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Background: In Australia, demand for specialist infectious diseases services exceeds capacity to provide timely management of latent tuberculosis infection (LTBI) in areas of high refugee and asylum seeker settlement. A model for treating LTBI patients in primary care has been developed and piloted in a refugee-focused primary health service (Monash Health Refugee Health and Wellbeing [MHRHW]) and a universal primary care clinic. This study reports on the development and evaluation of the model, focusing on the model feasibility, and barriers and enablers to its success.Methods: A convergent mix-methods design was used to evaluate the model for treating LTBI patients in primary care, where a prospective cohort study of patients commencing treatment either at MHRHW or the universal primary care clinic determined the model feasibility, while focus groups with clinicians directly involved in treating these patients explored barriers and enablers to sustainability and success of the model.Results: From January 2017 to April 2018, 65 patients with confirmed LTBI presented at participating clinics. Treatment was accepted by 31 (48%) patients, of whom 15(48%) were treated at MHRHW and 16 (52%) at the universal primary care clinic. The 6-months' treatment completion rate was higher at MHRHW compared to the universal primary care clinic (14 (93%) compared to 9 (56%) respectively, p = 0.0373). Reasons for non-completion included adverse reaction, opting out and relocation. At the completion of the pilot, 15 clinicians participated in two focus groups. Clinicians identified barriers and enablers for successful LTBI management at patient, provider, organisational and clinical levels. While barriers for treatment completion and adherence were consistent across the two pilot sites, enablers, such as resources to facilitate patient education and follow-up, were available only at MHRHW.Conclusion: Screening and management of LTBI patients can be achieved within the primary care setting, considerate of barriers and enablers at patient, provider, organisational and clinical levels. Upscaling of a primary care response to the management of LTBI will require supporting primary care clinics with resources to employ dedicated clinical staff for patient education, follow-up communication and monitoring medication adherence. [ABSTRACT FROM AUTHOR]

Background High-quality, evidence-based guidelines can improve the quality of health care and facilitate standardisation of practice within and across healthcare organisations. Limited information is known regarding existing antenatal corticosteroid ( ACS) guideline practices within organisations across Australia and New Zealand. Aims To assess existing ACS clinical practice guidelines ( CPG). To describe current organisational practice related to the production, implementation and renewal of CPG. Design A cross-sectional survey of hospital practice using an online questionnaire. Methods Clinical Managers at 27 secondary and 25 tertiary maternity hospitals, that contribute data to the Australia and New Zealand Neonatal Network, were approached from May to September 2015 and completed the questionnaire on behalf of their organisation. Results Of the hospitals surveyed, 93% reported having a CPG or protocol. Of these, 89% of CPG included recommendations on a single course of ACS, 37% on the use of repeat course/s and 41% on use prior to elective caesarean section at term. Variation in the recommendations provided existed between countries and depending on the level of neonatal care provided. A guideline development group existed in 85% of hospitals. The preferred tools to facilitate implementation of a CPG include: email with a link to the hospital intranet, education sessions and an opinion leader. Only 28% of respondents reported auditing the use of ACS administration. Conclusions There is significant variation in the recommendations provided by current ACS CPGs. Utilisation of a single ACS CPG reflective of the current available evidence base may limit this variation. [ABSTRACT FROM AUTHOR]

Introduction: The importance of meaningfully involving patients and the public in digital health innovation is widely acknowledged, but often poorly understood. This review, therefore, sought to explore how patients and the public are involved in digital health innovation and to identify factors that support and inhibit meaningful patient and public involvement (PPI) in digital health innovation, implementation and evaluation., Methods: Searches were undertaken from 2010 to July 2020 in the electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus and ACM Digital Library. Grey literature searches were also undertaken using the Patient Experience Library database and Google Scholar., Results: Of the 10,540 articles identified, 433 were included. The majority of included articles were published in the United States, United Kingdom, Canada and Australia, with representation from 42 countries highlighting the international relevance of PPI in digital health. 112 topic areas where PPI had reportedly taken place were identified. Areas most often described included cancer (n = 50), mental health (n = 43), diabetes (n = 26) and long-term conditions (n = 19). Interestingly, over 133 terms were used to describe PPI; few were explicitly defined. Patients were often most involved in the final, passive stages of an innovation journey, for example, usability testing, where the ability to proactively influence change was severely limited. Common barriers to achieving meaningful PPI included data privacy and security concerns, not involving patients early enough and lack of trust. Suggested enablers were often designed to counteract such challenges., Conclusions: PPI is largely viewed as valuable and essential in digital health innovation, but rarely practised. Several barriers exist for both innovators and patients, which currently limits the quality, frequency and duration of PPI in digital health innovation, although improvements have been made in the past decade. Some reported barriers and enablers such as the importance of data privacy and security appear to be unique to PPI in digital innovation. Greater efforts should be made to support innovators and patients to become meaningfully involved in digital health innovations from the outset, given its reported benefits and impacts. Stakeholder consensus on the principles that underpin meaningful PPI in digital health innovation would be helpful in providing evidence-based guidance on how to achieve this., Patient or Public Contribution: This review has received extensive patient and public contributions with a representative from the Patient Experience Library involved throughout the review's conception, from design (including suggested revisions to the search strategy) through to article production and dissemination. Other areas of patient and public contributor involvement include contributing to the inductive thematic analysis process, refining the thematic framework and finalizing theme wording, helping to ensure relevance, value and meaning from a patient perspective. Findings from this review have also been presented to a variety of stakeholders including patients, patient advocates and clinicians through a series of focus groups and webinars. Given their extensive involvement, the representative from the Patient Experience Library is rightly included as an author of this review., (© 2022 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

