Implementation of telehealth primary health care services in a rural Aboriginal Community-Controlled Health Organisation during the COVID-19 pandemic: a mixed-methods study.

INTRODUCTION: Globally, primary care organisations responded rapidly to COVID-19 physical distancing requirements through the adoption of telehealth to maintain the delivery of health care to communities. In Australia, temporary Medicare Benefits Schedule (MBS) telehealth items were introduced in March 2020 to enable the provision of telehealth services in the primary care setting. These changes included funding for two modes of telehealth delivery: videoconferencing and telephone consultations. As primary care organisations, Aboriginal Community Controlled Health Organisations (ACCHOs) rapidly adopted telehealth consultations to maintain the delivery of primary care services to Aboriginal and Torres Strait Islander clients. The aim of the present study was to evaluate the implementation (specifically the uptake, acceptability and requirements for delivery) of telehealth primary healthcare services for Aboriginal and/or Torres Strait Islander peoples by a rural ACCHO during COVID-19. METHODS: A single-site convergent-parallel mixed-methods study was undertaken in the context of an ongoing research partnership established between a rural ACCHO and a university department of rural health. De-identified health service data from March 2020 to March 2021 was extracted, including MBS telehealth consultations and client demographics (eg age, gender and postcode). Variables were analysed using descriptive statistics to examine the uptake of telehealth by Aboriginal and Torres Strait Islander clients. A geographical analysis of postcode data was also undertaken. Semi-structured interviews were undertaken concurrently with a purposive sample of health service personnel (including health professionals) involved in the implementation or delivery of telehealth, and Aboriginal and/or Torres Strait Islander clients who had accessed telehealth, to explore the acceptability of telehealth and requirements for delivery. Thematic analysis using an inductive approach was undertaken. The analyses of quantitative and qualitative findings were merged to identify key concepts pertaining to the uptake, acceptability and requirements for telehealth delivery. RESULTS: During the first year of implementation, 435 telehealth primary healthcare consultations were delivered to Aboriginal and/or Torres Strait Islander clients. Seven health personnel and six Aboriginal and/or Torres Strait Islander clients participated in interviews. Merged findings from an analysis of quantitative and qualitative data were grouped under three concepts: uptake of telehealth consultations by Aboriginal and Torres Strait Islander clients, maintaining the delivery of ACCHO services during COVID-19, and implications for sustaining telehealth in an ACCHO. Findings identified that telehealth maintained the delivery of ACCHO services to Aboriginal and/or Torres Strait Islander clients across the lifespan during COVID-19, despite a preference for face-to-face consultations. A greater uptake of telephone consultations compared to videoconferencing was identified. Barriers to the utilisation of videoconferencing were largely technology related, highlighting the need for additional support for clients. CONCLUSION: Telehealth was a useful addition to face-to-face consultations when used in the appropriate context such as the administration of long-term medication prescriptions by a GP. Engaging the ACCHO sector in the policy discourse around telehealth is imperative for identifying requirements for ongoing implementation.

Cigarette smoke exposure of hospitalised children: Prevalence of smoking in parents or carers and admission practices of health services.

AIM: The aim of this study is to understand the exposure to second-hand tobacco smoke in the homes of hospitalised children through: (i) understanding the prevalence of smoking in adults or carers and (ii) examining the health services' approach to identifying parental smoking status. METHODS: This prospective observational study consisted of two surveys: one administered to parents/carers of hospitalised children and one to health services. The first cross-sectional survey aimed to elicit the proportion of children requiring admission to a regional Victorian general paediatric unit who live with adults who smoke cigarettes. The survey was delivered to participating parents/carers during the standard nursing admission process. The second survey was administered across 15 public health services to determine if identification of parent/carer's smoking status is a routine part of their standard paediatric admission practice. RESULTS: For the parental survey, 453 responses were obtained from 782 consecutive new admissions. Nearly a third (n = 136, 30%) requiring hospital admission were found to be living with at least one parent/carer who identified as a current cigarette smoker. Of the 15 health services surveyed, only four (27%) nursing units reported routinely asking parents/carers about their smoking status as part of their standard admission process. CONCLUSION: Admission to hospital provides an opportunity to enhance care for children by addressing nicotine dependence within their families. Findings suggest routine recording of smoking status can be improved, to drive smoking cessation and brief intervention conversations with parents and carers of children admitted to hospital.

