Building evidence into youth health policy: a case study of the Access 3 knowledge translation forum.

BACKGROUND: Effective integration of evidence and youth perspectives into policy is crucial for supporting the future health and well-being of young people. The aim of this project was to translate evidence from the Access 3 project to support development of a new state policy on youth health and well-being within New South Wales (NSW), Australia. Ensuring the active contribution of young people within policy development was a key objective of the knowledge translation (KT) process. METHODS: The KT activity consisted of a 1-day facilitated forum with 64 purposively sampled stakeholders. Participants included eight young people, 14 policy-makers, 15 academics, 22 clinicians or managers from NSW health services, four general practitioners and one mental health service worker. Research to be translated came from the synthesized findings of the NSW Access 3 project. The design of the forum included stakeholder presentations and group workshops, guided by the 2003 Lavis et al. KT framework that was improved by the Grimshaw et al. KT framework in 2012. Members of the Access 3 research team took on the role of knowledge brokers throughout the KT process. Participant satisfaction with the workshop was evaluated using a brief self-report survey. Policy uptake was determined through examination of the subsequent NSW Youth Health Framework 2017-2024. RESULTS: A total of 25 policy recommendations were established through the workshop, and these were grouped into six themes that broadly aligned with the synthesized findings from the Access 3 project. The six policy themes were (1) technology solutions, (2) integrated care and investment to build capacity, (3) adolescent health checks, (4) workforce, (5) youth participation and (6) youth health indicators. Forum members were asked to vote on the importance of individual recommendations. These policy recommendations were subsequently presented to the NSW Ministry of Health, with some evidence of policy uptake identified. The majority of participants rated the forum positively. CONCLUSIONS: The utilization of KT theories and active youth engagement led to the successful translation of research evidence and youth perspectives into NSW youth health policy. Future research should examine the implementation of policy arising from these KT efforts.

Two Distinct Gonorrhea Trends and Risk Factors Among Women in Australia.

BACKGROUND: In recent years, gonorrhea notifications have increased in women in Australia and other countries. We measured trends over time and risk factors among Australian Aboriginal and Torres Strait Islander ("Aboriginal") and non-Aboriginal women. METHODS: We conducted a cross-sectional analysis of data from 41 sexual health clinics. Gonorrhea positivity at each patient's first visit (first-test positivity) during the period 2009 to 2016 was calculated. Univariate and multivariate analyses assessed risk factors for first-test positivity in Aboriginal and non-Aboriginal women. RESULTS: Gonorrhea positivity decreased among Aboriginal women (7.1% in 2009 to 5.2% in 2016, P < 0.001) and increased among non-Aboriginal women (0.6%-2.9%, P < 0.001). Among Aboriginal women, first-test positivity was independently associated with living in a regional or remote area (adjusted odds ratio [aOR], 4.29; 95% confidence interval [CI], 2.52-7.31; P < 0.01) and chlamydia infection (aOR, 4.20; 95% CI,3.22-5.47; P < 0.01). Among non-Aboriginal women, first-test positivity was independently associated with greater socioeconomic disadvantage (second quartile: aOR, 1.68 [95% CI, 1.31-2.16; P < 0.01]; third quartile: aOR, 1.54 [95% CI, 1.25-1.89; P < 0.01]) compared with least disadvantaged quartile: recent sex work (aOR, 1.69; 95% CI, 1.37-2.08; P < 0.01), recent injecting drug use (aOR, 1.85; 95% CI, 1.34-2.57; P < 0.01), and chlamydia infection (aOR, 2.35; 95% CI, 1.90-2.91; P < 0.01). For non-Aboriginal women, being aged 16 to 19 years (aOR, 0.62; 95% CI, 0.49-0.80; P < 0.01) compared with those ≥30 years was a protective factor. CONCLUSIONS: These findings highlight 2 different epidemics and risk factors for Aboriginal and non-Aboriginal women, which can inform appropriate health promotion and clinical strategies.

Predictors of young people's healthcare access in the digital age.

OBJECTIVE: To quantify barriers to healthcare for young people (12-24 years) and identify socio-demographic correlates and predictors. METHODS: This cross-sectional survey targeted young people living in New South Wales, Australia, with oversampling of marginalised groups. Principles Component Analysis (PCA) identified clusters of barriers. Ordinal regression identified predictors of each barrier cluster. RESULTS: A total of 1,416 young people completed surveys. Participants with chronic conditions and increasing psychological distress reported a greater number of barriers. Of 11 potential barriers to visiting a health service, cost was most common (45.8%). The PCA identified three clusters: structural barriers (61.3%), attitudinal barriers (44.1%) and barriers relating to emerging autonomy (33.8%). CONCLUSIONS: Barriers to healthcare reported by young people are multi-dimensional and have changed over time. Structural barriers, especially cost, are the most prominent among young people. Approaches to overcome structural barriers need to be addressed to better support marginalised young people's healthcare access. Implications for public health: Understanding predictors of different barrier types can inform more targeted approaches to improving access. Equitable access to healthcare is a priority for early diagnosis and treatment in young people, especially reducing out of pocket costs.