The demand for genetic testing of hereditary breast cancer genes such as BRCA1 and BRCA2 has continued to increase with the lowering costs of testing, raised awareness in the general public, and implications for breast cancer treatment when a patient is identified as having a germline pathogenic variant. Historically within Australia, patients affected by high genetic risk breast cancers have been referred to a familial cancer centre (FCC) for assessment and testing, resulting in wait times for an appointment for pre- and post-test genetic counselling and an increased demand on the public-funded FCC. To improve patient access and pace of genetic testing, as well as refocus FCC resources, a mainstream clinical genetic testing program was rolled out in September 2017 through the Parkville FCC (PFCC) in Australia at 10 hospital sites. This program enables specialist doctors of eligible patients affected by breast cancer to arrange genetic testing directly at an oncology/surgical appointment and follow up the results as part of the patients' routine clinical care. In this model, the specialist doctor is responsible for any treatment implications of the genetic test result, and the PFCC is responsible for result interpretation, future cancer risk, family cascade testing and segregation testing where warranted. To date the program has had successful uptake, a notable pathogenic variant detection rate, reduced the burden on the PFCC enabling a reallocation of resources and has streamlined the process of genetic testing for eligible patients. Investigation into the patient and clinician experiences of the mainstream program is required.

Background: We conducted a cluster randomized trial of a workplace mental health intervention in an Australian police department. The intervention was co-designed and co-implemented with the police department. Intervention elements included tailored mental health literacy training for all members of participating police stations, and a leadership development and coaching program for station leaders. This study presents the results of a mixed-methods implementation evaluation of the trial., Methods: Descriptive quantitative analyses characterized the extent of participation in intervention activities, complemented by a qualitative descriptive analysis of transcripts of 60 semistructured interviews with 53 persons and research team field notes., Results: Participation rates in the multicomponent leadership development activities were highly variable, ranging from <10% to approximately 60% across stations. Approximately 50% of leaders and <50% of troops completed the mental health literacy training component of the intervention. Barriers to implementation included rostering challenges, high staff turnover and changes, competing work commitments, staff shortages, limited internal personnel resources to deliver the mental health literacy training, organizational cynicism, confidentiality concerns, and limited communication about the intervention by station command or station champions. Facilitators of participation were also identified, including perceived need for and benefits of the intervention, engagement at various levels, the research team's ability to create buy-in and manage stakeholder relationships, and the use of external, credible leadership development coaches., Conclusions: Implementation fell far short of expectations. The identified barriers and facilitators should be considered in the design and implementation of similar workplace mental health interventions., (© 2020 Wiley Periodicals LLC.)

Malnutrition is highly prevalent in patients with foregut tumors comprising head and neck (HNC) and esophageal (EC) cancers, negatively impacting outcomes. International evidence-based guidelines (EBGs) for nutrition care exist; however, translation of research evidence into practice commonly presents considerable challenges and consequently lags. This study aimed to describe and evaluate current international nutrition care practices compared with the best-available evidence for patients with foregut tumors who are at high risk of malnutrition. A multi-centre prospective cohort study enrolled 170 patients commencing treatment of curative intent for HNC ( n = 119) or EC ( n = 51) in 11 cancer care settings in North America, Europe and Australia between 2016 and 2018. Adherence criteria were derived from relevant EBG recommendations with pooled results for participating centres reported according to the Nutrition Care Model at either system or patient levels. Adherence to EBG recommendations was: good (≥80%) for performing baseline nutrition screening and assessment, perioperative nutrition assessment and nutrition prescription for energy and protein targets; moderate (≥60 to 80%) for utilizing validated screening and assessment tools and pre-radiotherapy dietitian consultation; and poor (60%) for initiating post-operative nutrition support within 24 h and also dietetic consultation weekly during radiotherapy and fortnightly for 6 weeks post-radiotherapy. In conclusion, gaps in evidence-based cancer nutrition care remain; however, this may be improved by filling known evidence gaps through high-quality research with a concurrent evolution of EBGs to also encompass practical implementation guidance. These should aim to support multidisciplinary cancer clinicians to close evidence-practice gaps throughout the patient care trajectory with clearly defined roles and responsibilities that also address patient-reported concerns.

Background: Current Australian data highlight guideline noncompliant prescribing of antimicrobials for surgical prophylaxis. The study aim was to evaluate the implementability of the Australian national surgical prophylaxis (SAP) guidelines to identify facilitators for and barriers to compliance., Methods: Key stakeholders appraised the surgical prophylaxis guidelines using the GuideLine Implementability Appraisal (GLIA) tool. Questions with 100% agreement for the response 'Yes' were identified as facilitators and those with 100% agreement for 'No', a barrier. Questions that did not receive 100% agreement, but had a majority (40-60%) 'Yes' or 'No' consensus were considered as borderline facilitators and barriers respectively., Results: Ten appraisals were completed. Guideline recommendations were rated as easily identifiable and concise and were thus facilitators for implementation. The ability to measure guideline adherence and outcomes, and recommendations that were consistent with guideline user abilities and beliefs were also identified as facilitators. Borderline facilitators related to the clarity of the recommendations and whether they were explicit in what to do and in what circumstances. Evidence quality underpinning recommendations (validity), inflexibility of recommendations (flexibility) and the lack of patient data at the point of use (computability) were identified as borderline barriers to implementation. No recommendation reached agreement as being a barrier., Conclusion: The GLIA appraisal demonstrated overall implementability of the current Australian national surgical prophylaxis guidelines. Facilitators (i.e., measurability) and borderline facilitators highlight strengths of the current guideline. Borderline barriers (i.e., validity, flexibility and computability) may negatively impact upon implementability. Guideline developers should consider these dimensions to optimise guideline uptake and consequently patient care., (Copyright © 2019 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.)

