Medical termination of pregnancy service delivery in the context of decentralization: social and structural influences.

BACKGROUND: Medical termination of pregnancy (MToP) is a safe and acceptable abortion option. Depending on country context, MToP can be administered by general practitioners and mid-level healthcare providers in the first and second trimesters of pregnancy. Like other high-income countries, a range of social and structural barriers to MToP service provision exist in Australia. To counter some of these barriers, geographic decentralization of MToP was undertaken in rural Victoria, Australia, through training service providers about MToP to increase service delivery opportunities. The aim of this study was to investigate the factors that enabled and challenged the decentralization process. METHODS: Face-to-face and telephone interviews were undertaken between April and June 2016 with a purposeful sample of six training providers and 13 general practitioners (GP) and nurse training participants. Study participants were asked about their perceptions of motivations, enablers and challenges to MToP provision. A published conceptual framework of synergies between decentralization and service delivery was used to analyse the study findings. RESULTS: Three key themes emerged from the study findings. First, the effort to decentralize MToP was primarily supported by motivations related to making service access more equitable as well as the willingness of training providers to devolve their informal power, in the form of MToP medical expertise, to training participants. Next, the enablers for MToP decentralization included changes in the regulatory environment relating to decriminalization of abortion and availability of required medication, formation of partnerships to deliver training, provision of MToP clinical resources and local collegial support. Finally, challenges to MToP decentralization were few but significant. These included a lack of a state-wide strategy for service provision, provider concerns about coping with service demand, and provider stigma in the form of perceived negative community or collegial attitudes. These were significant enough to create caution for GPs and nurses considering service provision. CONCLUSIONS: Decentralization concepts offer an innovative way for reframing and tackling issues associated with improving MToP service delivery. There is scope for more research about MToP decentralization in other country contexts. These findings are important for informing future rural MToP service expansion efforts that improve equity in service access.

Facilitators of community participation in an Aboriginal sexual health promotion initiative.

INTRODUCTION: Community participation is a collaborative process aimed at achieving community-identified outcomes. However, approaches to community participation within Aboriginal health promotion initiatives have been inconsistent and not well documented. Smart and Deadly was a community-led initiative to develop sexual health promotion resources with young Aboriginal people in regional Victoria, Australia. The principles of community-centred practice, authentic participatory processes and respect for the local cultural context guided the initiative. The aim of this article is to report factors that facilitated community participation undertaken in the Smart and Deadly initiative to inform future projects and provide further evidence in demonstrating the value of such approaches. METHODS: A summative evaluation of the Smart and Deadly initiative was undertaken approximately 2 years after the initiative ended. Five focus groups and 13 interviews were conducted with a purposive sample of 32 participants who were involved with Smart and Deadly in one of the following ways: project participant, stakeholder or project partner, or project developer or designer. A deductive content analysis was undertaken and themes were compared to the YARN model, which was specifically created for planning and evaluating community participation strategies relating to Aboriginal sexual health promotion. RESULTS: A number of factors that facilitated community participation approaches used in Smart and Deadly were identified. The overarching theme was that trust was the foundation upon which the facilitators of community participation ensued. These facilitators were cultural safety and cultural literacy, community control, and legacy and sustainability. Whilst the YARN model was highly productive in identifying these facilitators of community participation, the model did not have provision for the element of trust between workers and community. Given the importance of trust between the project team and the Aboriginal community in the Smart and Deadly initiative, a suggested revision to the YARN model is that trust is included as the basis upon which YARN model factors are predicated. CONCLUSIONS: Adding trust to the YARN model as a basis upon which YARN model factors are grounded assists future Aboriginal health promotion projects in ensuring community participation approaches are more likely to be acceptable to the Aboriginal community.

A scoping review of Australian allied health research in ehealth.

BACKGROUND: Uptake of e-health, the use of information communication technologies (ICT) for health service delivery, in allied health appears to be lagging behind other health care areas, despite offering the potential to address problems with service access by rural and remote Australians. The aim of the study was to conduct a scoping review of studies into the application of or attitudes towards ehealth amongst allied health professionals conducted in Australia. METHODS: Studies meeting inclusion criteria published from January 2004 to June 2015 were reviewed. Professions included were audiology, dietetics, exercise physiology, occupational therapy, physiotherapy, podiatry, social work, and speech pathology. Terms for these professions and forms of ehealth were combined in databases of CINAHL (EBSCO), Cochrane Library, PsycINFO (1806 - Ovid), MEDLINE (Ovid) and AMED (Ovid). RESULTS: Forty-four studies meeting inclusion criteria were summarised. They were either trials of aspects of ehealth service delivery, or clinician and/or client use of and attitudes towards ehealth. Trials of ehealth were largely from two research groups located at the Universities of Sydney and Queensland; most involved speech pathology and physiotherapy. Assessments through ehealth and intervention outcomes through ehealth were comparable with face-to-face delivery. Clinicians used ICT mostly for managing their work and for professional development, but were reticent about its use in service delivery, which contrasted with the more positive attitudes and experiences of clients. CONCLUSION: The potential of ehealth to address allied health needs of Australians living in rural and remote Australia appears unrealised. Clinicians may need to embrace ehealth as a means to radicalise practice, rather than replicate existing practices through a different mode of delivery.

The role of stigma in the acceptance and disclosure of HIV among recently diagnosed men who have sex with men in Australia: A qualitative study.