Incomplete recording of Indigenous identification status under-estimates the prevalence of Indigenous population attending Australian general practices: a cross sectional study.

BACKGROUND: Australian Aboriginal and Torres Strait Islander (Indigenous) peoples face major health disadvantage across many conditions. Recording of patients' Indigenous status in general practice records supports equitable delivery of effective clinical services. National policy and accreditation standards mandate recording of Indigenous status in patient records, however for a large proportion of general practice patient records it remains incomplete. We assessed the completeness of Indigenous status in general practice patient records, and compared the patient self-reported Indigenous status to general practice medical records. METHODS: A cross sectional analysis of Indigenous status recorded at 95 Australian general practices, participating in the Australian Chlamydia Control Effectiveness Pilot (ACCEPt) in 2011. Demographic data were collected from medical records and patient surveys from 16 to 29 year old patients at general practices, and population composition from the 2011 Australian census. General practitioners (GPs) at the same practices were also surveyed. Completeness of Indigenous status in general practice patient records was measured with a 75% benchmark used in accreditation standards. Indigenous population composition from a patient self-reported survey was compared to Indigenous population composition in general practice records, and Australian census data. RESULTS: Indigenous status was complete in 56% (median 60%, IQR 7-81%) of general practice records for 109,970 patients aged 16-29 years, and Indigenous status was complete for 92.5% of the 3355 patients aged 16-29 years who completed the survey at the same clinics. The median proportion per clinic of patients identified as Indigenous was 0.9%, lower than the 1.8% from the patient surveys and the 1.7% in clinic postcodes (ABS). Correlations between the proportion of Indigenous people self-reporting in the patient survey (5.2%) compared to status recorded in all patient records (2.1%) showed a fair association (r = 0.6468; p < 0.01). After excluding unknown /missing data, correlations weakened. CONCLUSIONS: Incomplete Indigenous status records may under-estimate the true proportion of Indigenous people attending clinics but have higher association with self-reported status than estimates which exclude missing/unknown data. The reasons for incomplete Indigenous status recording in general practice should be explored so efforts to improve recording can be targeted and strengthened. TRIAL REGISTRATION: ACTRN12610000297022 . Registered 13th April 2010.

Influenza vaccination coverage in a population-based cohort of Australian-born Aboriginal and non-Indigenous older adults

Background: There is limited information on vaccination coverage and characteristics associated with vaccine uptake in Aboriginal and/or Torres Strait Islander adults. We aimed to provide more current estimates of influenza vaccination coverage in Aboriginal adults. Methods: Self-reported vaccination status (n=559 Aboriginal and/or Torres Strait Islander participants, n=80,655 non-Indigenous participants) from the 45 and Up Study, a large cohort of adults aged 45 years or older, was used to compare influenza vaccination coverage in Aboriginal and/or Torres Strait Islander adults with coverage in non-Indigenous adults. Results: Of Aboriginal and non-Indigenous respondents aged 49 to <65 years, age-standardised influenza coverage was respectively 45.2% (95% CI 39.5­50.9%) and 38.5%, (37.9­39.0%), p-value for heterogeneity=0.02. Coverage for Aboriginal and non-Indigenous respondents aged ≥65 years was respectively 67.3% (59.9­74.7%) and 72.6% (72.2­73.0%), p-heterogeneity=0.16. Among Aboriginal adults, coverage was higher in obese than in healthy weight participants (adjusted odds ratio (aOR)=2.38, 95%CI 1.44­3.94); in those aged <65 years with a medical risk factor than in those without medical risk factors (aOR=2.13, 1.37­3.30); and in those who rated their health as fair/poor compared to those who rated it excellent (aOR=2.57, 1.26­5.20). Similar associations were found among non-Indigenous adults. Conclusions: In this sample of adults ≥65 years, self-reported influenza vaccine coverage was not significantly different between Aboriginal and non-Indigenous adults whereas in those <65 years, coverage was higher among Aboriginal adults. Overall, coverage in the whole cohort was suboptimal. If these findings are replicated in other samples and in the Australian Immunisation Register, it suggests that measures to improve uptake, such as communication about the importance of influenza vaccine and more effective reminder systems, are needed among adults.

Health care equity and access for marginalised young people: a longitudinal qualitative study exploring health system navigation in Australia.

