Barriers and facilitators in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs: A qualitative study of midwives' experience.

BACKGROUND: Screening pregnant women for substance use is highly recommended in antenatal care settings. Although midwives provide routine screening for substance use and referral for treatment in pregnancy, little is known about the barriers and facilitators they experience. AIM: The study explored barriers and facilitators experienced by midwives in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs. DESIGN/SETTING: A semi-structured interview was adopted to explore barriers and facilitators experienced by midwives in screening and referring pregnant women for alcohol or other drugs specialised services. Eighteen midwives were recruited from urban, regional and rural antenatal settings in Victoria. Interviews were tape recorded and transcribed verbatim. Themes were generated by thematic analysis, the process of identifying patterns within the data. FINDINGS: Of the seven themes identified under barriers, five could be categorised as "institution and provider-related", namely: (i) lack of validated screening tool, (ii) inadequate support and training, (iii) discomfort in screening, (iv) lack of multidisciplinary team and specialised treatment in regional and rural areas, and (v) workload and limited consultation time. Conversely, two themes could be classified as 'client-related', namely (i) non- or partial-disclosure of substance use, and (ii) reluctance and non-adherence to referrals. All five themes under facilitators were "institution and provider-related." They are (i) a woman-centred philosophy of care, (ii) evidence of harms from substance use on neonates, (iii) experience and training, (iv) continuity of care, and (v) availability of multidisciplinary team and funding. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To the best of our knowledge, this is the first study of its kind conducted in Victoria. This study not only adds to the limited body of knowledge on barriers experienced by midwives but also identifies facilitators in antenatal settings that promote screening and referral of pregnant women who use substance. Most of the barriers and facilitators are interrelated. Despite midwives' willingness to screen all pregnant women for substance use and provision of referral, they often felt limited in their capacity. Availability and accessibility to validated screening tool(s), in addition to regular, ongoing training for all midwives to maintain clinical competence and provide effective communication are imperative. Availability of a multidisciplinary team, funds and specialised care facilities such as detoxification and mental health services, especially in regional and rural areas, are necessary to effectively support at-risk pregnant women.

Holistic primary health care for Aboriginal and Torres Strait Islander prisoners: exploring the role of Aboriginal Community Controlled Health Organisations.

OBJECTIVE: Aboriginal and Torres Strait Islander Community Controlled Health Organisations (ACCHOs) have been identified as having an important role in improving the health and wellbeing of individuals in prison; however, a lack of information exists on how to strengthen this role. This paper explores the experiences of ACCHO staff in primary health care to individuals inside or leaving prison. METHODS: Nineteen staff from four ACCHOs were interviewed. ACCHO selection was informed by proximity to prisons, town size and/or Local Government Area offending rates. Thematic analysis of the interviews was undertaken. RESULTS: While most ACCHOs had delivered post-release programs, primary health care delivery to prisoners was limited. Three themes emerged: i) a lack of access to prisoners; ii) limited funding to provide services to prisoners; and iii) the need for a team approach to primary health care delivery. CONCLUSION: A holistic model of care underpinned by a reliable funding model (including access to certain Medicare items) and consistent access to prisoners could strengthen ACCHOs' role in primary health care delivery to people inside or leaving prison. Implications for public health: ACCHOs have an important role to play in the delivery of primary health care to prisoners. Existing models of care for prisoners should be examined to explore how this can occur.

Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre.

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients. This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic. Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Development of a nurse-led primary healthcare service for injecting drug users in inner-city Sydney.

Injecting drug users (IDUs) experience numerous health problems, but report barriers to utilising general practitioners (GPs). A nurse-led Harm Minimisation-based Primary Healthcare (HMPH) service for IDUs was established within a needle and syringe program in inner-city Sydney with Area Health Service medical support and clinical governance. This paper aimed to describe the HMPH service, review service utilisation and assess nurses' perceptions of their work with IDUs. A review of the most recent 200 clinic files was undertaken. Service utilisation, GP and other health service use and access were extracted and analysed using SPSS. A semi-structured qualitative interview with clinic nurses regarding their experience working with IDUs and local GPs was conducted and analysed. Since its inception in mid-2006, the service has been utilised by 417 clients. Of the most recent 200 files, blood-borne virus and sexually transmitted infection screening were the primary reason for presentation (64.5%). At least one follow-up visit was attended by 90% of clients. A total of 62% of clients reported consulting a GP in the last 12 months. The service provided 102 referrals. Nurses believed that IDUs tend to utilise GPs ineffectively and that self-care is a low priority, but that they can support IDUs to overcome some barriers to GPs and facilitate access. Targeted primary health care services led by nurses with focussed medical support and co-located with needle and syringe programs can fill an important gap in delivering and facilitating health care to IDUs.