Process evaluation of a maintenance pulmonary rehabilitation trial for people with chronic obstructive pulmonary disease.

BACKGROUND: The ComEx3 community-based extended maintenance pulmonary rehabilitation (PR) randomised controlled trial (RCT) aimed to determine the optimal strategy for maintaining the benefits of exercise for people with chronic obstructive pulmonary disease (COPD). We conducted a process evaluation of this RCT to determine if the trial was implemented per protocol, and to explore the barriers and facilitators of the trial, and mechanisms of impact. METHODS: This was a mixed methods study consisting of analysis of PR class records, study diaries and interviews of those involved in the trial. We developed a reporting framework from available literature and performed a content analysis. RESULTS: Eleven of the 12 participants in the intervention group attended ≥70% of available classes before the trial was terminated due to the COVID-19 pandemic. Analysis of the study diaries found that adherence to the home exercise program was higher in the intervention than the control group. Analyses of interviews (n = 21) highlighted the complexity of standardising the processes across multiple sites, but revealed behaviour change amongst class physiotherapists who were able to conform with the required processes. Facilitators of participation included the desire to improve function and quality of life, while barriers included illnesses and lack of motivation. Mechanisms of impact included confidence in exercising and benefits from the education sessions. CONCLUSIONS: The ComEx3 RCT was implemented as planned largely due to commitment by the research team and the desire by patients to improve their quality of life by attending a PR program that they are familiar with. Successful implementation of PR RCTs requires good organisational skills, clear and consistent trial documentation, broad understanding of participant needs while being conscious of challenges experienced by people with COPD, and dedication by everyone involved in the RCT. SO WHAT?: This article shows the importance of running a process evaluation alongside an RCT. Although this RCT did not progress to completion, this process evaluation which was guided by a robust framework, will provide guidance for future interventions in this area.

The Application of Systems Thinking to the Prevention and Control of Sexually Transmissible Infections among Adolescents and Adults: A Scoping Review.

Systems thinking is a mechanism for making sense of complex systems that challenge linear explanations of cause-and-effect. While the prevention and control of sexually transmissible infections (STIs) has been identified as an area that may benefit from systems-level analyses, no review on the subject currently exists. The aim of this study is to conduct a scoping review to identify literature in which systems thinking has been applied to the prevention and control of STIs among adolescent and adult populations. Joanna Briggs Institute guidelines for the conduct of scoping reviews were followed. Five databases were searched for English-language studies published after 2011. A total of n = 6102 studies were screened against inclusion criteria and n = 70 were included in the review. The majority of studies (n = 34) were conducted in African nations. Few studies focused on priority sub-populations, and 93% were focused on HIV (n = 65). The most commonly applied systems thinking method was system dynamics modelling (n = 28). The review highlights areas for future research, including the need for more STI systems thinking studies focused on: (1) migrant and Indigenous populations; (2) conditions such as syphilis; and (3) innovations such as pre-exposure prophylaxis and at-home testing for HIV. The need for conceptual clarity around 'systems thinking' is also highlighted.

Measuring for primary prevention: An online survey of local community perspectives on family and domestic violence in regional Australia.

BACKGROUND: Family and domestic violence, encompassing diverse behaviours including physical, sexual, emotional and financial abuse, is endemic worldwide and has multiple adverse health and social consequences. Principal drivers include traditional gender values that disempower women. Changing these is a key prevention strategy. In Australia, high-quality national surveys provide data on public perspectives concerning family and domestic violence but may not capture community-level diversity. As part of a project for primary prevention family and domestic violence in outer regional Australia, our aims were to develop and administer a questionnaire-based survey suitable for the local community encompassing knowledge about, attitudes towards, and personal experiences of family and domestic violence, to describe and to investigate the theoretical (factor) structure and local socio-demographic predictors of responses, and to determine the extent to which the survey findings are locally distinctive. METHODS: The online community survey for local residents (≥15 years), comprised items on respondents' sociodemographic characteristics plus questions abridged from pre-existing national instruments on knowledge about, attitudes towards, and personal experiences of family and domestic violence. Responses were rake-weighted to correct census-ascertained sample imbalance and investigated using exploratory factor analysis, with sociodemographic predictors determined using multiple linear regression and dominance analysis. RESULTS: Among 914 respondents, males (27.0%), those from age-group extremes, and less-educated persons were underrepresented. Familiarity with diverse family and domestic violence behaviours was high among all subgroups. Poorer knowledge of the FDV behaviour continuum and attitudes supporting traditional gender roles and FDV were disproportionately evident among males, older respondents and those with lower education levels. Both the factor structure of extracted composite measures reflecting community perspectives and sociodemographic predictors of responses generally aligned with patterns evident in national data. CONCLUSIONS: Local reinforcement of existing nationwide findings on community understanding of and attitudes towards family and domestic violence provides salience for targeted interventions.