Aim: The provision and implementation of early intervention for psychosis services (early intervention services [EIS]) has received increasing attention over recent years. Maximizing engagement with EIS is of clinical and economic importance, and exploring the experiences of those who access EIS is vital. Although research has been conducted exploring the experiences of engaging with EIS from both a service user and carer/family member point of view, these data have not been systematically collated to generate new understanding. The primary aim of this study is to review, critically appraise and synthesize qualitative findings relating to the experiences of service users and/or carers and family members engaging with EIS., Methods: Four databases were systematically searched. Studies were analysed using an inductive thematic analysis approach, within a critical realist epistemological framework. Studies were critically appraised using the critical appraisal skills programme tool., Results: Fourteen papers were identified for inclusion. Three main themes were identified: the importance of a personal relationship with an EIS staff member, the impact of this relationship and consideration of life after EIS. The importance of a strong relationship with EIS staff was the most prominent theme throughout the papers reviewed., Conclusions: The quality of the therapeutic relationship with at least one EIS staff member was the single most important factor in determining whether the experience of accessing EIS was a positive or negative one. The majority of the studies reviewed were conducted in the United Kingdom or Australia. Therefore, more research across countries is needed to understand transferability of findings., (© 2019 John Wiley & Sons Australia, Ltd.)

Introduction: Stereotactic ablative radiotherapy (SABR) for lung cancer is a modality of treatment that has improved outcomes for lung cancer patients. However, radiotherapy for lung cancer is underutilized and fewer than half of elderly patients with non-small cell lung cancer (NSCLC) receive active treatment. The purpose of this study is to report on a collaboration in implementing an NSCLC SABR (stereotactic ablative body radiation) program safely, efficiently, and uniformly across several centers, including regional sites. The first aim of this paper is to detail the collaboration and implementation that started in 2013 and is ongoing. The second aim of this paper is to document early toxicities and quality of life outcomes., Method: A tripartite approach was used to develop the protocol and networks required for the implementation of SABR across multiple sites in NSW. Departments starting the programmes were supported and physics credentialing with central site submission was required before commencing the treatment. Additional ongoing support was available via an email discussion group involving all members of the collaboration., Results: Between July 22, 2013 and February 22, 2016, 41 patients were enrolled with 34 patients in active follow up. The toxicity profile so far is similar to those of published studies with no appreciable effect on quality of life outcomes., Conclusion: The collaboration formed an effective framework in facilitating the implementation of SABR across several sites in NSW and could be used as a model for the safe and uniform implementation of new technologies in Australia., (© 2019 John Wiley & Sons Australia, Ltd.)

Aim: Using standardised terminology in acute care has encouraged consistency in patient care and the evaluation of outcomes. As such, the Nutrition Care Process (NCP) and Nutrition Care Process Terminology (NCPT) may assist dietitian nutritionists in the delivery of high quality nutrition care worldwide; however, limited research has been conducted examining the consistency and accuracy of its use. We aimed to examine the NCPT that dietitian nutritionists would use to formulate a diagnostic statement relating to refeeding syndrome (RFS)., Methods: A multimethod action research approach was used, incorporating two projects. The first was a survey examining Australian dietitian nutritionists' (n = 195) opinions regarding NCPT use in cases of RFS. To establish if results were similar internationally, an interview was then conducted with 22 dietitian nutritionists working within 10 different countries., Results: 'Imbalance of nutrients' was only identified as a correct code by 17% of respondents in project 1. No mention of this term was made in project 2. Also 86% of respondents incorrectly selected more than one diagnostic code. The majority of respondents (80%, n = 52/65) who incorrectly selected 'Malnutrition', without also selecting 'Imbalance of nutrients', selected 'reduce intake' as an intervention, suggesting some misunderstanding in the requirement for interrelated diagnoses, interventions and goals., Conclusions: Our findings demonstrate that there is limited accuracy and consistency in selecting nutritional diagnostic codes in relation to RFS. Respondents also demonstrated limited knowledge regarding appropriate application of the NCP and NCPT. Implementation practices may require further refinement, as accurate and consistent use is required to procure the benefits of standardised terminology., (© 2017 Dietitians Association of Australia.)

