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Outbreaks of COVID-19 in a small number of aged care facilities in Australia had devastating mortality ratios. Strict infection control measures were implemented with little time to adapt. This study explored the views and experiences of residents, families, and care providers about the preparation for COVID-19 and identified areas for improvement. Twenty-one individual interviews were conducted. Using interpretative phenomenological analysis, we found rapid changes to visiting and activities, with physical and emotional impact. Some participants coped using personal resources. Family and residents valued the empathy and quality care provided, despite the overburdened workforce. Good leadership supported implementation of public health advice, but the severity of measures should be proportionate to local risk. Better pandemic planning that includes clear responsibilities, training, and evaluation is important. Consultation with residents, family, and health workers throughout a pandemic will help identify those most at risk of social isolation and physical decline and develop strategies to minimize their impact. The rights and welfare of residents must be respected at all times.

Objective: Community leadership enhances collective action in times of uncertainty, such as during the coronavirus disease (COVID-19) pandemic. This study explores the role of leadership related to the COVID-19 response and information sharing among a newly emerging Congolese community in the Hunter New England region of Australia. Methods: Semi-structured qualitative inquiry was used to interview four participants who were identified as being influential leaders of the local Congolese community. The findings of this study were part of a larger exploration of COVID-19 messaging among emerging culturally and linguistically diverse (CALD) communities. Two interviewers independently analysed the transcribed data before pairing their findings. Narrative analysis was employed. Results: Two major themes were identified: leadership as an assigned and trusted role, and leadership as a continuous responsibility. Several categories were identified within these themes, such as mutual connection, education level, multilingual ability and networking. Discussion: The Congolese community leaders reported feeling responsible and confident in their ability to proactively contribute to the local COVID-19 response by enhancing communication within the community. By partnering with and learning from respected leaders in CALD communities, government health services have the opportunity to improve how current public health messaging is developed.

Background Physiotherapists deliver evidence-based guideline recommended treatments only half of the time to patients with musculoskeletal conditions. Physiotherapist’s behaviours in clinical practice are influenced by many cognitive, social and environmental factors including time and financial pressures. Many initiatives aimed at improving physiotherapists’ uptake of evidence-based care have failed to appreciate the context involved in clinical decisions and clinical practice. Therefore, we aimed to describe: i) the opinions of regional physiotherapists toward evidence in relation to their clinical decision making; ii) how regional physiotherapists access evidence; iii) the factors influencing regional physiotherapists’ evidence access; iv) the factors influencing regional physiotherapists’ evidence application.MethodsWe used a mixed-methods study with online survey and focus groups. Quantitative and qualitative data were used to inform all research objectives. We used eight domains of the Transtheoretical Domains Framework to design survey questions. We analysed quantitative and qualitative data in parallel, then integrated both sources through by developing a matrix while considering the Transtheoretical Domains Framework domains to generate themes. Results57 physiotherapists participated in the study (survey only n = 41; focus group only n = 8; both survey and focus group n = 8). Participants reported that evidence was important, but they also considered patient expectations, colleagues’ treatment choices, and business demands in clinical decision making. Physiotherapists reported they access evidence on average 30 minutes or less per week. Accessing evidence may not be prioritised among competing demands like business administration. Participants reported that patient expectations were a major barrier to applying evidence-based care. Environmental and systemic factors, like funding structures or incentives for evidence-based care, and social factors, like lacking or having a culture of accountability and mentorship, were reported as both barriers and enablers to evidence application.ConclusionsIn this study, we provide a description of contextual considerations for the provision of evidence-based care and suggest some potentially modifiable targets for future strategies aimed at improving evidence uptake. Physiotherapist’s provision of evidence-based care may be improved by enhancing structural support from workplaces to access and apply evidence and exploring discrepancies between physiotherapists’ perceptions of patient expectations and actual patient expectations.