Patient-reported outcome measures for paediatric acute lower respiratory infection studies.

BACKGROUND: Patient-reported outcome measures (PROMs) are recommended for capturing meaningful outcomes in clinical trials. The use of PROMs for children with acute lower respiratory infections (ALRIs) has not been systematically reported. We aimed to identify and characterise patient-reported outcomes and PROMs used in paediatric ALRI studies and summarise their measurement properties. METHODS: Medline, Embase and Cochrane were searched (until April 2022). Studies that reported on patient-reported outcome (or measure) use or development and included subjects aged <18 years with ALRIs were included. Study, population and patient-reported outcome (or measure) characteristics were extracted. RESULTS: Of 2793 articles identified, 18 met inclusion criteria, including 12 PROMs. Two disease-specific PROMs were used in settings in which they had been validated. The Canadian Acute Respiratory Illness and Flu Scale was the most frequently used disease-specific PROM (five studies). The EuroQol-Five Dimensions-Youth system was the most frequently used generic PROM (two studies). There was considerable heterogeneity in validation methods. The outcome measures identified in this review lack validation for young children and none involve sufficient content validity for use with First Nations children. CONCLUSIONS: There is an urgent need for PROM development that considers the populations in which the burden of ALRI predominates.

The 5C model: A proposed continuous quality improvement framework for volunteer dental services in remote Australian Aboriginal communities.

OBJECTIVES: Aboriginal and Torres Strait Islander communities in remote parts of Australia are some of the most underserviced communities in regard to oral health care. These communities rely on volunteer dental programmes such as the Kimberley Dental Team to fill the gaps in care, however, there are no known continuous quality improvement (CQI) frameworks to guide such organizations to ensure that they are delivering high-quality, community-centred, culturally appropriate care. This study proposes a CQI framework model for voluntary dental programmes providing care to remote Aboriginal communities. METHODS: Relevant CQI models wherein the (i) behaviour of interest was quality improvement, and (ii) the health context was volunteer services in Aboriginal communities were identified from the literature. The conceptual models were subsequently augmented using a 'best fit' framework and the existing evidence synthesized to develop a CQI framework that aims to guide volunteer dental services to develop local priorities and enhance current dental practice. RESULTS: A cyclical five-phase model is proposed starting with consultation and moving through the phases of data collection, consideration, collaboration and celebration. CONCLUSIONS: This is the first proposed CQI framework for volunteer dental services working with Aboriginal communities. The framework enables volunteers to ensure that the quality of care provided is commensurate with the community needs and informed by community consultation. It is anticipated that future mixed methods research will enable formal evaluation of the 5C model and CQI strategies focusing on oral health among Aboriginal communities.

'Corona is coming': COVID-19 vaccination perspectives and experiences amongst Culturally and Linguistically Diverse West Australians.