Purpose of Review: Populations surrounding the Mediterranean basin have traditionally reaped health benefits from a Mediterranean diet (MedDiet), which may benefit Westernized countries plagued by chronic disease. But is it feasible to implement beyond the Mediterranean? To answer this question, we present evidence from randomized controlled trials that achieved high dietary compliance rates with subsequent physical and mental health benefits., Recent Findings: In the 1960s, the Seven Countries Study identified dietary qualities of Mediterranean populations associated with healthy aging and longevity. The PREDIMED study confirmed reductions in CVD-related mortality with a MedDiet; a meta-analysis in over 4.7 million people showed reduced mortality, CVD-related mortality, and reduced risk of Parkinson's and Alzheimer's disease. Continually emerging research supports the MedDiet's benefits for chronic diseases including metabolic syndrome, cancers, liver disease, type 2 diabetes, depression, and anxiety. We summarize components of studies outside the Mediterranean that achieved high compliance to a Med-style diet: dietitian led, dietary education, goal setting, mindfulness; recipe books, meal plans, and food checklists; food hampers; regular contact between volunteers and staff through regular cooking classes; clinic visits; and recipes that are simple, palatable, and affordable. The next step is testing the MedDiet's feasibility in the community. Potential obstacles include access to dietetic/health care professionals, high meat intake, pervasive processed foods, and fast food outlets. For Western countries to promote a Med-style diet, collective support from government, key stakeholders and policy makers, food industry, retailers, and health professionals is needed to ensure the healthiest choice is the easiest choice.

Online counselling services for a range of health conditions have proliferated in recent years. However, there is ambiguity and tension around their role and function. It is often unclear whether online counselling services are intended to provide only a brief intervention, the provision of information or referral, or constitute an alternative to face-to-face treatment. In line with recent analyses of alcohol and other drug (AOD) policy and interventions that draw on a critical social science perspective, we take an evidence-making intervention approach to examine how online counselling in the AOD field is made in policy and through processes of local implementation. In this article, we analyse how online AOD counselling interventions and knowledges are enacted in Australia's AOD policy, and compare these enactments with an analysis of information about Australia's national online AOD counselling service, Counselling Online, and transcripts of counselling sessions with clients of Counselling Online. We suggest that while the policy enacts online counselling as a brief intervention targeting AOD use, and as an avenue to facilitate referral to face-to-face treatment services, in its implementation in practice online counselling is enacted in more varied ways. These include online counselling as attempting to attend to AOD use and interconnected psychosocial concerns, as a potential form of treatment in its own right, and as supplementing face-to-face AOD treatment services. Rather than viewing online counselling as a singular and stable intervention object, we suggest that multiple 'online counsellings' emerge in practice through local implementation practices and knowledges. We argue that the frictions that arise between policy and practice enactments need to be considered by policy makers, funders, clinicians and researchers as they affect how the concerns of those targeted by the intervention are attended to., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Aim: Assessing changes in dietetic perceptions, attitudes and knowledge regarding the Nutrition Care Process Terminology (NCPT) is important to determine implementation effectiveness. This study aimed to investigate changes in the perceptions and attitudes of Australian dietitians over a three-year period, identify changes in benefits and barriers to support successful NCPT implementation and determine future directions for NCPT progression., Methods: An online survey was performed in 2011 and repeated in 2014 by recruiting members of the Dietitians Association of Australia (DAA) through an email link. The survey assessed familiarity, knowledge, attitudes, benefits, barriers, concerns and use of educational enablers around the NCPT., Results: The survey was completed by 218 respondents in 2011 and 205 respondents in 2014. Survey respondents from both years were representative of overall DAA membership. Respondent knowledge of NCPT increased significantly over the three-years, as did confidence, preparation, access to support and training and NCPT usage. Respondent's identification of benefits to implementation increased whilst barriers reduced. Attitudes regarding NCPT implementation were conflicting., Conclusions: Over three years, improvements were evident in NCPT knowledge, attitudes and usage. However, not all dietitians saw reason to implement NCPT in their practice, and some attitudes have become less supportive. A collective vision is required to foster positive attitudes towards the transformational professional benefits possible from NCPT. With ongoing uptake of electronic health records, the potential for NCPT to evaluate and justify dietetic interventions is increasing., (© 2017 State of Queensland. Nutrition and Dietetics © 2017 Dietitians Association of Australia.)

Evidence for effective falls prevention interventions in acute wards is limited. One reason for this may be suboptimal program implementation. This study aimed to identify perceived barriers and enablers of the implementation of the 6-PACK falls prevention program to inform the implementation in a randomised controlled trial. Strategies to optimise successful implementation of 6-PACK were also sought. A mixed-methods approach was applied in 24 acute wards from 6 Australian hospitals. Participants were nurses working on participating wards and senior hospital staff including Nurse Unit Managers; senior physicians; Directors of Nursing; and senior personnel involved in quality and safety or falls prevention. Information on barriers and enablers of 6-PACK implementation was obtained through surveys, focus groups and interviews. Questions reflected the COM-B framework that includes three behaviour change constructs of: capability, opportunity and motivation. Focus group and interview data were analysed thematically, and survey data descriptively. The survey response rate was 60% (420/702), and 12 focus groups (n = 96 nurses) and 24 interviews with senior staff were conducted. Capability barriers included beliefs that falls could not be prevented; and limited knowledge on falls prevention in patients with complex care needs (e.g. cognitive impairment). Capability enablers included education and training, particularly face to face case study based approaches. Lack of resources was identified as an opportunity barrier. Leadership, champions and using data to drive practice change were recognised as opportunity enablers. Motivation barriers included complacency and lack of ownership in falls prevention efforts. Motivation enablers included senior staff articulating clear goals and a commitment to falls prevention; and use of reminders, audits and feedback. The information gained from this study suggests that regular practical face-to-face education and training for nurses; provision of equipment; audit, reminders and feedback; leadership and champions; and the provision of falls data is key to successful falls prevention program implementation in acute hospitals.

