Improving rural and regional access to long-acting reversible contraception and medical abortion through nurse-led models of care, task-sharing and telehealth (ORIENT): a protocol for a stepped-wedge pragmatic cluster-randomised controlled trial in Australian general practice.

INTRODUCTION: Women living in rural and regional Australia often experience difficulties in accessing long-acting reversible contraception (LARC) and medical abortion services. Nurse-led models of care can improve access to these services but have not been evaluated in Australian general practice. The primary aim of the ORIENT trial (ImprOving Rural and regIonal accEss to long acting reversible contraceptioN and medical abortion through nurse-led models of care, Tasksharing and telehealth) is to assess the effectiveness of a nurse-led model of care in general practice at increasing uptake of LARC and improving access to medical abortion in rural and regional areas. METHODS AND ANALYSIS: ORIENT is a stepped-wedge pragmatic cluster-randomised controlled trial. We will enrol 32 general practices (clusters) in rural or regional Australia, that have at least two general practitioners, one practice nurse and one practice manager. The nurse-led model of care (the intervention) will be codesigned with key women's health stakeholders. Clusters will be randomised to implement the model sequentially, with the comparator being usual care. Clusters will receive implementation support through clinical upskilling, educational outreach and engagement in an online community of practice. The primary outcome is the change in the rate of LARC prescribing comparing control and intervention phases; secondary outcomes include change in the rate of medical abortion prescribing and provision of related telehealth services. A within-trial economic analysis will determine the relative costs and benefits of the model on the prescribing rates of LARC and medical abortion compared with usual care. A realist evaluation will provide contextual information regarding model implementation informing considerations for scale-up. Supporting nurses to work to their full scope of practice has the potential to increase LARC and medical abortion access in rural and regional Australia. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Monash University Human Research Ethics Committee (Project ID: 29476). Findings will be disseminated via multiple avenues including a knowledge exchange workshop, policy briefs, conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000086763).

Nurse-led service delivery models in primary care: a scoping review protocol.

BACKGROUND: Ensuring equitable access to health care is reliant on the strengthening of primary care services. Increasing the utilisation of task-sharing and telehealth models is one strategy to improve patient access and outcomes in primary care. This protocol details the methodology of a proposed scoping review of nurse and midwife involvement in task-sharing and telehealth models in primary care. AIM: To identify what task-sharing and telehealth models have been utilised in the primary care setting globally, and to capture the characteristics and health and economic outcomes of the models, and whether they are acceptable and feasible. DESIGN & SETTING: This protocol was developed in line with the Joanna Briggs Institute (JBI) methodology for scoping reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA-P). METHOD: Five databases (Ovid MEDLINE, Embase, PubMed, Cumulative Index to Nursing and Allied Health Literature [CINAHL] and Cochrane Library) will be searched for relevant studies published in English. Articles will be screened for inclusion in Covidence by three authors, with data extracted and synthesised using a chart designed for this review. Evidence will be mapped in both tabular and narrative forms to show characteristics, outcomes, and acceptability of the models of care. CONCLUSION: Understanding how nurse- and midwife-led models of care may operate is crucial to strengthening service provision in primary care. Evidence on nurse and midwife-led primary care models will be collated and synthesised to inform future models.