BACKGROUND: Culturally and Linguistically Diverse (CALD) groups within high-income countries are at risk of being left behind by the COVID-19 vaccination rollout. They face both access and attitudinal barriers, including low trust in government and health authorities. OBJECTIVE: To explore perceptions and attitudes towards COVID-19 vaccination, as well as facilitators, barriers and strategies to promote uptake among CALD residents of Western Australia (WA), where there were almost no COVID-19 cases for 2 years. DESIGN AND PARTICIPANTS: Perth, WA's capital, was chosen as the state's study site because most of the state's CALD population lives there. Eleven semistructured in-depth interviews and three focus groups (with 37 participants) were conducted with CALD residents between August and October 2021. Thematic analysis was conducted, informed by the 'Capability', 'Opportunity', 'Motivation', 'Behaviour' model. RESULTS: CALD participants faced barriers including a lack of knowledge about COVID-19 and the vaccines, low self-rated English proficiency and education levels, misinformation, passive government communication strategies and limited access to vaccine clinics/providers. They were, however, motivated to vaccinate by the imminent opening of state and international borders, trust in government and healthcare authorities, travel intentions and the desire to protect themselves and others. CONCLUSIONS: Despite high levels of trust and significant desire for vaccines among CALD communities in Perth, current strategies were not meeting their needs and the community remains at risk from COVID-19. Tailored intervention strategies are required to provide knowledge, address misinformation and facilitate access to ensure uptake of COVID-19 vaccines-including for additional doses-amongst CALD communities. Governments should work with trusted CALD community members to disseminate tailored COVID-19 vaccine information and adequately translated resources. PATIENT OR PUBLIC CONTRIBUTION: The Wesfarmers Centre of Vaccines and Infectious Diseases Community Reference Group at Telethon Kids Institute consulted on this project in September 2020; Ishar Multicultural Women's Health Services consulted on and facilitated the focus groups.

Experiences of Western Australian rural nursing graduates: A mixed method analysis.

AIMS AND OBJECTIVES: To determine whether the current rural graduate programmes in Western Australia adequately support new graduate nurses transitioning into practice. BACKGROUND: Graduate nurse's transition to employment is a time of significant change and challenge, often resulting in periods of transition shock. These challenges are magnified in rural areas where graduates have to relocate to commence their career with limited rural nursing experience. Graduate programmes were developed to smooth the transition for university trained bachelor's degree registered nurses into the workforce. Supportive graduate nursing programmes are essential for enabling transition to practice and reduce attrition rates. DESIGN: Longitudinal convergent mixed method parallel design was informed by Duchscher's transition stage model. METHOD: Thematic analysis was applied to all interviews. COREQ checklist was completed. Descriptive statistics and content analysis were used to analyse the survey responses. RESULTS: New graduates cycled through both transition shock and honeymoon periods on commencement of employment, reporting high levels of satisfaction in simultaneity with signs of transition shock. Satisfaction dropped within 7 months indicating a transition crisis before an adjustment period occurred at the end of their graduate year. Limited resources were highlighted as obstacles to providing adequate support to rural graduate nurses. CONCLUSION: The honeymoon stage of transition co-existed with transition shock at the commencement of graduate programmes, which may obscure the need for continuing adequate support. Inadequate and/or a lack of preceptorship was evident throughout the Western Australian rural graduate programmes. Graduate programmes need to be structured but flexible to allow for individual differences in graduates' and clinical contexts. RELEVANCE TO CLINICAL PRACTICE: Structured but flexible graduate programmes allow for individual differences in graduates and clinical situations. New graduate nurses would benefit from a break midway through their graduate year to assist and overcome the transition crisis stage. Education of nurses undertaking the preceptor role is required to deliver adequate support to graduate nurses and decrease transition shock.

Establishment of a sentinel surveillance network for sexually transmissible infections and blood borne viruses in Aboriginal primary care services across Australia: the ATLAS project.

