisation in Lismore is limited by access barriers to health services, some families may need additional support to access vaccination services, health services need to ensure that Aboriginal families feel safe and comfortable when accessing their service, parents and carers value reminders and recalls to keep their children's vaccinations up to date, parents' and carers' views influence their decisions to immunise their children, and reliable information about immunisation needs to be available in ways that are meaningful and appropriate for parents and carers. CONCLUSION: Access barriers and vaccine hesitancy have been contributing to children falling behind in their scheduled vaccinations in Lismore. More flexible health services, culturally safe and appropriate care and more practical support can help overcome structural barriers to health services. Tailored health messages for both Aboriginal and non-Aboriginal parents and carers can assist parents in making wise immunisation choices. More consistent analysis and reporting of routinely available data can identify pockets of low coverage. Publicly funded health services and Aboriginal Community Controlled Health Services are well placed to provide flexible vaccination services for those families who may struggle with access barriers.

A stakeholder co-design approach for developing a community pharmacy service to enhance screening and management of atrial fibrillation.

BACKGROUND: Community pharmacies provide a suitable setting to promote self-screening programs aimed at enhancing the early detection of atrial fibrillation (AF). Developing and implementing novel community pharmacy services (CPSs) is a complex and acknowledged challenge, which requires comprehensive planning and the participation of relevant stakeholders. Co-design processes are participatory research approaches that can enhance the development, evaluation and implementation of health services. The aim of this study was to co-design a pharmacist-led CPS aimed at enhancing self-monitoring/screening of AF. METHODS: A 3-step co-design process was conducted using qualitative methods: (1) interviews and focus group with potential service users (n = 8) to identify key needs and concerns; (2) focus group with a mixed group of stakeholders (n = 8) to generate a preliminary model of the service; and (3) focus group with community pharmacy owners and managers (n = 4) to explore the feasibility and appropriateness of the model. Data were analysed qualitatively to identify themes and intersections between themes. The JeMa2 model to conceptualize pharmacy-based health programs was used to build a theoretical model of the service. RESULTS: Stakeholders delineated: a clear target population (i.e., individuals ≥65 years old, with hypertension, with or without previous AF or stroke); the components of the service (i.e., patient education; self-monitoring at home; results evaluation, referral and follow-up); and a set of circumstances that may influence the implementation of the service (e.g., quality of the service, competency of the pharmacist, inter-professional relationships, etc.). A number of strategies were recommended to enable implementation (e.g.,. endorsement by leading cardiovascular organizations, appropriate communication methods and channels between the pharmacy and the general medical practice settings, etc.). CONCLUSION: A novel and preliminary model of a CPS aimed at enhancing the management of AF was generated from this participatory process. This model can be used to inform decision making processes aimed at adopting and piloting of the service. It is expected the co-designed service has been adapted to suit existing needs of patients and current care practices, which, in turn, may increase the feasibility and acceptance of the service when it is implemented into a real setting.

How do residents of aged care homes perceive physical activity and functional independence? A qualitative study.

Limited evidence exists concerning knowledge and understanding of how to optimally support residents' physical activity, mobility and functional independence in residential aged care homes. An interpretive qualitative study was conducted to explore residents' perceptions and experiences of opportunities for physical activity and functional independence, and how physical activity and functional independence are challenged in their care home environment. Purposefully sampled 24 participants (male = 13) from five not-for-profit residential aged care homes in the outskirts of a metropolitan area in Australia, were interviewed between August and September 2017. Maintaining independence was found to be the utmost priority for nearly all participants in this study. Yet, many did not make the connection between physical activity and independence, and regarded 'exercise' as an inappropriate activity for them, perceiving it as high-impact, high-intensity activity in commercial gyms that was only appropriate for the young. Walking and gardening were found to be most popular. Walking could be a physical activity, social activity, solo recreational activity and a means of maintaining mobility and functional independence-all of which residents considered to be appropriate to them and achievable. The study identified key factors influencing physical activity and functional independence of residents: levels of activity prior to living in residential aged care, ageism, social capital and loss of a loved one, pain and staff support. Findings highlight the need for a 'flexible and inclusive' approach in facilitating the resident's physical activity, and a greater role for staff in encouraging residents' engagement in, and communicating the benefits and requirements of, physical activity, through, for example, motivational interviewing.

