Study protocol for the family empowerment program: a randomized waitlist-controlled trial to evaluate the effectiveness of online Community Reinforcement and Family Training (CRAFT) on the wellbeing of family members with a relative experiencing substance dependence and mental illness.

BACKGROUND: Systematic reviews consistently show that family-focused interventions are effective at improving substance treatment engagement and outcomes across the lifespan. Yet, Australian substance use treatment services rarely incorporate family members and concerned significant others. Testing of family focussed interventions in the Australian context is required. METHODS: The trial is a randomized wait-list control trial assessing the effectiveness, feasibility and acceptability of online CRAFT with a parallel group. Participants will be randomised to receive either online CRAFT or to a wait-list control group who are provided with CRAFT related reading material during the waiting period. Outcomes will be assessed at baseline and then at 6- and 15-weeks post baseline. The primary outcome will be improved wellbeing of participating family members. The trial reporting will comply with SPIRIT guidelines. DISCUSSION: This study will focus on people living in rural areas. Substance treatment programs are limited in rural Australia. The provision of the Family Empowerment Program (CRAFT) online should make family focused substance treatment support accessible and attainable for the first time in rural areas. The outcomes of this trial could have meaningful implications for the future funding and support of family focused substance treatment services that are inclusive of people with mental health conditions. TRIAL REGISTRATION: ANZCTR, ACTRN12623000796684p, Registered 26 July 2023. Prospectively registered with protocol version 3.

Supporting recovery, healing and wellbeing with Aboriginal communities of the southeast coast of Australia: a practice-based study of an Aboriginal community-controlled health organisation's response to cumulative disasters.

BACKGROUND: The recent crises of bushfires, floods, and the COVID-19 pandemic on the southeast coast of Australia were unprecedented in their extent and intensity. Few studies have investigated responses to cumulative disasters in First Nations communities, despite acknowledgement that these crises disproportionately impact First Nations people. This study was conducted by Aboriginal and non-Aboriginal researchers in partnership with Waminda, South Coast Women's Health and Wellbeing Aboriginal Corporation, an Aboriginal Community Controlled Health Organisation (ACCHO). It investigated the collective experiences of people affected by cumulative disasters to identify the practices that support healing, and recovery for Aboriginal communities. The study addresses a knowledge gap of how Waminda, designs, manages and delivers responses to address complex health and social issues in the context of cumulative disasters. METHODS: Underpinned by practice theory this study employed Indigenous-informed, narrative inquiry. Culturally-appropriate, multiple interpretive methods were used to collect data including: observations; yarns with Aboriginal community members, yarns with Waminda practitioners, management and board members; interviews-to-the-double, visual images and documentation. The data were collated and analysed using the phases of reflexive thematic analysis. RESULTS: The paper articulates a suite of culturally safe and place-based practices that enhance social, emotional and spiritual well-being following cumulative disasters. These practice bundles include: adopting a Country-centred conception of local communities; being community-led; viewing care as a collective, relational, sociomaterial accomplishment and having fluid boundaries. These practice bundles 'hang together' through organising practices including the Waminda Model of Care, staff wellbeing framework and emergency management plan which orient action and manage risks. The paper demonstrates the need for disaster responses to be community-led and culturally situated. ACCHOs are shown to play a crucial role, and their local responses to immediate community needs are grounded in contextual knowledge and use existing resources rather than relying on mainstream system-wide interventions. CONCLUSIONS: The paper suggests crafting responses that focus on assisting communities (re)gain their sense of belonging, hope for the future, control over their lives and their capacities to care for and to be cared for by Country, are key to both enhancing healing, health and well-being and harnessing the strengths of communities.

Randomized effectiveness-implementation trial of dialectical behavior therapy interventions for young people with borderline personality disorder symptoms.