COVID-19 and access to sexual and reproductive healthcare for young people

[...]the incidence of COVID-19 is lower in children than adults,1 and the prevalence of severe disease is lower among children than adults.2-4 Furthermore, medium-term sequelae (four months) have proven rare among children who recover from COVID-19,5 and their case fatality rate is also lower than that of adults.4 The World Health Organization (WHO) defines adolescents as individuals aged between 10 and 19 years;however, research often focuses on young people, defined as people under the age of 25 years.6 SRH covers services that promote sexual wellbeing and reproductive health, and prevent and treat sexually transmissible infections (STIs) and blood-borne viruses (BBVs). Adolescence and young adulthood are risky times for the development of mental health problems, with most disorders commencing during this time;however, diagnosis may occur later if healthcare access is limited.12 Young people are often reluctant to seek help, particularly if services are not specifically designed for young people.13 Young people with poor mental health have higher rates of physical health problems, including those related to SRH.12 This makes access to appropriate, high-quality mental healthcare for young people critical for maintaining their SRH. Results Sexual and reproductive wellbeing of young people during the COVID-19 pandemic In an Australian survey during lockdown (66.3% respondents aged 18-29 years), the frequency of sex with a partner varied depending on cohabitation, with the survey suggesting fewer casual partners and less group sex, while use of sex toys and masturbation increased.15 Some women also reported delaying childbearing because of the pandemic.16 Surveys from China reported reduced frequency of sex,17 reduced number of partners,17 increased relationship dissatisfaction18 and increased use of pornography.18 This is likely due to lockdown conditions and the high number of young people who live with their parents.17'18 A US survey of sexual minority males aged 14-17 years mirrored this finding, with online sexting and messaging becoming more common.19 This contrasted with data from African nations, where pockets of increased sexual activity20 led to increases in teenage pregnancy.21 School closures have been implicated with less visibility of children and increased potential for abuse from family and neighbours.21 One article highlighted the potential longer-term reduction in sexual wellbeing, with young people having reduced 'normative experiences' due to lockdown and increased parental scrutiny.22 The authors suggested increasing focus on young people in post-lockdown periods to ensure their sexual wellbeing.22 Access to sexual and reproductive healthcare during COVID-19 In Australia and internationally, SRH - including access to contraception and abortion services, STI screening and treatment, and HIV care - is recognised as an essential service during the COVID-19 pandemic.23-25 Despite this recognition, a rapid survey of 64 nations found services were scaled back across all nations and 5633 SRH clinics closed;26 2 7 00 young people from Africa reported reductions in access to SRH services due to clinic closures and fear of contracting COVID-19.20 As a result, contraception, HIV care, abortion services and comprehensive sexuality education (including menstrual education)20 for youth have been affected.26 A semi-rural area in the UK saw no people aged under 18 years access emergency contraception for six weeks, and there was a fall in accessing other sexual health services, especially for those aged under 18 years.27 This may be appropriate (eg a result of reduced intimacy18'22'27) or inappropriate (eg a consequence of disruption to public transport).28 The review also highlighted that young people may feel judged if they have broken lockdown restrictions and then need SRH.27 Few articles were focused on SRH within a generalist setting, such as general practice, so issues such as opportunistic preventive healthcare, cervical screening and general healthcare were not discussed. In the setting of SRH, telehealth can be used for contraception,10'25'29-33 STI screening,27'34 syndromic management of STIs28'33 and medical abortion.17'23'24'27'30'32'35 However, challenges to providing SRH via telehealth included: * maintaining confidentiality and privacy;especially for young people in crowded housing during lockdown conditions22,27 * providing culturally appropriate care22 * examining sensitive body parts33 * institutional support to implement telehealth, including appropriate funding and access to technology.33 Telehealth is also more difficult for those without access to a device and for individuals with poor internet access.22'31'33 Suggestions for overcoming these barriers are outlined in Table 1.

COVID-19 and access to sexual and reproductive healthcare for young people: An overview of the international literature and policy.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic has reduced the ability of young people to access appropriate and timely sexual and reproductive healthcare (SRH). The aim of this study was to summarise international innovations aimed at ensuring ongoing access. METHOD: This study was an overview of peer­reviewed literature and policy statements from international and national organisations related to SRH for young people during COVID-19. RESULTS: Innovations have focused on improving access to appropriate and timely SRH for young people, mostly through telehealth; increasing community and healthcare worker awareness of the heightened risk of gender-based violence and its consequences; and removing restrictions on contraception and abortion access. Despite this, a substantial decline in sexual wellbeing and SRH access has been reported from many parts of the world, although Australian data are lacking. DISCUSSION: Support for young people to access timely and appropriate SRH during the COVID-19 pandemic should be a priority for policymakers around the world.

Scoping review of pharmacy-based initiatives for preventing unintended pregnancy: protocol.

INTRODUCTION: Due to a high global incidence of unintended pregnancy, finding novel ways to increase the accessibility of contraceptive products and information is critical. One proposed strategy is to use the accessibility of community pharmacies and expand the role of pharmacists to deliver these services. This protocol reports the methods of a proposed scoping review of pharmacy-based initiatives for preventing unintended pregnancy. We intend to identify the range of interventions employed by pharmacists worldwide and their outcomes and aim to infer the value of task sharing for reducing certain access and equity barriers to contraception. METHODS AND ANALYSIS: This protocol was developed with guidance from the Joanna Briggs Institute Methodology for Scoping Reviews. Reporting is compliant with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocols. The scoping review will be reported according to the PRISMA Extension for Scoping Reviews. Seven electronic databases (PubMed, Ovid Medline, Embase, Cochrane Library, Scopus and Cumulative Index to Nursing and Allied Health Literature) were systematically searched for relevant literature published in English from 2000, on 22 August 2019. Two authors will individually screen articles for eligibility in Covidence and data will be charted and reported using a tool developed for the purpose of this review. ETHICS AND DISSEMINATION: Findings will be disseminated in publications and presentations with relevant stakeholders. Ethical approval is not required as we will be using data from publicly available literature sources. We will map available evidence across the breadth of studies that have been conducted and identify the effectiveness and acceptability of interventions.