Background: Inhospital falls cause morbidity, staff burden and increased healthcare costs. It is unclear if the persistent problem of inhospital falls is due to the use of ineffective interventions or their suboptimal implementation. The 6-PACK programme appears to reduce fall injuries and a randomised controlled trial (RCT) was undertaken to confirm effects. This paper describes the protocol for the preimplementation studies that aimed to identify moderators of the effective use of the 6-PACK programme to inform the development of an implementation plan to be applied in the RCT., Methods: The 6-PACK project included five preimplementation studies: (1) a profile of safety climate; (2) review of current falls prevention practice; (3) epidemiology of inhospital falls; (4) acceptability of the 6-PACK programme; and (5) barriers and enablers to implementation of the 6-PACK programme. The Theoretical Domain Framework that includes 12 behaviour change domains informed the design of these studies that involved 540 staff and 8877 patients from 24 wards from six Australian hospitals. Qualitative and quantitative methods were applied with data collected via: structured bedside observation; daily nurse unit manager verbal report of falls; audit of medical records, incident reporting and hospital administrative data; surveys of ward nurses; focus groups with ward nurses; and key informant interviews with senior staff., Discussion: Information on contextual, system, intervention, patient and provider level factors is critical to the development of an implementation plan. Information gained from these studies was used to develop a plan applied in the RCT that addressed the barriers and harnessed enablers., Trial Registration Number: The RCT is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000332921., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

The majority of trauma nursing education is focused on the emergency phases of care. We describe the development and evaluation of a trauma eLearning module for the ward environment. The module was developed using adult learning principles and implemented in 2 surgical wards. There were 3 phases of evaluation: (1) self-efficacy of nurses; (2) relevance and usability of the module and; (3) application of knowledge learnt. The majority indicated they had applied new knowledge, particularly when performing a physical assessment (85.7%), communicating (91.4%), and identifying risk of serious illness (90.4%). Self-efficacy relating to confidence in caring for patients, communication, and escalating clinical deterioration improved (p = .023). An eLearning trauma patient assessment module for ward nursing staff improves nursing knowledge and self-efficacy.

Introduction: Rural-remote communities report higher smoking rates and poorer health outcomes than that of metropolitan areas. While anti-smoking programs are an important measure for addressing smoking and improving health, little is known of the challenges faced by primary healthcare staff implementing those programs in the rural-remote setting. The aim of this study was to explore the challenges and strategies of implementing an anti-smoking program by primary healthcare staff in rural-remote Australia., Methods: Guided by a phenomenological approach, semi-structured interviews and focus groups were conducted with health service managers, case managers and general practitioners involved in program implementation in Australian rural-remote communities between 2008 and 2010., Results: Program implementation was reported to be challenged by limited primary and mental healthcare resources and client access to services; limited collaboration between health services; the difficulty of accessing staff training; high levels of community distress and disadvantage; the normalisation of smoking and its deleterious impact on smoking abstinence among program clients; and low morale among health staff. Strategies identified to overcome challenges included appointing tobacco-dedicated staff; improving health service collaboration, access and flexibility; providing subsidised pharmacotherapies and boosting staff morale., Conclusions: Findings may assist health services to better tailor anti-smoking programs for the rural-remote setting, where smoking rates are particularly high. Catering for the unique challenges of the rural-remote setting is necessary if anti-smoking programs are to be efficacious, cost-effective and capable of improving rural-remote health outcomes.

Background: After the introduction of a quadrivalent human papillomavirus (HPV) vaccination programme in Australia in April, 2007, we measured the prevalence of vaccine-targeted and closely related HPV types with the aim of assessing direct protection, cross-protection, and herd immunity., Methods: In this repeat cross-sectional study, we recruited women aged 18-24 years who attended Pap screening between October, 2005, and July, 2007, in three major metropolitan areas of Australia to form our prevaccine-implementation sample. For our postvaccine-implementation sample, we recruited women aged 18-24 years who attended Pap screening in the same three metropolitan areas from August, 2010, to November, 2012. We compared the crude prevalence of HPV genotypes in cervical specimens between the prevaccine and the postvaccine implementation groups, with vaccination status validated against the National HPV Vaccination Program Register. We estimated adjusted prevalence ratios using log linear regression. We estimated vaccine effectiveness both for vaccine-targeted HPV types (16, 18, 6, and 11) and non-vaccine but related HPV types (31, 33, and 45)., Findings: 202 women were recruited into the prevaccine-implementation group, and 1058 were recruited into the postvaccine-implementation group. Crude prevalence of vaccine-targeted HPV genotypes was significantly lower in the postvaccine-implementation sample than in the prevaccine-implementation sample (58 [29%] of 202 vs 69 [7%] of 1058; p<0·0001). Compared with the prevaccine-implementation sample, adjusted prevalence ratios for vaccine-targeted HPV genotypes were 0·07 (95% CI 0·04-0·14; p<0·0001) in fully vaccinated women and 0·65 (0·43-0·96; p=0·03) in unvaccinated women, which suggests herd immunity. No significant declines were noted for non-vaccine-targeted HPV genotypes. However, within the postvaccine-implementation sample, adjusted vaccine effectiveness against vaccine-targeted HPV types for fully vaccinated women compared with unvaccinated women was 86% (95% CI 71-93), and was 58% (26-76) against non-vaccine-targeted but related genotypes (HPV 31, 33, and 45)., Interpretation: 6 years after the initiation of the Australian HPV vaccination programme, we have detected a substantial fall in vaccine-targeted HPV genotypes in vaccinated women; a lower prevalence of vaccine-targeted types in unvaccinated women, suggesting herd immunity; and a possible indication of cross-protection against HPV types related to the vaccine-targeted types in vaccinated women., Funding: Australian National Health and Medical Research Council and Cancer Council Victoria., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: This article reports on an international collaborative study which compared school-based health care in the United States of America, Canada and Australia., Method: Tri-nation school-based health care was compared and contrasted through the utilisation of a series of interpretive case studies. Grounded theory approaches informed the data analysis and reporting processes., Findings: Unlike the US, Canadian and Australian school students rarely have access to school-based health care on site. All three nations face structural, cultural and societal barriers, often related to limited resources which limit the effectiveness of school-based health care., Discussion: The benefits of school-based health care and providing comprehensive services through schools can include healthier children, better learning, healthier parents, and healthier communities. Unfortunately, based on our research, comprehensive school health services have not been adequately implemented in the US, Canada or Australia., Implications for Practice: Given the findings of this study, increased comprehensive school-based health services are urgently needed in the US, Canada and Australia.