OBJECTIVES: Dialectical behavior therapy (DBT) is an evidence-based treatment for people with emerging borderline personality disorder (BPD). In "real world" clinical settings, standard DBT is resource intensive. Emerging evidence suggests that group-based DBT skills training alone can lead to promising outcomes. This hybrid type 1 effectiveness-implementation trial directly compared the effectiveness of an 8-week group DBT-skills training program and a 16-week DBT-informed program including individual treatment and group-based skills training. METHODS: This pragmatic trial employed a staggered, parallel-groups design. We recruited 104 participants, aged 16-25 years, with emotion dysregulation or emerging BPD symptoms. Participants were randomized to receive either program at a youth mental health service located in the Gold Coast, Australia. Data was collected via online surveys at baseline, 8-week, 16-week, and 24-week follow-up. Mixed effect linear models compared groups on the primary outcomes of emotion dysregulation and BPD symptoms, and secondary outcomes of suicidal ideation, coping skills, depression, anxiety, and stress. RESULTS: Across groups there were significant and sustained improvements relating to emotion dysregulation, BPD symptoms, stress, depression, and emotion-focused coping; but not suicide risk, anxiety, or task-focused coping. There was no significant time by group differences between the 8-week and 16-week interventions on any primary or secondary outcome. CONCLUSION: The more intensive mode of delivering DBT was not more effective than the brief group-based skills training. Both interventions resulted in significant improvements across both primary and most secondary outcomes. These results have implications for clinical practice regarding length and intensity of DBT treatment in young people.

Cognitive remediation therapy - implementation and translation into clinical practice in rural and metropolitan New South Wales mental health services.

OBJECTIVE: Cognitive Remediation Therapy (CRT) is an effective intervention in managing the significant cognitive deficits experienced by those living with psychosis. Given its strong evidence base CRT is recommended in Australian and international guidelines for rehabilitation of people with psychosis, however, access to CRT remains limited. In this commentary, we describe recent efforts to implement CRT programs within NSW mental health services. Development of CRT delivery has been successfully achieved in both rural and metropolitan settings, utilising both face-to-face and telehealth methods. CONCLUSIONS: The delivery of CRT in public mental health services is feasible and adaptable to diverse settings. We strongly advocate for sustainable implementation of CRT into routine clinical practice. This will require policy and practice change to enable resources for CRT training and delivery to become embedded in the roles of the clinical workforce.

A comparison of rural Australian First Nations and Non-First Nations survey responses to COVID-19 risks and impacts: implications for health communications.

INTRODUCTION: This study investigated differences between rural Australian First Nations and non-First Nations survey respondents' perceptions of COVID-19-related risks and analysed other variables that could predict an exacerbation of anxiety related to COVID-19 harms. METHODS: A cross-sectional online and paper survey of rural residents from the western regions of NSW, Australia, was conducted. Descriptive and multivariate statistical analyses were used to assess links between First Nations status and demographic measures including postcode, age, gender, education, rural or town/village location, proximity to medical services and living situation. The analysis included five items related to perceptions about COVID-19: perceived likelihood of contracting COVID-19 in the next 12 months, perceived harmfulness of the virus, how often people felt afraid, perception about respondents' ability to do something about the virus and perceived economic impacts of the pandemic. RESULTS: There were significant differences between First Nations (n=60) and non-First Nations (n= 639) respondents across all sociodemographic categories. The results reflect a significantly higher level of anxiety among the First Nations Australians in the sample: they felt afraid more often, felt it was highly likely they would catch the virus and if they did catch the virus perceived that it would be very harmful. Living with children under eighteen years of age and in small rural towns were key factors linked to feeling afraid of COVID-19 and First Nations status. CONCLUSION: Health risk communication in pandemic response should include an equitable focus on rural areas, recognising that First Nations Australians are a significant proportion of the rural population with different risk factors and concerns than those of non-First Nations Australians. This principle of First Nations-led design is critical to all health policy and planning. The Australian Government should include rural areas in planning pandemic responses, recognising that First Nations populations are a significant proportion of the rural population creating syndemic conditions.

Mental health clinicians' perceptions of nature-based interventions within community mental health services: evidence from Australia.