BACKGROUND: Sexually transmissible infection (STI) and blood-borne virus (BBV) diagnoses data are a core component of the Australian National Notifiable Diseases Surveillance System (NNDSS). However, the NNDSS data alone is not enough to understand STI and BBV burden among priority population groups, like Aboriginal and Torres Strait Islander people, because it lacks testing, treatment and management data. Here, we describe the processes involved in establishing a STI and BBV sentinel surveillance network representative of Aboriginal Community-Controlled Health Services (ACCHS)-known as the ATLAS network-to augment the NNDSS and to help us understand the burden of disease due to STI and BBV among Aboriginal and Torres Strait Islander peoples. METHODS: Researchers invited participation from ACCHS in urban, regional and remote areas clustered in five clinical hubs across four Australian jurisdictions. Participation agreements were developed for each clinical hub and individual ACCHS. Deidentified electronic medical record (EMR) data relating to STI and BBV testing, treatment and management are collected passively from each ACCHS via the GRHANITEtm data extraction tool. These data are analysed centrally to inform 12 performance measures which are included in regular surveillance reports generated for each ACCHS and clinical hub. RESULTS: The ATLAS network currently includes 29 ACCHS. Regular reports are provided to ACCHS to assess clinical practice and drive continuous quality improvement initiatives internally. Data is also aggregated at the hub, jurisdictional and national level and will be used to inform clinical guidelines and to guide future research questions. The ATLAS infrastructure can be expanded to include other health services and potentially linked to other data sources using GRHANITE. CONCLUSIONS: The ATLAS network is an established national surveillance network specific to Aboriginal and Torres Strait Islander peoples. The data collected through the ATLAS network augments the NNDSS and will contribute to improved STI and BBV clinical care, guidelines and policy program-planning.

Contemporary nursing graduates' transition to practice: A critical review of transition models.

AIM AND OBJECTIVE: To critically review contemporary transition theories to determine how they apply to the newly qualified graduate registered nurse programmes. BACKGROUND: Graduate nurse transition to employment is the time of significant change which has resulted in high attrition rates. Graduates are often challenged by their expectation of nursing practice and the reality of the role. The transition from hospital-based training to university-based training has resulted in the need for primary employment to commence with graduate/orientation/internship programmes to help support new graduates transition into clinical practice. One transition model, Duchscher's stages of transition theory, utilised three former theories to develop a final model. DESIGN: A narrative critical literature review. METHOD: The theories selected for the review were Kramer's reality shock theory, Benner's novice to expert theory, Bridges transition theory and Duchscher's stages of transition theory. CONCLUSION: Duchscher's stages of transition theory reflects the experiences of registered nursing transition into the workforce directly from university. The application of the theory is effective to guide understanding of the current challenges that new graduate nurse's experience today. There is a need for new graduates to complete their university degree as advanced beginners in order to decrease the experience of transition shock and keep pace with rapidly changing demands of the clinical environment. This may be achieved by increasing ward-based simulation in university education. A theoretical framework can provide a deep understanding of the various stages and processes of transition and enable development of successful programmes. RELEVANCE TO CLINICAL PRACTICE: Both universities and hospitals need to adapt their current practice to align with the needs of new graduates due to large student numbers and ongoing systematic advancements to decrease the attrition rate.

Service Level Factors Associated with Cervical Screening in Aboriginal and Torres Strait Islander Primary Health Care Centres in Australia.

Aboriginal and Torres Strait Islander women have significantly higher cervical cancer incidence and mortality than other Australian women. In this study, we assessed the documented delivery of cervical screening for women attending Indigenous Primary Health Care (PHC) centres across Australia and identified service-level factors associated with between-centre variation in screening coverage. We analysed 3801 clinical audit records for PHC clients aged 20-64 years from 135 Indigenous PHC centres participating in the Audit for Best Practice in Chronic Disease (ABCD) continuous quality improvement (CQI) program across five Australian states/territories during 2005 to 2014. Multilevel logistic regression models were used to identify service-level factors associated with screening, while accounting for differences in client-level factors. There was substantial variation in the proportion of clients who had a documented cervical screen in the previous two years across the participating PHC centres (median 50%, interquartile range (IQR): 29-67%), persisting over years and audit cycle. Centre-level factors explained 40% of the variation; client-level factors did not reduce the between-centre variation. Screening coverage was associated with longer time enrolled in the CQI program and very remote location. Indigenous PHC centres play an important role in providing cervical screening to Aboriginal and Torres Strait Islander women. Thus, their leadership is essential to ensure that Australia's public health commitment to the elimination of cervical cancer includes Aboriginal and Torres Strait Islander women. A sustained commitment to CQI may improve PHC centres delivery of cervical screening; however, factors that may impact on service delivery, such as organisational, geographical and environmental factors, warrant further investigation.