Issue addressed Modifying the scheduling of physical activity opportunities to provide children with more frequent opportunities for outdoor free play has been demonstrated to increase child physical activity while in care. The primary aim of this study was to describe the implementation of continuous free play schedules to allow children to access outdoor play areas, consistent with sector guidelines in a national sample of Australian childcare services. Secondary aims were to investigate the associations between the implementation of such schedules and service characteristics, and assess the perceived barriers and enablers to implementation. Methods A cross-sectional study was undertaken with a random sample of 326 centre-based childcare services located across Australia. Childcare service characteristics, continuous free play scheduling and perceived barriers and enablers to implementation were assessed via a survey administered to service managers online or via telephone. Results A total of 203 service managers (62%) reported implementing a continuous free play schedule, for three periods of 126 minutes per period, each day on average. Service type (long day care services), size (services with higher numbers of child enrolments [≥80 children]) and socio-economic area (services located in lower socio-economic areas) were associated with the implementation of a continuous free play schedule. The most prevalent barriers to implementation included insufficient staff to ensure adequate supervision of children (69%) and service layout being unsuitable (65%), while the most prevalent enablers included advice on how to overcome staffing or supervision issues (89%) and to re-orientate the service layout (54%). Conclusions There is scope to support the implementation of continuous free play schedules consistent with childcare sector guidelines. SO WHAT?: Future intervention research that targets the reported barriers and enablers to implementation is needed.

Background Repeated, data-driven optimisation processes have been applied in many fields to rapidly transform the performance of products, processes and interventions. While such processes may similarly be employed to enhance the impact of public health initiatives, optimisation has not been defined in the context of public health and there has been little exploration of its key concepts. Methods We used a modified, three-round Delphi study with an international group of researchers, public health policy-makers and practitioners to (1) generate a consensus-based definition of optimisation in the context of public health and (2i) describe key considerations for optimisation in that context. A pre-workshop literature review and elicitation of participant views regarding optimisation in public health (round 1) were followed by a daylong workshop and facilitated face-to-face group discussions to refine the definition and generate key considerations (round 2); finally, post-workshop discussions were undertaken to refine and finalise the findings (round 3). A thematic analysis was performed at each round. Study findings reflect an iterative consultation process with study participants. Results Thirty of 33 invited individuals (91%) participated in the study. Participants reached consensus on the following definition of optimisation in public health: “A deliberate, iterative and data-driven process to improve a health intervention and/or its implementation to meet stakeholder-defined public health impacts within resource constraints”. A range of optimisation considerations were explored. Optimisation was considered most suitable when existing public health initiatives are not sufficiently effective, meaningful improvements from an optimisation process are anticipated, quality data to assess impacts are routinely available, and there are stable and ongoing resources to support it. Participants believed optimisation could be applied to improve the impacts of an intervention, an implementation strategy or both, on outcomes valued by stakeholders or end users. While optimisation processes were thought to be facilitated by an understanding of the mechanisms of an intervention or implementation strategy, no agreement was reached regarding the best approach to inform decisions about modifications to improve impact. Conclusions The study findings provide a strong basis for future research to explore the potential impact of optimisation in the field of public health.

Background: Childhood immunisation is a safe and effective way to protect children and communities from serious diseases. In Australia childhood immunisation is generally well accepted with high coverage rates however pockets of low coverage exist. Five previous studies in New South Wales found that socio-economic disadvantage, gender inequity, health service access barriers and under-utilisation of immunisation data, rather than ideological opposition, contributed to children’s incomplete vaccination. Methods: Common findings across five studies were identified. Literature was reviewed using a number of lenses, underpinned by a social determinants of health framework. The lensed approach allowed further exploration of the impact of financial stress, poor mental health, drug and alcohol problems, domestic violence, assumed gender roles, lack of culturally acceptable health care for Indigenous families, geography and changes to immunisation policies on families and how this may have contributed to pockets of low immunisation coverage. Results: Social and structural inequities were revealed. These often contributed to conflicting priorities that meant children’s immunisations fell behind. Strategies to address inequities may include reorientation of existing community based child health services to include flexible options such as drop in clinics, outreach services, home visiting and ensuring Indigenous families have access to culturally safe and acceptable services. Assistance with transport would further improve access to services. Better use of immunisation data can aid in the identification of pockets of low coverage and monitor and evaluate service effectiveness. Conclusions: Greater awareness of social and structural barriers and their impact on families can inform the design of tailored strategies that address the needs of disadvantaged children and families. Without efforts to overcome the inequities that contribute to low immunisation coverage, the status quo persists, leaving children and communities at risk of vaccine preventable diseases.