BACKGROUND: Mental health conditions are one of the largest burdens of disease in Australia and globally. There is a need to seek innovative and alternative interventions that can prevent and alleviate mental health symptoms. Nature-based interventions (NBIs), namely programs and activities where individuals engage with natural environments with the aim of improving their health and wellbeing (e.g., nature walking groups), may be such an alternative. This study aimed to explore the perceptions of mental health clinicians on the potential benefits of, and barriers to, implementing NBIs within a community mental health setting. METHODS: This study used a qualitative, exploratory research design. Fifteen mental health clinicians were recruited from the Illawarra Shoalhaven Local Health District, Australia, and interviewed (September-October 2021) about their perceptions of NBIs within mental health settings. The semi-structured interviews were analysed using an inductive thematic approach and managed with NVivo. RESULTS: Mental health clinicians viewed spending time in nature as relaxing, refreshing, and therapeutic. Many described it as part of their lifestyle and encouraged consumers to engage in nature-based activities on their own time. If NBIs were to be introduced as part of mental health services, clinicians expressed willingness to promote them to their consumers. Clinicians listed many potential benefits of NBIs for mental health consumers including improved mood, calmness and relaxation, a sense of empowerment, and social connections. Despite these benefits, clinicians were concerned about a variety of barriers to NBIs including consumers' mental health symptoms such as anxiety or lack of motivation, scepticism, and geographic accessibility, as well as organisational barriers such as policies around safety risk. CONCLUSION: Responding to the individual and organisational factors that could hinder the implementation of NBIs while building on the existing evidence of the positive impact of nature on health and wellbeing and, as demonstrated in this study, mental health clinicians' interest and supportiveness of NBIs, mental health services should consider the implementation of NBIs as part of routine practice.

"This is streets ahead of what we used to do": staff perceptions of virtual clinical pharmacy services in rural and remote Australian hospitals.

BACKGROUND: The use of medications is the most common intervention in healthcare. However, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. A Virtual Clinical Pharmacy Service (VCPS) was introduced in rural and remote New South Wales public hospitals to support safe and effective use of medications. In this model clinical pharmacy services are delivered via a telehealth cart at the patient's bedside and through electronic medical and pharmaceutical record systems. The aim of this research was to understand healthcare staff perspectives of the VCPS and identify areas for improvement. METHODS: A qualitative approach informed by Appreciative Inquiry was used to investigate healthcare staff perceptions of the VCPS. Focus group discussions (n = 15) with hospital staff and medical officers were conducted via videoconference at each study site. Focus groups explored issues, benefits and barriers 3 months after service implementation. Transcribed data were analysed using thematic analysis and team discussion to synthesise themes. RESULTS: Focus group participants identified the value of the VCPS to patients, to the health service and to themselves. They also identified enhancements to increase value for each of these groups. Perceived benefits to patients included access to specialist medication advice and improved medication knowledge. Staff valued access to an additional, trusted workforce who provided back-up and guidance. Staff also reported confidence in improved patient safety and identification of medication errors. Enhanced compliance with antimicrobial stewardship and hospital accreditation standards were beneficial to the health service. Suggested improvements included extending virtual service hours and widening patient eligibility to include aged care patients. CONCLUSIONS: The VCPS brought a positive, collegiate culture regarding medications. Healthcare staff perceived the VCPS was effective and an efficient way for the health service to supply pharmacy services to smaller hospitals. The ease of use, model of delivery, availability, local knowledge and responsiveness of highly skilled pharmacists was the key to user satisfaction. TRIAL REGISTRATION: ANZCTR ACTRN12619001757101 , 11/12/2019.

Formative process evaluation of a guideline-driven process for improving the cultural responsiveness of alcohol and drug treatment services.

BACKGROUND: To improve Australian Aboriginal and Torres Strait Islander people's access to, and experience of, healthcare services, including Alcohol and other Drug (AoD) treatment services, principles and frameworks have been developed to optimise cultural responsiveness. Implementing those principles in practice, however, can be difficult to achieve. This study has five aims: i) to describe a five-step process developed to operationalise improvements in culturally responsive practice in AoD services; ii) to evaluate the fidelity of implementation for this five-step process; iii) to identify barriers and enablers to implementation; iv) to assess the feasibility and acceptability of this approach; and v) to describe iterative adaptation of implementation processes based on participant feedback. METHODS: Participating services were 15 non-Aboriginal AoD services in New South Wales, Australia. Implementation records were used to assess the implementation fidelity of the project. Structured interviews with chief executive officers or senior management were conducted, and interview data were thematically analysed to identify project acceptability, and the key enablers of, and barriers to, project implementation. Quantitative descriptive analyses were performed on the post-implementation workshop survey data, and responses to the free text questions were thematically analysed. RESULTS: A high level of implementation fidelity was achieved. Key enablers to improving culturally responsive practice were the timing of the introduction of the five-step process, the active interest of staff across a range of seniority and the availability of resources and staff time to identify and implement activities. Key barriers included addressing the unique needs of a range of treatment sub-groups, difficulty adapting activities to different service delivery models, limited time to implement change in this evaluation (three months) and the varied skill level across staff. The project was rated as being highly acceptable and relevant to service CEOs/managers and direct service staff, with planned changes perceived to be achievable and important. Based on CEO/management feedback after the project was implemented at the initial services, several improvements to processes were made. CONCLUSION: The operationalisation of the five-step process developed to improve cultural responsiveness was feasible and acceptable and may be readily applicable to improving the cultural responsiveness of a wide variety of health and human services.