BACKGROUND: Our primary study aimed to explore the experiences of men who have sex with men (MSM) recently diagnosed with HIV and their partner notification practices. Themes relating to acceptance, and disclosure of, their HIV status strongly emerged during analysis in our larger study and are reported separately here. METHOD: Fifteen MSM participated in semi-structured interviews by phone or face to face about their experience of a recent HIV diagnosis. In this paper we report on how they received and accepted the diagnosis, who they disclosed their diagnosis to and what is needed to improve support for MSM recently diagnosed with HIV. RESULTS: MSM's reactions to their HIV diagnosis ranged from shock, devastation and anger to a calm acceptance and feeling HIV would not have a significant impact on their lives. MSM who reported strong social support networks, or knew others with HIV, seemed better able to cope with and accept their diagnosis than those with fewer support networks. Due to prevailing stigma around HIV, most MSM were very selective about who they disclosed their status to, often only telling partners perceived to be at risk but no, or only few, close friends. Regardless of how well men accepted their diagnosis, most did not disclose their status to family members for fear of rejection or causing distress due to ideologies based on outdated information about HIV. CONCLUSION: The prevailing stigma around HIV can have a significant impact on MSM's acceptance of, and willingness to disclose their HIV serostatus to others, and consequently the levels of professional and social support they receive. HIV-related stigma needs to be addressed through community campaigns which better educate the wider population about the current state of HIV prognosis and treatment.

Providing accessible medical abortion services in a Victorian rural community: A description and audit of service delivery and contraception follow up.

OBJECTIVE: To describe how a nurse led, MToP service is run in primary care in regional Victoria and investigate the characteristics and contraceptive choices of the women who have attended. STUDY DESIGN: Descriptive study of the development and implementation of a rural MToP service and a retrospective chart audit of patients attending between January 2015 and September 2016. MAIN OUTCOME MEASURES: Characteristics and clinical outcomes for women attending an MToP service in a primary care setting in rural Victoria. Contraceptive usage pre and post attending a rural service for MToP. RESULTS: There were 229 presentations, representing 223 women, of which 172 women (75.1%; 95%CI: 69.0%, 80.6%) had a successful MToP and for two further women, MToP failed, requiring a surgical termination (0.9%; 95%CI: 0.1%, 3.1%). At the time of presentation, the mean age of women was 25 years, the median length of gestation was 49 days and 171 (75%) had not had a previous termination. Data about contraceptive use was available for 195 women, 143 (73.3%) reported no contraception, 2 reported emergency contraceptive pill (1.0%), 10 used condoms (2.1%) and 39 (20.0%) reported hormonal contraception. Among the 156 women using no contraception, condoms or emergency contraception at the time of pregnancy, 113 (72.4%) initiated a reliable form of contraception post presentation to the MToP service. CONCLUSION: Provision of accessible, affordable MToP through an integrated primary health service is one strategy to address access inequity in regional areas.

A Qualitative Study of Means to Improve Partner Notification After an HIV Diagnosis Among Men Who Have Sex with Men in Australia.

Improved partner notification (PN) after HIV diagnosis could help control HIV among men who have sex with men (MSM). However, there is little evidence exploring what this experience is like for Australian MSM and how achievable it is in the era of the Internet and smartphones. Fifteen of 39 invited MSM recently diagnosed with HIV undertook a semistructured interview about PN. Interviews were thematically analyzed using a combined deductive/inductive approach. Three main themes arose: fear of PN and HIV disclosure, partners' unexpected reactions, and the need for more patient support. MSM found PN difficult and uncomfortable and described fear about potential repercussions of PN; however, they felt it was the right thing to do. Regular partners were more likely to be notified, and in person, because of the availability of contact information but more notably because of a sense of moral responsibility. Men commonly had few contact details for casual partners and preferred PN strategies that allowed them to remain anonymous, largely reflecting the reasons for and ways in which they met casual partners: online or through apps and predominantly for once-off, anonymous sex. Most described unexpected positive responses from partners who were contacted personally by the men. Our study also showed that participants required professional support to carry out PN, especially with casual partners, as well as support around understanding the implications of and treatments relating to being HIV positive. PN could be improved by offering more options that allow the index patient to remain anonymous, particularly when notifying casual partners.

Developing sustainable social programmes for rural ethnic seniors: perspectives of community stakeholders.

This qualitative study explores barriers to delivering sustainable rural community programmes to increase social participation among Australian ethnic seniors. In 2013, in-depth interviews were conducted with 14 stakeholders across eight rural/regional organisations that had received state government funding to provide social participation initiatives for ethnic seniors. Within interviews, participants were asked to outline factors that had enhanced or hindered their capacity to deliver the funded projects, and their plans for sustainability. Data were analysed thematically in accordance with Shediac-Rizkallah and Bone's (1998) tripartite programme sustainability framework (project design and implementation, organisational setting and broader community environment). Findings indicate that in the context of resource and staffing constraints and a lack of ethnic critical mass, programme sustainability reflected the increased capacity of rural ethnic seniors to integrate into existing community groups and maintain their own groups and activities. However, this is dependent on the ability of mainstream government, health and social care services to cater for diverse cultural needs and preferences, the ability of rural organisations to support ethnic seniors to manage their own cultural groups and activities, and the capacity of funding bodies, rural community and policy structures to maintain cultural sensitivity while compensating for the rural premium. In addition to identifying some key learnings for rural governments, health and community organisations, this research highlights the precarious nature of rural programme sustainability for ethnic seniors in the context of wider community, organisational and policy constraints.