Clinic predictors of better syphilis testing in Aboriginal primary healthcare: a promising opportunity for primary healthcare service managers.

Integration of public health and primary healthcare (PHC) is a hallmark of comprehensive PHC to reduce inequitable rates of preventable diseases in communities at risk. In the context of a syphilis outbreak among Indigenous people in Northern Australia, the association between PHC clinic factors and syphilis testing performance (STP) was examined to produce empirical insights for service managers. Data from the Audit and Best Practice for Chronic Disease National Program (2012-14) were analysed to examine associations between clinic factors and STP (proportion of clients ≥15 years who were tested for or offered a test for syphilis in the prior 24 months). Univariate analyses were conducted for 77 clinics and a subset of 67 remote clinics. Multivariate linear regression models were used to determine independent predictors of STP. Syphilis testing performance across PHC clinics ranged from 0 to 93.8% (median 46.5%). In univariate analysis, Delivery system design, which refers to clinic infrastructure, staffing profile and allocation of roles and responsibilities, was significantly associated with higher STP in all clinics (P=0.004) and in the subset of remote clinics (P=0.008). Syphilis testing performance was higher in the Northern Territory compared to other states, in remote clinics and clinics serving smaller populations. In multivariate analysis, Delivery system design and jurisdiction remained associated with STP. To better realise the potential of comprehensive PHC, service managers should focus on PHC delivery system design to enhance the current syphilis outbreak response.

An integrative review of rural and remote nursing graduate programmes and experiences of nursing graduates.

AIMS AND OBJECTIVES: To examine international studies that specifically focus on transition to practice for graduate registered nurses in rural and remote areas. BACKGROUND: Supportive graduate nursing programmes are essential for enabling nursing graduates' transition to practice and reducing attrition rates. Literature examining support measures for nursing graduates within metropolitan areas is abundant. However, there is a paucity of evidence on effective graduate programmes for rural and remote-based nursing graduates. DESIGN: A systematic approach was used to identify robust research within appropriate electronic databases. METHOD: Eligible articles were critically reviewed using the Mixed Method Appraisal Tool critical appraisal tool. Eligible articles were thematically analysed using the Braun and Clark approach. RESULTS: Eight articles met the selection criteria for inclusion. Findings revealed that while most graduate nurses survived the transition process, they often felt overwhelmed and abandoned with intense feelings of frustration. Many suffered transition shock and did not feel ready for the role. Socialisation of graduates to the clinical environment was lacking. Support offered in many graduate programmes was ad hoc and unstructured. Senior staff were inadequately supported in their roles as preceptors to assist with the transition. Critical support measures recommended included both debrief sessions and regular one-on-one support. CONCLUSIONS: Graduate programmes need to be structured yet flexible to accommodate the needs of rural and remote nurse graduates. Graduates need to be transitioned into practice with decremental support processes for both workloads and education. Preceptors require education on how to mentor before they can provide the appropriate support for graduates. Without these measures in place, a decrease in transition shock may not be possible. RELEVANCE TO CLINICAL PRACTICE: Graduate programmes need to be structured yet flexible, including assistance with both clinical skills and socialisation. Senior staff require education before they can adequately support new graduates.

Social and Emotional Wellbeing Screening for Aboriginal and Torres Strait Islanders within Primary Health Care: A Series of Missed Opportunities?