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.

Reducing drug and alcohol use and improving well-being for Indigenous and non-Indigenous Australians using the Community Reinforcement Approach: A feasibility and acceptability study.

There is a lack of evidence of effective and appropriate drug and alcohol treatment for Aboriginal and Torres Strait Islander peoples. This paper contributes to addressing the evidence gap by examining the feasibility and acceptability and conducting a pre/post-evaluation of the Aboriginal-adapted Community Reinforcement Approach (CRA) delivered in New South Wales, Australia. Aboriginal and non-Aboriginal clients (n = 55) received tailored CRA delivery between March and November 2013. Compared to the original US version, tailored CRA had reduced technical language, reduced number of treatment sessions, and the addition of group delivery option. An Australian training manual with local case studies was developed. Alcohol, Smoking and Substance Involvement Test (ASSIST), Kessler-5 (K-5) and the Growth Empowerment Measure were used. 58% of participants were followed-up at 3 months. Tailored CRA was feasible to deliver in a rural, community-based health setting, and rated by clients as highly effective and acceptable. CRA was associated with statistically significant reductions in the use of alcohol, tobacco, cannabis, amphetamine and over the counter medication, and levels of psychological distress, and an increase in levels of empowerment for Aboriginal and non-Aboriginal clients. This study provides evidence for the feasibility and acceptability of an Aboriginal-adapted psychological intervention addressing drug, alcohol and mental health outcomes.

Patterns of emergency department use in rural and metropolitan New South Wales from 2012 to 2018.

OBJECTIVE: To explore the patterns of and investigate the factors associated with rises in emergency department presentations in rural and metropolitan New South Wales from 2012 to 2018. DESIGN: A retrospective descriptive study of de-identified data from the New South Wales Emergency Department Data Collection. SETTING: New South Wales, Australia. PARTICIPANTS: All individuals presenting to 99 New South Wales emergency departments, which continuously reported to the Emergency Department Data Collection between 2012 and 2018. A total of 2 166 449 presentations recorded throughout New South Wales in 2012 (rural 786 278; metropolitan 1 380 171) and 2 477 192 in 2018 (rural 861 761; metropolitan 1 615 431). MAIN OUTCOME MEASURES: Total emergency department presentations, plus Poisson regression modelled annual changes in emergency department presentations over the period 2012-2018. RESULTS: Growth in emergency department presentations outpaced population growth in both rural and metropolitan New South Wales between 2012 and 2018. The patterns of age-standardised rates of presentations were broadly similar between rural and metropolitan areas, with highest rates observed in the youngest (0-4 years) and oldest (85+ years) cohorts. The rural sample also displayed a distinct third peak in ages 15-39 years, and rates were higher across all age groups. Rural New South Wales displayed disproportionately higher emergency department presentations in the two most deprived socio-economic status quintiles. While rural New South Wales displayed significant reductions in triage category 5 (non-urgent cases) over time, the relative proportion remained approximately double that of metropolitan sites. CONCLUSIONS: There are differences between rural and metropolitan emergency department presentations relating to demographic factors, triage levels, acuity and admissions. Detailed local investigations are required to determine specific contextual issues that impact on emergency department demand.

Implementation of advanced radiotherapy technology to improve clinical outcomes in rural NSW.