Background: There is growing evidence that government health information related to COVID-19 has failed to adequately reach culturally and linguistically diverse (CALD) populations in Australia. People who were refugees are a unique sub-set of the CALD communities and are subject to numerous barriers preventing adequate health care, both pre- and post-migration. The barriers are accentuated during emergencies, such as a pandemic, as a result of an intersection of various social and economic inequalities. The recently resettled Ezidi refugee community in a regional area of Australia is an example of a community sitting at the intersection of various inequities and thus at greater risk from COVID-19. The purpose of this study is to describe the experiences of the Ezidi in a regional area with COVID-19 information and how this has been communicated to and shared within this group; what barriers the community may experience in accessing COVID-19 information; and how the government led COVID-19 information communication could be improved.Methods: This qualitative study was designed to explore the perceptions and views of the Ezidi and service providers regarding COVID-19 messaging. Working within a participatory framework the Multicultural and Refugee Health staff facilitated interviews with four local service providers and ten Ezidi community members, including seven influential leaders. Thematic analysis was employed across individual, pair and group data analysis. Similar categories were grouped into themes. Results: The main findings of the study are: the refugee experience influences the communication of COVID-19 messages; Cultural, social and gender norms influence responses to COVID-19; trusted individuals and service providers are key in community’s uptake of COVID-19 messages; currently available governmental COVID-19 information resources and sharing strategies were found unhelpful and inappropriate; COVID-19 communiqués and message delivery for this regional minority refugee community can be improved. Conclusion: The recently resettled Ezidi community, and likely other similar communities, would benefit from tailored engagement by government organisations, as well as settlement services to improve the communication of COVID-19 health information and reduce related inequities.

Background There is growing evidence that government health information related to COVID-19 has failed to adequately reach culturally and linguistically diverse (CALD) populations in Australia. Refugees are a unique sub-set of the CALD communities and are subject to numerous barriers preventing adequate health care, both pre- and post-migration. The barriers are accentuated during emergencies, such as a pandemic, as a result of an intersection of various social and economic inequalities. The recently resettled Ezidi refugee community in a regional area of Australia is an example of a community sitting at the intersection of various inequities and thus at greater risk from COVID-19. The purpose of this study is to describe the experiences of the Ezidi in a regional area with COVID-19 information and how this has been communicated to and shared within this group; what barriers the community may experience in accessing COVID-19 information; and how the government-led COVID-19 information communication could be improved. Methods This qualitative study was designed to explore the perceptions and views of the Ezidi and service providers regarding COVID-19 messaging. Multicultural and Refugee Health staff facilitated interviews with four local service providers and ten Ezidi community members, including seven influential leaders. Thematic analysis was employed across individual, pair and group data analysis. Similar categories were grouped into themes. Results The main findings of the study are: the refugee experience influences the communication of COVID-19 messages; cultural, social and gender norms influence responses to COVID-19; trusted individuals and service providers are key in communities’ uptake of COVID-19 messages; currently available governmental COVID-19 information resources and sharing strategies were found unhelpful and inappropriate; COVID-19 communiqués and message delivery for this regional minority refugee community can be improved. Conclusion The recently resettled Ezidi community, and likely other similar communities, would benefit from tailored engagement by government organisations, as well as settlement services to improve the communication of COVID-19 health information and reduce related inequities.