BACKGROUND: Social and emotional wellbeing (SEWB) is a critical determinant of health outcomes for Indigenous Australians. This study examined the extent to which primary healthcare services (PHSs) undertake SEWB screening and management of Aboriginal and Torres Strait Islander clients, and the variation in SEWB screening and management across Indigenous PHS. METHODS: Cross-sectional analysis between 2012 and 2014 of 3,407 Indigenous client records from a non-representative sample of 100 PHSs in 4 Australian states/territory was undertaken to examine variation in the documentation of: (1) SEWB screening using identified measurement instruments, (2) concern regarding SEWB, (3) actions in response to concern, and (4) follow up actions. Binary logistic regression was used to determine the factors associated with screening. RESULTS: The largest variation in SEWB screening occurred at the state/territory level. The mean rate of screening across the sample was 26.6%, ranging from 13.7 to 37.1%. Variation was also related to PHS characteristics. A mean prevalence of identified SEWB concern was 13% across the sample, ranging from 9 to 45.1%. For the clients where SEWB concern was noted, 25.4% had no referral or PHS action recorded. Subsequent internal PHS follow up after 1 month occurred in 54.7% of cases; and six-monthly follow up of referrals to external services occurred in 50.9% of cases. CONCLUSION: Our findings suggest that the lack of a clear model or set of guidelines on best practice for screening for SEWB in Indigenous health may contribute to the wide variation in SEWB service provision. The results tell a story of missed opportunities: 73.4% of clients were not screened and no further action was taken for 25.4% for whom an SEWB concern was identified. There was no follow up for just under half of those for whom action was taken. There is a need for the development of national best practice guidelines for SEWB screening and management, accompanied by dedicated SEWB funding, and training for health service providers as well as ongoing monitoring of adherence with the guidelines. Further research on barriers to screening and follow up actions is also warranted.

Wide variation in sexually transmitted infection testing and counselling at Aboriginal primary health care centres in Australia: analysis of longitudinal continuous quality improvement data.

BACKGROUND: Chlamydia, gonorrhoea and syphilis are readily treatable sexually transmitted infections (STIs) which continue to occur at high rates in Australia, particularly among Aboriginal Australians. This study aimed to: explore the extent of variation in delivery of recommended STI screening investigations and counselling within Aboriginal primary health care (PHC) centres; identify the factors associated with variation in screening practices; and determine if provision of STI testing and counselling increased with participation in continuous quality improvement (CQI). METHODS: Preventive health audits (n = 16,086) were conducted at 137 Aboriginal PHC centres participating in the Audit and Best Practice for Chronic Disease Program, 2005-2014. STI testing and counselling data were analysed to determine levels of variation in chlamydia, syphilis and gonorrhoea testing and sexual health discussions. Multilevel logistic regression was used to determine factors associated with higher levels of STI-related service delivery and to quantify variation attributable to health centre and client characteristics. RESULTS: Significant variation in STI testing and counselling exists among Aboriginal PHC centres with health centre factors accounting for 43% of variation between health centres and jurisdictions. Health centre factors independently associated with higher levels of STI testing and counselling included provision of an adult health check (odds ratio (OR) 3.40; 95% Confidence Interval (CI) 3.07-3.77) and having conducted 1-2 cycles of CQI (OR 1.34; 95% CI 1.16-1.55). Client factors associated with higher levels of STI testing and counselling were being female (OR 1.45; 95% CI 1.33-1.57), Aboriginal (OR 1.46; 95% CI 1.15-1.84) and aged 20-24 years (OR 3.84; 95% CI 3.07-4.80). For females, having a Pap smear test was also associated with STI testing and counselling (OR 4.39; 95% CI 3.84-5.03). There was no clear association between CQI experience beyond two CQI cycles and higher levels of documented delivery of STI testing and counselling services. CONCLUSIONS: A number of Aboriginal PHC centres are achieving high rates of STI testing and counselling, while a significant number are not. STI-related service delivery could be substantially improved through focussed efforts to support health centres with relatively lower documented evidence of adherence to best practice guidelines.

Gaining a 'proper sense' of what happens out there: An 'Academic Bush Camp' to promote rural placements for students.