PROBLEM: Availability of advanced radiotherapy technology to treat cancer is limited in regional Australia. At Central West Cancer Care Centre, the utilisation rate of intensity-modulated radiotherapy and volumetric modulated arc therapy was significantly lower compared to other NSW public health services. Stereotactic ablative body radiotherapy treatment was not available at Central West Cancer Care Centre. DESIGN: To increase the intensity-modulated radiotherapy/volumetric modulated arc therapy utilisation rate and to make stereotactic ablative body radiotherapy treatment available through quality improvement projects with multi-disciplinary collaboration. SETTING: Central West Cancer Care Centre is part of Western NSW Local health District. Central West Cancer Care Centre has two linear accelerators for delivering intensity-modulated radiotherapy, volumetric modulated arc therapy and stereotactic ablative body radiotherapy treatments, and a computed tomography simulator with 4D computed tomography capability. KEY MEASURES FOR IMPROVEMENT: Intensity-modulated radiotherapy/volumetric modulated arc therapy utilisation rate increases to > 65% Stereotactic ablative body radiotherapy available to Central West Cancer Care Centre patients STRATEGY FOR CHANGE: A multi-disciplinary active of team radiation oncologists, medical physics specialists and radiation therapists developed an implementation plan for each treatment technique. EFFECT OF CHANGE: There was a significant increase in use of advanced techniques. The impact on patients included the following: Fewer side effects and improved control of disease as the advanced techniques directed the dose to the tumour and reduced the radiation dose to organ at risk. Treatment completed sooner than conventional radiotherapy, as the required dose required fewer trips to the hospital. Rural and remote patients were not required to travel to a metropolitan centre to have stereotactic ablative body radiotherapy treatment. LESSONS LEARNT: Strong commitment from a trained team and a collaborative approach is important for the implementation of advanced technology in regional centres.

Riding the rural radio wave: The impact of a community-led drug and alcohol radio advertising campaign in a remote Australian Aboriginal community.

OBJECTIVE: Aboriginal people experience a higher burden of disease as a consequence of drug and alcohol (D&A) abuse. Although media campaigns can be a popular tool for disseminating health promotion messages, evidence of the extent to which they reduce the impact of substance abuse is limited, especially for rural Aboriginal communities. This paper is the first to examine the impact a locally designed D&A radio advertising campaign for Aboriginal people in a remote community in Western NSW. DESIGN: A post-intervention evaluation. SETTING: The radio campaign was implemented in Bourke, (population 2465, 30% Aboriginal). PARTICIPANTS: Fifty-three community surveys were completed. MAIN OUTCOME MEASURE(S): The self-reported level of awareness of the campaign and the number of self-referrals to local D&A workers in the intervention period. RESULTS: Most respondents (79%) reported they listen to radio on a daily basis, with 75% reporting that they had heard one or more of the advertisements. The advertisement that was remembered best contained the voice of a respected, local person. There was one self-referral to local health services during the intervention timeframe. CONCLUSION: The community-led radio advertising campaign increased community awareness of substance abuse harms, but had limited impact on formal help-seeking. This paper highlights the value of radio as a commonly used, trusted and culturally relevant health promotion medium for rural communities, especially when engaging local respected Aboriginal presenters.

The prevalence and characteristics of homelessness in the NSW substance treatment population: implications for practice.

This study examines the prevalence and characteristics of homelessness episodes in Australian substance misuse treatment. A dataset containing all closed substance treatment episodes in NSW, Australia from July 2006 to June 2011 was used. Statistical analysis was used to determine any relationships between demographic and treatment variables and homelessness. Of the 213, 129 treatment episodes in the dataset 12.8% have some form of homelessness. Non-government and residential services have the highest prevalence of homelessness. Sex, age, and drug type have weak relationships with homelessness. Leaving against the advice of the treatment provider is more common in episodes where homelessness is a factor. Homelessness is a problem experienced by a significant proportion of the substance treatment population and treatment providers have an opportunity and an obligation to address it in their treatment delivery.

A pilot study examining the impact of a pragmatic process for improving the cultural responsiveness of non-Aboriginal alcohol and other drug treatment services using routinely collected data in Australia.