Objective To identify and explore ED clinician perspectives on: (i) why patients with low back pain (LBP) present to the ED and are admitted into hospital from ED; (ii) barriers and enablers they face when providing care to patients with LBP; and (iii) strategies to improve the care of patients with LBP, and associated care processes, in the ED. Methods We undertook a qualitative exploratory study with ED clinicians (medical officers, nurses and physiotherapists) at a tertiary-level public hospital in New South Wales, Australia, using focus groups and individual interviews. We used thematic analysis to synthesise participant responses to answer the predefined research questions. Results Twenty-one clinicians participated (two individual interviews, 19 focus groups). Perceptions about better access to the ED and advanced care within ED were thought to drive presentations to the ED for LBP. Barriers and enablers to optimal patient care included patient-, clinician- and service-level factors. The main strategies to improve care included a department LBP pathway, modernised patient and clinician resources, better follow-up options post-discharge and improved communication between ED and primary care. Conclusion We identified a range of targets to improve LBP management in ED. Clinicians perceived internal and external factors to the ED as influences of ED presentation and hospital admission. Clinicians also reported that patient-, clinician- and service-level barriers and enablers influenced patient management in ED. Strategies suggested by clinicians included improved follow-up options, access to resources and an 'LBP pathway' to support decision making.

The 2019 coronavirus disease (COVID-19) pandemic has globally caused widespread disruption, morbidity and mortality. The uptake of COVID-19 vaccination is critical for minimising further impacts of the pandemic. Health and aged care workers (HACWs) play a central role in public confidence in vaccines and are one of the priority groups for COVID-19 vaccination in Australia. Qualitative phone interviews with 19 HACWs aged 21–50 years old from New South Wales, Australia, were conducted, and the data were analysed thematically in order to understand the factors influencing HACWs’ acceptance of COVID-19 vaccination. We found that HACWs reported a continuum of COVID-19 vaccination intentions with 12 enthusiastically accepting and 7 hesitant. Using the Behavioral and Social Drivers of COVID-19 Vaccination (BeSD) Framework, we found that participants’ acceptance of vaccination was primarily driven by their perceptions of COVID-19 vaccination (such as safety, risk and benefits) and by the information sources, people and norms they trusted. Informed by study findings, we propose several communication strategies which may be helpful in addressing HACWs vaccination acceptance. We note however that as the pandemic continues, further studies with HACWs from diverse backgrounds are needed in order to provide accurate data on diverse motivational and practical drivers of evolving perceptions and attitudes towards vaccination.

OBJECTIVES This study aimed to understand the reasons for childhood under-immunisation in Kempsey, New South Wales, among First Nations and non-First Nations families, and potential strategies to improve coverage. DESIGN The World Health Organization's Tailoring Immunization Programmes guide was employed. Tailoring Immunization Programmes uses social science, qualitative research methods and community participation and is underpinned by the Capabilities Opportunities Motivations-Behaviors (COM-B) theoretical model of behaviour change. A cultural lens was applied throughout the study design. Using a thematic analysis, factors found to influence childhood under-immunisation were loosely mapped against COM-B framework. SETTING Face-to-face interviews and focus groups conducted in locations and at times convenient to participants were audio-recorded and transcribed verbatim. PARTICIPANTS Fifty-six participants (25 First Nations and 13 non-First Nations mothers and grandmothers, and 18 health service respondent) took part in the study (July-October 2019). RESULTS Four themes were identified: (a) parents are supportive of immunisation and effective reminders would make it easier to prioritise it (b) services could be more accessible for families (c) addressing workforce shortages could improve access to immunisation services and (d) addressing entrenched racism in the community will help build cultural safety in health services. While parents in Kempsey were supportive of immunisation, resourceful and resilient, many struggled to overcome entrenched structural and cultural barriers to accessing services. This was particularly difficult for First Nations, socially disadvantaged and single mums. CONCLUSIONS Public health services can provide more support to those mothers and grandmothers who need it most, to ensure they are able to access immunisation services without delay.