The impact of variable implementation of the Assertive Community Treatment (ACT) model on patient outcomes is increasingly recognised. We conducted the first study of four established Australian ACT teams, examining team composition, processes and model fidelity, using previously validated questionnaires. Demographic and clinical details of patients and their own experiences of ACT were gathered from staff. Associations between burnout and work experiences were examined. All teams were ACT-like (mean DACTS score = 3.7, SD = 0.3) with few significant patient differences between teams, except diagnosis (schizophrenia 61-93%, co-morbid substance abuse 16-33%) and proportion living alone (23-72%). Clinicians were fairly satisfied, but inter-team differences in staffing profile and experience emerged and one team scored highly on emotional exhaustion. Increased burnout was associated with greater stress due to taking a team approach. Inter-team differences suggested that attention to effective team working and leadership, as well as model fidelity, may be warranted.

Global public health policies span national borders and affect multitudes of people. The spread of infectious disease has neither political nor economic boundaries, and when elevated to a status of pandemic proportions, immediate action is required. In federal systems of government, the national level leads the policy formation and implementation process, but also collaborates with supranational organisations as part of the global health network. Likewise, the national level of government cooperates with sub-national governments located in both urban and rural areas. Rural areas, particularly in less developed countries, tend to have higher poverty rates and lack the benefits of proper medical facilities, communication modes and technology to prevent the spread of disease. From the perspective of epidemiological surveillance and intervention, this article will examine federal health policies in three federal systems: Australia, Malaysia and the USA. Using the theoretical foundations of collaborative federalism, this article specifically examines how collaborative arrangements and interactions among governmental and non-governmental actors help to address the inherent discrepancies that exist between policy implementation and reactions to outbreaks in urban and rural areas. This is considered in the context of the recent H1N1 influenza pandemic, which spread significantly across the globe in 2009 and is now in what has been termed the 'post-pandemic era'.

OUR PROBLEM: The length of wait lists to access specialist clinics in the public system is problematic for Queensland Health, general practitioners and patients. To address this issue at The Townsville Hospital, the GP Liaison Officer, GPs and hospital staff including specialists, collaborated to develop a process to review patients waiting longer than two years. GPs frequently send referrals to public hospital specialist clinics. Once received, referrals are triaged to Category A, B or C depending on clinical criteria resulting in appointment timeframes of 30, 90 or 365 days for each category, respectively. However, hospitals often fail to meet these targets, creating a long wait list. These wait listed patients are only likely to be seen if their condition deteriorates and an updated referral upgrades them to Category A. PROCESS TO ADDRESS THE PROBLEM: A letter sent to long wait patients offered two options 1) take no action if the appointment was no longer required or 2) visit their GP to update their referral on a clinic specific template if they felt the referral was still required. Local GPs were advised of the trial and provided education on the new template and minimum data required for specialist referrals. WHAT HAPPENED: In 2008, 872 letters were sent to long wait orthopaedic patients and 101 responded. All respondents were seen at specially arranged clinics. Of these, 16 patients required procedures and the others were discharged. In 2009 the process was conducted in the specialties of orthopaedics, ENT, neurosurgery, urology, and general surgery. Via this new process 6885 patients have been contacted, 633 patients have been seen by public hospital specialists at specially arranged clinics and 197 have required a procedure. LEARNINGS: Since the start of this process in 2008, the wait time to access a specialist appointment has reduced from eight to two years. The process described here is achievable across a range of specialties, deliverable within the routine of the referral centre and identifies the small number of people on the long wait list in need of a procedure.

Background: Between 2007 and 2009, Australian general practitioners (GPs) were involved in implementing a population-based human papillomavirus (HPV) vaccination program. We investigated GPs' experiences of delivering the HPV vaccine to women aged 18-26., Methods: We posted a survey to 1000 GPs. The survey was informed by 12 domains incorporating constructs from psychological theories that focus on individual and environmental barriers and facilitators to effective implementation of evidence-based practice by health professionals., Results: The response rate was 32%. The 298 vaccinating GPs were positive about HPV vaccine implementation as part of their professional role as a worthwhile initiative within existing general practice infrastructure. They had more negative views about some aspects of program organisation, such as the timelines and potential adverse impacts on cervical screening rates. Vaccine safety was not a key concern. Actual levels of knowledge about HPV were moderate (mean score 3.41 out of 6 (s.d. 0.99)) and contrasted with self-rated knowledge, which was high (93% perceived their knowledge to be adequate). Notably, there were unrealistic expectations about the likely reduction in Pap abnormalities due to vaccination, which is important to clarify to avoid loss of confidence in the vaccine when this reduction does not eventuate., Conclusions: Australian GPs viewed HPV vaccination of women aged 18-26 years as an integrated part of their routine practice, with positive attitudes regarding its benefits and achievability. GPs are well placed to implement mass immunisation programs as long as they are supported by effective and timely communication strategies and resources.