Objective: Routine health data has the potential to identify changes in patient-related outcomes, in close to real time. This pilot project used routine data to explore and compare the impact of changes to cultural responsiveness on service use by Aboriginal and Torres Strait Islander (hereafter, Aboriginal) clients in Australia.Methods: The New South Wales Minimum Data Set (MDS) for alcohol and other drug use treatment services was provided for 11 services for a period of 30 months from March 2019 to September 2021 (four months prior to two years after the intervention; data were analysed between March 2022 to February 2023). Change in cultural responsiveness was assessed via practice audits of services at baseline and two years. The average change in audit rating was analysed using a linear mixed regression model. Generalised Linear Mixed Models were used to identify changes in service use by Aboriginal clients. Results: All 11 services showed increased audit scores at two years, with a statistically significant mean increase of 18.6 (out of 63 points; b = 18.32, 95% CI 12.42-24.22). No statistically significant pre-to post-changes were identified in: (1) the proportion of episodes delivered to Aboriginal versus non-Aboriginal clients (OR = 1.15, 95% CI = 0.94-1.40), (2) the number of episodes of care provided to Aboriginal clients per month (IRR = 1.01, 95% CI = 0.84-1.23), or (3) the proportion of episodes completed by Aboriginal clients (OR = 0.96, 95% CI = 0.82-1.13). Conclusions: The lack of statistically significant impact on service use outcomes using MDS contrasts to the improvements in cultural responsiveness, suggesting further work is needed to identify appropriate outcome measures. This may include patient-reported experience measures. This project showed that routine data has potential as an efficient method for measuring changes in patient-related outcomes in response to health services improvements.

Experiences of Young People and Their Carers with a Rural Mobile Mental Health Support Service: A Qualitative Study.

Mental health difficulties during teenage years are common. They are also a risk factor for later mental and physical health problems. Rural young people are at a greater risk for mental health difficulties and have less access to services than their urban counterparts. The purpose of this study was to explore the experiences of young people and their carers with mental health support provided by a rural mobile service, and to identify access enablers from the perspective of the service users. A qualitative descriptive approach was used to analyse twelve interviews with current service users and eight interviews with family members of young people who had accessed the service. Three main themes were identified: (a) access and flexibility, (b) the qualities and strategies of the clinicians, and (c) experiences of change. The mobile service was perceived to be effective in producing a positive change in mental health, relationships, and the attainment of life goals. Key enablers to access included the flexibility of the mobile service, the variety of service delivery modes and therapeutic methods offered, the ease of access facilitated by the location in schools, and the autonomy of young people in how they chose to utilise the service. This study provides information about what is important to rural young people and their families in the provision of mental health services. The findings have implications for changing the way services are organized and operated. Healthcare policies and services could support a user-led model design that incorporates access and use-enablers and removes barriers to rural mental health support.

"I didn't even know headspace had the drug thing until today": A socio-ecological analysis of access to drug and alcohol interventions in integrated youth health care services.

BACKGROUND: With 150 centers Australia-wide, the headspace National Youth Mental Health Foundation is an exemplary integrated youth health service. Headspace centers provide medical care, mental health interventions, alcohol and other drug (AOD) services, and vocational support to Australian young people (YP) aged 12 to 25 years. Co-located headspace salaried youth workers, private health care practitioners (e.g. psychologists, psychiatrists, and medical practitioners) and in-kind community service providers (e.g. AOD clinicians) form coordinated multidisciplinary teams. This article aims to identify the factors influencing the access to AOD interventions for YP, in the Australian rural headspace setting; as perceived by YP, their family and friends, and headspace staff. METHODS: The study purposively recruited YP (n = 16), their family and friends (n = 9), and headspace staff (n = 23) and management (n = 7) in four headspace centers in rural New South Wales, Australia. Recruited individuals participated in semistructured focus groups about the access to YP AOD interventions in the headspace setting. The study team thematically analyzed the data through the lens of the socio-ecological model. RESULTS: The study identified convergent themes across groups and found several barriers to the access of AOD interventions; 1) YP's personal factors, 2) YP's family and peer attitudes, 3) practitioner skills, 4) organizational processes and 5) societal attitudes were all identified as negatively impacting access to YP AOD interventions. Practitioners' client-centered stance, and the youth-centric headspace model were factors that were considered as enablers of engagement of YP with an AOD concern. INTERPRETATION: While this Australian example of an integrated youth health care model is well placed to provide YP AOD interventions, a mismatch existed between practitioner capability and YP needs. The sampled practitioners described limited AOD knowledge, and low confidence in providing AOD interventions. At the organizational level, multiple AOD intervention supply and utilization issues occurred. Taken together, these problems likely underlie previous findings of poor service utilization and low user satisfaction. CONCLUSION: Clear enablers exist for AOD interventions to be better integrated into headspace services. Future work should determine how this integration can be achieved and what early intervention means in relation to AOD interventions.