Background As immunisation program launches have previously demonstrated, it is essential that careful planning occurs now to ensure the readiness of the public for a COVID-19 vaccine. As part of that process, this study aimed to understand the public perceptions regarding a future COVID-19 vaccine in Australia. Methods A national cross-sectional online survey of 1420 Australian adults (18 years and older) was undertaken between 18 and 24 March 2020. The statistical analysis of the data included univariate and multivariable logistic regression model analysis. Results Respondents generally held positive views towards vaccination. Eighty percent (n = 1143) agreed with the statement that getting myself vaccinated for COVID-19 would be a good way to protect myself against infection. Females (n = 614, 83%) were more likely to agree with the statement than males (n = 529, 78%) (aOR = 1.4 (95% CI: 1.1–1.8); P = 0.03), while 91% of those aged 70 years and above agreed compared to 76% of 18–29-year-olds (aOR = 2.3 (95% CI:1.2–4.1); P = 0.008). Agreement was also higher for those with a self-reported chronic disease (aOR = 1.4 (95% CI: 1.1–2.0); P = 0.04) and among those who held private health insurance (aOR = 1.7 (95% CI: 1.3–2.3); P Conclusion This study presents an early indication of public perceptions towards a future COVID-19 vaccine and represents a starting point for mapping vaccine perceptions. To support an effective launch of these new vaccines, governments need to use this time to understand the communities concerns and to identify the strategies that will support engagement.

BackgroundSince the emergence of SARS-CoV-2, the virus that causes coronavirus disease (COVID-19) in late 2019, communities have been required to rapidly adopt community mitigation strategies rarely used before, or only in limited settings. This study aimed to examine the attitudes and beliefs of Australian adults towards the COVID-19 pandemic, and willingness and capacity to engage with these mitigation measures. In addition, we aimed to explore the psychosocial and demographic factors that are associated with adoption of recommended hygiene-related and avoidance-related behaviors.MethodsA national cross-sectional online survey of 1420 Australian adults (18 years and older) was undertaken between the 18 and 24 March 2020. The statistical analysis of the data included univariate and multivariate logistic regression analysis.FindingsThe survey of 1420 respondents found 50% (710) of respondents felt COVID-19 would ‘somewhat’ affect their health if infected and 19% perceived their level of risk as high or very high. 84·9% had performed ≥1 of the three recommended hygiene-related behaviors and 93·4% performed ≥1 of six avoidance-related behaviors over the last one month. Adopting avoidance behaviors was associated with trust in government/authorities (aOR: 5·5, 95% CI 3-9·0), higher perceived rating of effectiveness of behaviors (aOR: 4·3, 95% CI: 2·8-6·9) and higher levels of perceived ability to adopt social distancing strategies (aOR: 1·8, 95% CI 1·1-3·0).InterpretationIn the last two months, members of the public have been inundated with messages about hygiene and social (physical) distancing. However, our results indicate that a continued focus on supporting community understanding of the rationale for these strategies, as well as instilling community confidence in their ability to adopt or sustain the recommendations is needed.FundingNone

Background While there is some guidance to support the adaptation of evidence-based public health interventions, little is known about adaptation in practice and how to best support public health practitioners in its operationalization. This study explored public health researchers’ and practitioners’ views on available adaptation frameworks, identified potential improvements to increase the application of such guidance and identified opportunities to advance the adaptation literature to improve implementation of public health initiatives and achieve public health outcomes. Methods This qualitative study was undertaken with researchers, methodologists, policy makers and practitioners representing various public health expert organizations and universities internationally. Participants attended a face to face workshop in Newcastle, Australia in October 2018 where structured facilitated focus group discussions and small group activities were undertaken. Two qualitative methods - World Café and Appreciative Inquiry - were used to explore participants’ experiences of and opinions about adaptation frameworks, and to elicit suggestions for practical, detailed solutions to address identified gaps. Results Participants reported a number of limitations with current guidance including a lack of detail on ‘how’ to adapt, limited information on adaptation of implementation strategies and a number of structural issues with the wording and recommended order of adaptation framework elements. Participants noted that the generation of overarching principles that could be applied together with existing frameworks and/or related resources provides a practical way of supporting adaptation decisions in practice. Finally, participants identified a number of opportunities to further advance the field, including the building of an empirical evidence base on adaptation, advancing adaptation methods and developing data collection systems to capture adaptations. Conclusions This study provides an overview of expert views regarding existing frameworks for adaptation and their ability to be applied in practice. It identified a number of limitations, and suggests overarching principles to be applied when adapting public health initiatives.