UNLABELLED: Undergraduates who undertake rural placements often choose a rural career. Reluctance from universities to send students to rural settings limits placement numbers. The Western Australian Centre for Rural Health (WACRH) invited allied health and nursing academics and clinical placement coordinators from Western Australian (WA) universities to an Academic Bush Camp. Based on situated learning theory, this camp modelled student programs through experiential learning and structured workshops. It aimed to build relationships and showcase innovative rural learning opportunities. OBJECTIVE: To build relationships and showcase innovative rural learning opportunities. DESIGN: An evaluation of a residential camp based on situated learning theory. SETTING: The camp stated and finished in Geraldton, WA and was centered in Mt Magnet, WA a remote town 600 kilometres northeast of Perth. PARTICIPANTS: WACRH invited allied health and nursing academics and clinical placement coordinators from Western Australian (WA) universities. INTERVENTION: This camp modelled student programs through experiential learning and structured workshops. Online pre- and post-camp questionnaires included open-ended questions and questions on a 5-point Likert scale. Responses were analysed in SPSS 22 using descriptive statistics and Wilcoxon signed-rank test. Follow-up phone interviews six months later assessed longer-term reflections and changes in student placement practice. MAIN OUTCOME MEASURES: The main outcome measure was whether the camp met participants' expectations, and their knowledge about and interest in WACRH's programs. RESULTS: Twelve academics from five WA universities and seven health disciplines attended. Nine had previously lived or worked rurally. The camp met participants' expectations and all would recommend the opportunity to a colleague. Many valued the interaction with community and clinical placement partners and would have preferred more of this. The camp increased awareness of WACRH's programs and benefits of longer rural placements and a service-learning environment. Six months later, participants' familiarity with WACRH's placement model, supports and staff had led to an enhanced willingness to place students. CONCLUSION: Rural academics can influence rural placement intentions by demonstrating the infrastructure, learning and academic support available. A camp experience increases metropolitan academics' awareness of rural placement programs and willingness to encourage student participation. Participants with rural backgrounds appeared more receptive to rural learning possibilities.

'I could never have learned this in a lecture': transformative learning in rural health education.

Health indicators for rural populations in Australia continue to lag behind those of urban populations and particularly for Indigenous populations who make up a large proportion of people living in rural and remote Australia. Preparation of health practitioners who are adequately prepared to face the 'messy swamps' of rural health practice is a growing challenge. This paper examines the process of learning among health science students from several health disciplines from five Western Australian universities during 'Country Week': a one-week intensive experiential interprofessional education program in rural Western Australia. The paper weaves together strands of transformative theory of learning with findings from staff and student reflections from Country Week to explore how facilitated learning in situ can work to produce practitioners better prepared for rural health practice.

Between a rock and a hard place: stigma and the desire to have children among people living with HIV in northern Uganda.

BACKGROUND: HIV-related stigma, among other factors, has been shown to have an impact on the desire to have children among people living with HIV (PLHIV). Our objective was to explore the experiences of HIV-related stigma among PLHIV in post-conflict northern Uganda, a region of high HIV prevalence, high infant and child mortality and low contraception use, and to describe how stigma affected the desires of PLHIV to have children in the future. METHODS: Semi-structured interviews were conducted with 26 PLHIV in Gulu district, northern Uganda. The interviews, conducted in Luo, the local language, were audio recorded, transcribed and then translated into English. Thematic data analysis was undertaken using NVivo8 and was underpinned by the "Conceptual Model of HIV/AIDS Stigma". RESULTS: HIV-related stigma continues to affect the quality of life of PLHIV in Gulu district, northern Uganda, and also influences PLHIV's desire to have children. PLHIV in northern Uganda continue to experience stigma in various forms, including internal stigma and verbal abuse from community members. While many PLHIV desire to have children and are strongly influenced by several factors including societal and cultural obligations, stigma and discrimination also affect this desire. Several dimensions of stigma, such as types of stigma (received, internal and associated stigma), stigmatizing behaviours (abusing and desertion) and agents of stigmatization (families, communities and health systems), either directly, or indirectly, enhanced or reduced PLHIV's desire to have more children. CONCLUSIONS: The social-cultural context within which PLHIV continue to desire to have children must be better understood by all health professionals who hope to improve the quality of PLHIV's lives. By delineating the stigma process, the paper proposes interventions for reducing stigmatization of PLHIV in northern Uganda in order to improve the quality of life and health outcomes for PLHIV and their children.