Organisational change aimed at service improvement continues to be a challenging process for many health services, managers and teams. Current imperatives to develop service models responsive to the growing demands of chronic conditions on health systems suggest that reflection on core change principles is warranted.

Background: The success of guidelines is determined by their use in the real world. The GuideLine Implementability Appraisal (GLIA) tool was developed as a quality-improvement tool to assist guideline developers and guideline users identify potential problems in implementing recommendations. The objective of this study was to assess the feasibility of using the electronic version of GLIA (eGLIA) by implementers of a clinical guideline for acute stroke management in Australia., Methods: Health professionals who had no previous experience with the eGLIA tool but who are involved in implementing guidelines volunteered for the study. These health professionals were provided background information about the tool and were provided a short training session (<30 min). The participants were asked to consider at least two recommendations from the guideline document. Time spent, numbers of recommendations reviewed and subjective feedback of the process were used for evaluation., Results: 40 participants completed the study, representing nursing and allied health professions from different geographical regions of Australia. The median number of recommendations per participant completed was 2 (range 2-10), taking an average of 47 min (range 15-120 min) to complete or about 22 min per recommendation. Ninety-four per cent of participants agreed or strongly agreed that eGLIA was useful, while 77% indicated they would use the tool again. eGLIA helped participants think systematically about implementation, although only 72% agreed that the tool allowed them to clearly identify potential barriers to implementation., Conclusion: This study suggests that eGLIA may be a useful tool which is relatively easy to use for implementers of guidelines. eGLIA enables a detailed, systematic evaluation of guidelines. Further refinement of the tool is recommended to better assist implementers to clearly identify barriers to implementation and therefore facilitate greater implementation. Further work is also warranted to determine the effect of using eGLIA as part of an implementation strategy and if it improves health outcomes.

Background: Influenza A virus has a range of subtypes characterised by the display of particular surface structures and is associated with significant symptoms and a tendency to cause epidemics and pandemics., Objective: This article presents a checklist to assist general practitioners in preparing for an influenza pandemic., Discussion: The Australian Federal Government launched 'Exercise Cumpston' in October 2006 to assess Australian pandemic preparedness. The report of the outcomes recommends the integration of general practice into the planning process at a national and jurisdictional level. General practitioners are enthusiastic about receiving further information and training in pandemic preparedness but preparing a general practice to deal with an influenza pandemic is a complex task.

A survey, which achieved a 54% response rate, was completed to assess the availability and type of rehabilitation health services in Australia. 1044 surveys were sent out and 561 were returned. The details of a total of 346 rehabilitation services were obtained. There were more services in metropolitan compared with rural areas, more services in New South Wales and Victoria than in the other states, and a higher proportion of services led by health care workers other than rehabilitation physicians in rural compared with metropolitan areas. There is likely to be a need for additional rehabilitation services of all types across Australia. The majority of rural, regional and remote areas are likely to need additional physician-led, allied health and nursing services. Further work is needed to assess the size and catchment areas of services in the capital cities and other large population centres to assess whether additional services are also needed in these areas.

The evaluation of the Sharing Health Care Initiative addressed the translation of different models of chronic disease self-management into health and community service contexts in Australia. Across seven projects, four intervention models were adopted: (1) the Stanford Chronic Disease Self Management course; (2) generic disease management planning, training and support; (3) tailored disease management planning, training and support, and; (4) telephone coaching. Targeted recruitment through support groups and patient lists was most successful for reaching high-needs clients. Projects with well developed organisational structures and health system networks demonstrated more effective implementation. Engagement of GPs in recruitment and client support was limited. Future self-management programs will require flexible delivery methods in the primary health care setting, involving practice nurses or the equivalent. After 12 months there was little evidence of potential sustainability, although structures such as consumer resource centres and client support clubs were established in some locations. Only one project was able to use Medicare chronic disease-related items to integrate self-management support into routine general practice. Participants in all projects showed improvements in self-management practices, but those receiving Model 3, flexible and tailored support, and Model 4, telephone coaching, reported the greatest benefits.

In Australia, many deaths and significant cardiac disability result from delayed response to symptoms of heart attack. Although delays due to transport and initiation of reperfusion therapy in hospital may contribute to late treatment, the major component of delay is the time patients take in deciding to seek help. A critical examination of campaigns to shorten patient delay concludes that they were based on a factual, short-term, non-targeted approach that included education and mass media strategies. They achieved equivocal results. One randomised controlled trial has been conducted. Although this showed an improved understanding of heart attack symptoms, it did not shorten pre-hospital delays. The implications of these findings are that future campaigns to shorten patient delay are likely to be more effective if they address the psychosocial and behavioural blocks to action, are ongoing rather than short term, and focus on people at highest risk, including those with known or high risk of coronary heart disease, those in rural locations, and Indigenous Australians. The National Heart Foundation of Australia proposes a comprehensive strategy to incorporate this approach into its future campaigns to reduce patient delay for suspected heart attack.