In the Central Coast Local Health District of New South Wales, Australia, childhood immunisation (CI) rates are around 95%, but pockets of underimmunisation exist. Using the World Health Organization’s Tailoring Immunization Programmes, we identified areas of potential low vaccine coverage using Australian Immunisation Register (AIR) data (2016–18) and investigated factors that influence CI. Individual and group interviews with carers, community members and service providers (n=52 participants) were conducted. Data were analysed thematically and the themes presented to stakeholders for feedback before finalisation. During 2018, Umina had 218 children at least 1 month overdue for at least one vaccination. Five themes emerged: (1) broader socioeconomic factors may apply pressures that influence CI; (2) parents largely supported immunisation and knew of its benefits to their children and the community; (3) immunisation service providers are committed, experienced and collaborate with community partners; (4) there is potential to increase access to free immunisation services in Umina; and (5) AIR data and reminder systems could be better used to inform service delivery and prompt parents before immunisations are due. This study identified opportunities to improve CI coverage in Umina and new information useful in developing a tailored immunisation strategy. Awareness of the pressures socioeconomic factors may have on families could help plan and deliver supportive primary health care that includes equitable access to immunisation.

With advancements in highly effective anti-retroviral treatments (ART) to drastically reduce HIV transmission and facilitate healthy long-term living for HIV positive people (thereafter referred to as positive people), the perception of HIV has changed from a terminal to manageable illness. The prevailing policy discourse around HIV as a chronic manageable illness may not however represent the lived reality of people living long-term with HIV. For many, living with HIV means managing multiple comorbidities at the intersection of biologic, social and structural factors that requires resilience and ability to navigate various systems of support. Within neoliberal policies or reduced social spending and formal support services for the vulnerable populations, many positive people are left responsible for self-care. As a first generation of living with HIV long-term, they navigate uncharted waters, facing health and support needs which are not well understood. This PhD thesis examines the social context and the social processes implicated in living long-term with HIV in regional Queensland, Australia. It is embedded within an ongoing larger study Living Positive in Queensland, funded by the Australian Research Council, where up to 72 long-term positive people over the age of 35 from regional Queensland were interviewed annually over a period of three years (2013-16). It responds to the needs of the leading HIV organizations for a Queensland- specific research into the care and service needs of positive people who live regionally. Regional living comes with a set of additional challenges for positive people, yet there is virtually no research on the topic. For this PhD 32 long-term positive people (men and women) were interviewed annually over two years. Qualitative longitudinal research (QLR) methodology involving data analysis at each and across time points was employed to examine participants’ social practices on the continuum of care. Practices examined include adherence to treatment, forming and using social networks and social ties to manage everyday life, and caregiving. Analysis of the changing macro and regional health systems, policies and cultural paradigms provided a background within which participants’ practices were examined. Findings illustrate that regardless of the level of vulnerability, the sense of agency implicated in gaining control over one’s life was a driving force in participants’ social practices on the care continuum. For the most vulnerable participants, however, the persistent structural barriers experienced over time, exacerbated by regional living, have undermined their resilience and limited their choices. It was the historicized social connectedness (or lack thereof, social deprivation) that mediated the relationship between the complexities of aging with HIV regionally and an individual’s sense of support and wellbeing in a changing policy environment. It was the ability to receive as well as give care and support to others that was instrumental in people’s day-to-day management of chronic conditions and of their increasingly precarious living. Together these findings question the prevailing policy discourse around HIV and contribute to the bio-social perspective on what living with HIV entails. Informed by the findings I argue that achievements of state should be measured by how well the state meets its social goals such as fair distribution of health and well-being and equitable social participation. Policies in Queensland and Australia need to strengthen rather than limit the programmes which enable positive people to meet their social needs.