How can hospitals change practice to better implement smoking cessation interventions? A systematic review.

Smoking cessation reduces the risk of death, improves recovery, and reduces the risk of hospital readmission. Evidence and policy support hospital admission as an ideal time to deliver smoking-cessation interventions. However, this is not well implemented in practice. In this systematic review, the authors summarize the literature on smoking-cessation implementation strategies and evaluate their success to guide the implementation of best-practice smoking interventions into hospital settings. The CINAHL Complete, Embase, MEDLINE Complete, and PsycInfo databases were searched using terms associated with the following topics: smoking cessation, hospitals, and implementation. In total, 14,287 original records were identified and screened, resulting in 63 eligible articles from 56 studies. Data were extracted on the study characteristics, implementation strategies, and implementation outcomes. Implementation outcomes were guided by Proctor and colleagues' framework and included acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. The findings demonstrate that studies predominantly focused on the training of staff to achieve implementation. Brief implementation approaches using a small number of implementation strategies were less successful and poorly sustained compared with well resourced and multicomponent approaches. Although brief implementation approaches may be viewed as advantageous because they are less resource-intensive, their capacity to change practice in a sustained way lacks evidence. Attempts to change clinician behavior or introduce new models of care are challenging in a short time frame, and implementation efforts should be designed for long-term success. There is a need to embrace strategic, well planned implementation approaches to embed smoking-cessation interventions into hospitals and to reap and sustain the benefits for people who smoke.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. STUDY DESIGN: Rapid review of articles published between January 2000 and May 2020. DATA SOURCES: We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. DATA SYNTHESIS: Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. CONCLUSION: Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. STUDY DESIGN: We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. DATA SOURCES: We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. DATA SYNTHESIS: Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. CONCLUSION: There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. STUDY DESIGN: Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. DATA SOURCES: We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. DATA SYNTHESIS: Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. CONCLUSION: We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. STUDY DESIGN: Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km2 . DATA SOURCES: We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. DATA SYNTHESIS: We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). CONCLUSION: Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. STUDY DESIGN: We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. DATA SOURCES: We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. DATA SYNTHESIS: During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. CONCLUSION: We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. STUDY DESIGN: Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. DATA SOURCES: English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing,deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. DATA SYNTHESIS: Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. CONCLUSION: Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

High-intensity interval training improves cardiorespiratory fitness in cancer patients and survivors: A meta-analysis.

OBJECTIVE: The primary objective of this systematic review and meta-analysis was to compare the effects of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) and usual care (UC) on cardiorespiratory fitness (peak V̇O2 ) in cancer patients and survivors. Secondary objectives were to compare the effects of HIIT versus MICT and UC on other cardiopulmonary exercise testing (CPET) indices. Safety and adherence to HIIT were also evaluated. METHODS: A systematic review and meta-analysis of controlled trials were undertaken using eligible studies from electronic database searching (inception-December 2019). Mean differences (MD) with 95% confidence intervals (CI) were compared and heterogeneity assessed using Cochran's Q and I2 statistic. RESULTS: Twelve eligible studies included 516 participants with post-intervention CPET data. No serious adverse events occurred. Adherence to HIIT ranged between 71.2% and 95.6%. HIIT had significantly higher peak V̇O2 compared with UC (MD = 2.11 ml kg-1  min-1 , 95% CI 0.75-3.47, p = .002). No significant difference was found between HIIT and MICT (MD = 2.03 ml kg-1  min-1 , 95%CI -0.75-4.83, p = .15). HIIT was more effective than UC to improve peak oxygen pulse (MD = 1.59 ml/beat, 95%CI 0.06-3.12, p = .04). CONCLUSIONS: Quantitative assessment of HIIT studies indicates good compliance, with a significant effect on peak V̇O2 and peak oxygen pulse compared with UC in cancer patients and survivors. HIIT demonstrates a comparable effect with MICT to improve peak V̇O2 .