Issues: Evidence-based policy is promoted as the ideal in drug policy, yet public policy theorists suggest that policy-based evidence may be a more fitting analogy, where evidence is used selectively to support a predetermined policy direction. The following paper assesses the resonance of this notion to the development of the Illicit Drug Diversion Initiative (IDDI), an apparently pragmatic reform adopted in Australia in 1999 through the Federal Coalition 'Tough on Drugs' strategy. It utilises interviews with key informants from the Australian drug policy arena conducted in 2005 to assess the role of evidence in the design and implementation of the IDDI., Key Findings: The current paper shows that while policy-makers were generally supportive of the IDDI and viewed drug diversion as a more pragmatic response to drug users, they contend that implementation has suffered through a selective and variable emphasis upon evidence. Most notably, the IDDI is not premised upon best-practice objectives of reducing harm from drug use, but instead on 'Tough on Drugs' objectives of reducing drug use and crime., Implications: This paper contends that policy-based evidence may facilitate the adoption of pragmatic reforms, but reduce the capacity for effective reform. It therefore has both functional and dysfunctional elements. The paper concludes that greater attention is needed to understanding how to mesh political and pragmatic objectives, and hence to maximise the benefits from policy-based evidence.

There is a growing interest in Clinical Supervision (CS) as a central workforce development (WFD) strategy. This paper provides a definition of and rationale for CS, characterises its various forms, identifies selection and training issues, and advises on policy and implementation issues central to redressing shortcomings in supervision practice within the alcohol and other drugs (AOD) field. Relevant selective literature is reviewed. Key conceptual issues were identified, and strategies developed to address implementation barriers and facilitate relevant policy. There is a common conceptual confusion between administrative supervision and CS. Clarification of the role, function and implementation of CS is required. Priority issues for the AOD field include: enhancing belief in CS; ensuring adequate resource allocation; developing evaluation protocols; and addressing specific arrangements under which supervision should occur. CS has been underutilised to date but holds considerable potential as a WFD strategy. It is fundamental to workers' professional development, can contribute to worker satisfaction and retention, and may improve client outcomes. Critical next steps are to establish the generalisability to the AOD field of the benefits observed from CS in other disciplines, and evaluate longer-term gains of CS programs.

Objective: To determine if an evidence-based implementation (EBI) strategy could lead to the successful implementation of guidelines for the management of adult asthma in a large rural ED., Methods: This was a pre- and post-intervention trial, comparing data for seven clinical indicators from a study hospital and a control hospital. Retrospective pre-intervention audits were conducted at the study hospital for 3 months (1 April-30 June 2004) and the control hospital for 4 months (1 March-30 June 2004). The effect of an EBI to implement established guidelines for the management of asthma at the study hospital was compared with the effect of a mail-out of guideline booklets and wall charts to the control hospital. Post-intervention audits were then performed at both hospitals. Sustainability of the EBI was gauged by 12 month follow-up data at the study hospital., Results: There were 55 presentations of adult asthma at the study hospital in the pre-intervention phase and 67 post-intervention. The corresponding numbers for the control hospital were 51 and 42, respectively. Following the EBI there were significant improvements at the study hospital for the documentation of severity (27-99%, P < 0.01), use of spirometry (38-84%, P < 0.01), medication delivery via spacer device (0-26%, P < 0.01), use of systemic steroids (66-84%P < 0.05), use of written short-term asthma plans (14-82%, P < 0.01), reduction of ipratropium use in mild asthma (43-16%, P < 0.05) and reduction in antibiotic use in afebrile asthmatics (37-6%, P < 0.01). For the control hospital there was a significant increase in spirometry use from 2% to 40% (P < 0.01). For seven clinical indicators combined, compliance with the guideline increased from 38% to 79.1% (P < 0.01) at the study hospital, whereas there was no change at the control hospital, 44.3% to 43% (P = 0.75) There were 68 presentations at 12 month follow up at the study hospital and compliance with the seven clinical indicators was 78.2%., Conclusion: An EBI significantly improved compliance at the study hospital with no improvement noted in the control hospital. These improvements were maintained at 12 month follow up. An EBI can lead to significant improvements in the management of asthma at a large rural referral hospital ED and might have implications for hospitals with similar roles and profiles.

We propose the formation of evidence-based clinical practice support units in hospitals and clinical research implementation networks. The purpose of these initiatives will be to increase the uptake of beneficial forms of care and remove harmful or ineffective practices. They will bring together clinicians and other professionals to improve clinical care across the healthcare system.

Traditional approaches to disseminating research findings have failed to achieve optimal healthcare. In a systematic review of 235 studies of guideline dissemination and implementation strategies, we observed the following: there was a median 10% improvement across studies, suggesting that it is possible to change healthcare provider behaviour and improve quality of care; most dissemination and implementation strategies resulted in small to moderate improvements in care; multifaceted interventions did not appear more effective than single interventions. The interpretation of our systematic review is hindered by the lack of a robust theoretical base for understanding healthcare provider and organisational behaviour. Future research is required to develop a better theoretical base and to evaluate further guideline dissemination and implementation strategies.

There are internationally agreed optimal methods for developing clinical practice guidelines. The quality of published guidelines varies. A validated assessment instrument should be used to identify well developed guidelines that can be used with confidence. There are multiple ways of presenting guidelines, including computerised systems. Computerisation of guidelines can cover a range of formats, from brief prompts through to complex decision-support systems. Integrating guidelines into computerised reminder systems has been shown to be effective in improving patient care, but there is less evidence to support the effectiveness of guidelines integrated into computerised decision-support systems.