"You've got to breathe, you know" - asthma patients and carers' perceptions around purchase and use of asthma preventer medicines.

OBJECTIVE: To explore influences on patients' purchase and use of asthma preventer medicines and the perceived acceptability of financial incentives via reduced patient co-payments. METHODS: Semi-structured telephone or face-to-face interviews were conducted with adults and carers of children with asthma. Interviews were recorded, transcribed verbatim and coded. Data were analysed using thematic analysis via grounded theory. RESULTS: Twenty-four adults and 20 carers for children aged 3-17 years with asthma were interviewed. For medicines choice, most participants did not consider themselves the primary decision-maker; cost of medicines was an issue for some, but effectiveness was described as more important. For adherence, cost, side-effects, perceived benefit and patient behaviours were important. CONCLUSIONS: Patient barriers to adherence with asthma preventer medicines including cost are ongoing. Healthcare professionals need to encourage empathic discussion with patients about cost issues. Implications for public health: Asthma patients and carers could benefit from greater involvement and respect within shared decision-making. Healthcare professionals should be aware that cost may be a barrier for patient adherence, and provided with information about the relative costs of guideline-recommended asthma medicines. Patients and healthcare professionals need education around the efficacy of ICS-alone treatment and the rationale behind co-payments, for initiatives around quality use of medicines to succeed.

General practitioners' views on the influence of cost on the prescribing of asthma preventer medicines: a qualitative study.

Objective Out-of-pocket costs strongly affect patient adherence with medicines. For asthma, guidelines recommend that most patients should be prescribed regular low-dose inhaled corticosteroids (ICS) alone, but in Australia most are prescribed combination ICS-long-acting ß2-agonists (LABA), which cost more to patients and government. The present qualitative study among general practitioners (GPs) explored the acceptability, and likely effect on prescribing, of lower patient copayments for ICS alone. Methods Semistructured telephone interviews were conducted with 15 GPs from the greater Sydney area; the interviews were transcribed and thematically analysed. Results GPs reported that their main criteria for selecting medicines were appropriateness and effectiveness. They did not usually discuss costs with patients, had low awareness of out-of-pocket costs and considered that these were seldom prohibitive for asthma patients. GPs strongly believed that patient care should not be compromised to reduce cost to government. They favoured ICS-LABA combinations over ICS alone because they perceived that ICS-LABA combinations enhanced adherence and reduced costs for patients. GPs did not consider that lower patient copayments for ICS alone would affect their prescribing. Conclusion The results suggest that financial incentives, such as lower patient copayments, would be unlikely to encourage GPs to preferentially prescribe ICS alone, unless accompanied by other strategies, including evidence for clinical effectiveness. GPs should be encouraged to discuss cost barriers to treatment with patients when considering treatment choices. What is known about the topic? Australian guidelines recommend that most patients with asthma should be treated with low-dose ICS alone to minimise symptom burden and risk of flare ups. However, most patients in Australian general practice are instead prescribed combination ICS-LABA preventers, which are indicated if asthma remains uncontrolled despite treatment with ICS alone. It is not known whether GPs are aware that the combination preventers have a higher patient copayment and a higher cost to government. What does this paper add? This qualitative study found that GPs favoured combination ICS-LABA inhalers over ICS alone because they perceived ICS-LABA combinations to have greater effectiveness and promote patient adherence. This aligned with GPs' views that their primary responsibility was patient care rather than generating cost savings for government. However, it emerged that GPs rarely discussed medicine costs with patients, had low knowledge of medicine costs to patients and the health system and reported that patients rarely volunteered cost concerns. GPs believed that lower patient copayments for asthma preventer medicines would have little effect on their prescribing practices. What are the implications for practitioners? This study suggests that, when considering asthma treatment choices, GPs should empathically explore with the patient whether cost-related medication underuse is an issue, and should be aware of the option of lower out-of-pocket costs with guideline-recommended ICS alone treatment. Policy makers must be aware that differential patient copayments for ICS preventer medicines are unlikely to act as an incentive for GPs to preferentially prescribe ICS alone preventers, unless the position of these preventers in guidelines and evidence for their clinical effectiveness are also reiterated.