Wellness Warriors: a qualitative exploration of healthcare staff learning to support their colleagues in the aftermath of the Australian bushfires.

PURPOSE: Healthcare staff are on the frontline during disasters despite any personal adversity and vicarious trauma they may be experiencing. Wellness Warrior training is a post-disaster intervention developed in response to the 2019-2020 Australian bushfires to support staff in a rural hospital located on the South Coast of New South Wales, Australia. METHOD: This study explored the experiences and perspectives of 18 healthcare staff who were trained to provide emotional and peer support to their colleagues in the aftermath of a crisis. All the Wellness Warriors participated in semi-structured interviews between March and April 2020. Data were analysed using the reflexive thematic approach. RESULTS: Healthcare staff reported developing interpersonal skills around deep listening and connecting with others which allowed for hearing the core of their colleagues' concerns. The training also helped staff to feel differently about work and restored their faith in healthcare leadership. CONCLUSION: Wellness Warrior training provided staff with knowledge and skills to support their colleagues in the aftermath of a natural disaster and later during the COVID-19 pandemic. As such, these findings suggest that peer support programs such as Wellness Warriors could be one way healthcare organisations can attempt to alleviate the psychological impact of natural disasters.

A Cluster-Randomised Stepped-Wedge Impact Evaluation of a Pragmatic Implementation Process for Improving the Cultural Responsiveness of Non-Aboriginal Alcohol and Other Drug Treatment Services: A Pilot Study.

There is limited evidence regarding implementing organisational improvements in the cultural responsiveness of non-Aboriginal services. Using a pragmatic implementation process to promote organisational change around cultural responsiveness, we aimed to (i) identify its impact on the cultural responsiveness of participating services; (ii) identify areas with the most improvement; and (iii) present a program logic to guide cultural responsiveness. A best-evidence guideline for culturally responsive service delivery in non-Aboriginal Alcohol and other Drug (AoD) treatment services was co-designed. Services were grouped geographically and randomised to start dates using a stepped wedge design, then baseline audits were completed (operationalization of the guideline). After receiving feedback, the services attended guideline implementation workshops and selected three key action areas; they then completed follow-up audits. A two-sample Wilcoxon rank-sum (Mann-Whitney) test was used to analyse differences between baseline and follow-up audits on three key action areas and all other action areas. Improvements occurred across guideline themes, with significant increases between median baseline and follow-up audit scores on three key action areas (median increase = 2.0; Interquartile Range (IQR) = 1.0-3.0) and all other action areas (median increase = 7.5; IQR = 5.0-11.0). All services completing the implementation process had increased audit scores, reflecting improved cultural responsiveness. The implementation process appeared to be feasible for improving culturally responsive practice in AoD services and may be applicable elsewhere.

Utilising the Implementation of Integrated Care to Develop a Pragmatic Framework for the Sustained Uptake of Service Innovations (SUSI).

The provision of integrated care (IC) across alcohol and other drug (AOD) and mental health (MH) services represents the best practice, yet the consistent delivery of IC in routine practice rarely occurs. Our hypothesis is that there is no practical or feasible systems-change approach to guide staff, researchers, or consumers through the complex transition that is required for the sustained uptake of IC across diverse clinical settings. To address this gap, we combined clinical and consumer expertise with the best available research evidence to develop a framework to drive the uptake of IC. The goal was to develop a process that is both standardised by the best available evidence and can be tailored to the specific characteristics of different health services. The result is the framework for Sustained Uptake of Service Innovation (SUSI), which comprises six core components that are applied in a specified sequence and a range of flexible activities that staff can use to deliver the core components according to their circumstances and preferences. The SUSI is evidence-based and practical, and further testing is currently underway to ensure it is feasible to implement in different AOD and MH services.