Family planning among people living with HIV in post-conflict Northern Uganda: A mixed methods study.

BACKGROUND: Northern Uganda experienced severe civil conflict for over 20 years and is also a region of high HIV prevalence. This study examined knowledge of, access to, and factors associated with use of family planning services among people living with HIV (PLHIV) in this region. METHODS: Between February and May 2009, a total of 476 HIV clinic attendees from three health facilities in Gulu, Northern Uganda, were interviewed using a structured questionnaire. Semi-structured interviews were conducted with another 26 participants. Factors associated with use of family planning methods were examined using logistic regression methods, while qualitative data was analyzed within a social-ecological framework using thematic analysis. RESULTS: There was a high level of knowledge about family planning methods among the PLHIV surveyed (96%). However, there were a significantly higher proportion of males (52%) than females (25%) who reported using contraception. Factors significantly associated with the use of contraception were having ever gone to school [adjusted odds ratio (AOR) = 4.32, 95% confidence interval (CI): 1.33-14.07; p = .015], discussion of family planning with a health worker (AOR = 2.08, 95% CI: 1.01-4.27; p = .046), or with one's spouse (AOR = 5.13, 95% CI: 2.35-11.16; p = .000), not attending the Catholic-run clinic (AOR = 3.67, 95% CI: 1.79-7.54; p = .000), and spouses' non-desire for children (AOR = 2.19, 95% CI: 1.10-4.36; p = .025). Qualitative data revealed six major factors influencing contraception use among PLHIV in Gulu including personal and structural barriers to contraceptive use, perceptions of family planning, decision making, covert use of family planning methods and targeting of women for family planning services. CONCLUSIONS: Multilevel, context-specific health interventions including an integration of family planning services into HIV clinics could help overcome some of the individual and structural barriers to accessing family planning services among PLHIV in Gulu. The integration also has the potential to reduce HIV incidence in this post-conflict region.

Factors associated with perceived stigma among people living with HIV/AIDS in post-conflict northern Uganda.

HIV-related stigma continues to persist in several African countries including Uganda. This study quantified the burden of stigma and examined factors associated with stigma among 476 people living with HIV (PLHTV) in Gulu, northern Uganda. Data were collected between February and May 2009 using the HIV/AIDS Stigma Instrument-PLWA. Females more than males, respondents aged above 30 years, and those who had been on antiretroviral therapy for a longer time experienced higher levels of stigma. Verbal abuse and negative self-perception were more common forms of stigma. The association between antiretroviral therapy and stigma suggested that organizational aspects of antiretroviral delivery may lead to stigmatization of PLHIV. Interventions such as counseling of PLHIV, education of health workers and the community would lead to reductions in negative self-perception and verbal abuse and in turn improve the quality of life for PLHIV in northern Uganda.

A systematic review of factors influencing fertility desires and intentions among people living with HIV/AIDS: implications for policy and service delivery.

With availability of antiretroviral treatments, HIV is increasingly recognised as a chronic disease people live with for many years. This paper critically reviews the current literature on fertility desires and reproductive intentions among people living with HIV/AIDS (PLHIV) and critiques the theoretical frameworks and methodologies used. A systematic review was conducted using electronic databases: ISI Web of Knowledge, Science Direct, Proquest, Jstor and CINAHL for articles published between 1990 and 2008. The search terms used were fertility desire, pregnancy, HIV, reproductive decision making, reproductive intentions, motherhood, fatherhood and parenthood. Twenty-nine studies were reviewed. Fertility desires were influenced by a myriad of demographic, health, stigma-associated and psychosocial factors. Cultural factors were also important, particularly in Sub-Saharan Africa and Asia. Future research that examines fertility desires among PLHIV should include cultural beliefs and practices in the theoretical framework in order to provide a holistic understanding and to enable development of services that meet the reproductive needs of PLHIV.