Community, hospital and industry preceptor perceptions of their role in experiential placements- the need for standardization of preceptor responsibilities and evaluations on students.

INTRODUCTION: Appropriate evaluation processes are important in experiential placements. With the growing diversity between placements, consideration for standardization of some of these processes would be beneficial, particularly for those skills that are transferable regardless of the placement type. The objectives of this study was: (1) to explore the experiences, evaluation strategies, and feedback processes of Australian preceptor pharmacists from three primary experiential areas (community, hospital, and industry) in providing student placements; and (2) to inform the future development of the current local experiential program and future extended international experiential programs. METHODS: A qualitative, exploratory study with three preceptor focus groups (community, hospital, and industry) were conducted, recorded, and transcribed verbatim. Data were analyzed using Bazeley's "describe - compare - relate" method for thematic analysis. RESULTS: There were a total of 16 participants. Four themes emerged: (1) motivation and purpose of being a preceptor; (2) expectations of students and the university; (3) organizational planning and conduct of experiential placements; and (4) importance of appropriate evaluation and feedback processes to include evaluation of interpersonal skills, which were considered by all focus group members as highly desirable for future employability. CONCLUSIONS: The need for standardized processes across different experiential placements, although difficult given the diversity, is important particularly with respect to evaluation and feedback. As interpersonal attributes are transferable and desirable for all types of experiential settings including rural and international environments, standardizing the evaluation of students to include these could be beneficial and applicable for students on local experiential placements and/or cross globally on international experiential placements.

A multilevel stakeholder approach for identifying the determinants of implementation of government-funded community pharmacy services at the primary care level.

BACKGROUND: A key early step to enhance the integration of community pharmacy services (CPSs) into primary care practice is identifying key determinants of practice (i.e., critical circumstances that influence the implementation of such services). Involving relevant stakeholders in identifying key determinants enables findings to be more relevant to the context in which CPSs will be implemented. OBJECTIVE: To identify key determinants of practice that can influence the implementation of government-funded CPSs in a primary health network in Australia. METHODS: A stakeholder collaborative approach was used, encompassing two phases. In the first phase, semi-structured interviews were conducted with ground-level stakeholders in Western Sydney between August 2016 to October 2016. Framework analysis was used to code and analyse the data from the interviews into determinants of pharmacy practice. In the second phase, a workshop was conducted with a mixed-group of ground-level and system-level stakeholders from the primary health network to identify key determinants. A four-quadrant prioritization matrix was employed in the workshop to classify determinants based on their importance and feasibility. RESULTS: Sixty-five determinants of practice that can influence CPS implementation were identified in Phase 1. These determinants were allocated at different levels of the healthcare system, and can exist as a barrier or facilitator or both. Twenty-two key determinants were selected in Phase 2, of which three were agreed to be addressed initially: (1) Patient understanding of the aims of the service; (2) Commitment of the organization and its leaders to provide services; (3) Coordination of the healthcare system to prompt collaboration between pharmacists and GPs. CONCLUSIONS: This collaborative stakeholder approach identified a set of key determinants of pharmacy practice in this Australian primary care setting. To enhance the implementation of CPSs in this region, initial efforts should be aimed at developing implementation strategies based on these key determinants of practice.