BACKGROUND: Young people have unique social, emotional and developmental needs that require a welcoming and responsive health system, and policies that support their access to health care. Those who are socially or culturally marginalised may face additional challenges in navigating health care, contributing to health inequity. The aim of this study was to understand health system navigation, including the role of technology, for young people belonging to one or more marginalised groups, in order to inform youth health policy in New South Wales, Australia. METHODS: This qualitative longitudinal study involved 2-4 interviews each over 6 to 12 months with marginalised young people aged 12-24 years living in NSW. The analysis used Nvivo software and grounded theory. RESULTS: We interviewed 41 young people at baseline who were living in rural or remote areas, sexuality and/or gender diverse, refugee, homeless, and/or Aboriginal. A retention rate of over 85% was achieved. Nineteen belonged to more than one marginalised group allowing an exploration of intersectionality. General practitioners (family physicians) were the most commonly accessed service throughout the study period. Participants were ambivalent about their healthcare journeys. Qualitative analysis identified five themes: 1. Technology brings opportunities to understand, connect and engage with services 2. Healthcare journeys are shaped by decisions weighing up convenience, engagement, effectiveness and affordability. 3. Marginalised young people perceive and experience multiple forms of discrimination leading to forgone care. 4. Multiple marginalisation makes health system navigation more challenging 5. The impact of health system complexity and fragmentation may be mitigated by system knowledge and navigation support CONCLUSIONS: The compounding effects of multiple discrimination and access barriers were experienced more strongly for young people belonging to mutiple marginalised groups. We identify several areas for improving clinical practice and policy. Integrating technology and social media into processes that facilitate access and navigation, providing respectful and welcoming services that recognise diversity, improving health literacy and involving professionals in advocacy and navigation support may help to address these issues.

Access 3 project protocol: young people and health system navigation in the digital age: a multifaceted, mixed methods study.

BACKGROUND: The integration of digital technology into everyday lives of young people has become widespread. It is not known whether and how technology influences barriers and facilitators to healthcare, and whether and how young people navigate between face-to-face and virtual healthcare. To provide new knowledge essential to policy and practice, we designed a study that would explore health system access and navigation in the digital age. The study objectives are to: (1) describe experiences of young people accessing and navigating the health system in New South Wales (NSW), Australia; (2) identify barriers and facilitators to healthcare for young people and how these vary between groups; (3) describe health system inefficiencies, particularly for young people who are marginalised; (4) provide policy-relevant knowledge translation of the research data. METHODS AND ANALYSIS: This mixed methods study has four parts, including: (1) a cross-sectional survey of young people (12-24 years) residing in NSW, Australia; (2) a longitudinal, qualitative study of a subsample of marginalised young people (defined as young people who: identify as Aboriginal and/or Torres Strait Islander; are experiencing homelessness; identify as sexuality and/or gender diverse; are of refugee or vulnerable migrant background; and/or live in rural or remote NSW); (3) interviews with professionals; (4) a knowledge translation forum. ETHICS AND DISSEMINATION: Ethics approvals were sought and granted. Data collection commenced in March 2016 and will continue until June 2017. This study will gather practice and policy-relevant intelligence about contemporary experiences of young people and health services, with a unique focus on five different groups of marginalised young people, documenting their experiences over time. Access 3 will explore navigation around all levels of the health system, determine whether digital technology is integrated into this, and if so how, and will translate findings into policy-relevant recommendations.

Trends in the prevalence of hepatitis B infection among women giving birth in New South Wales.

OBJECTIVES: To evaluate the effect of targeted and catch-up hepatitis B virus (HBV) vaccination programs in New South Wales on HBV prevalence among women giving birth for the first time. DESIGN: Observational study linking data from the NSW Perinatal Data Collection for women giving birth during 2000-2012 with HBV notifications in the NSW Notifiable Conditions Information Management System. MAIN OUTCOME MEASURES: HBV prevalence in Indigenous Australian, non-Indigenous Australian-born, and overseas-born women giving birth. RESULTS: Of 482 944 women who gave birth to their first child, 3383 (0.70%) were linked to an HBV notification. HBV prevalence was 1.95% (95% CI, 1.88-2.02%) among overseas-born women, 0.79% (95% CI, 0.63-0.95%) among Indigenous Australian women, and 0.11% (95% CI, 0.09-0.12%) among non-Indigenous Australian-born women. In Indigenous Australian women, prevalence was significantly lower for those who had been eligible for inclusion in the targeted at-risk newborn or universal school-based vaccination programs (maternal year of birth, 1992-1999: 0.15%) than for those who were not (born ≤ 1981: 1.31%; for trend, P < 0.001). There was no statistically significant downward trend among non-Indigenous Australian-born or overseas-born women. HBV prevalence was higher among Indigenous women residing in regional and remote areas than those in major cities (adjusted odds ratio [aOR], 2.23; 95% CI, 1.40-3.57), but lower for non-Indigenous (aOR, 0.39; 95% CI, 0.28-0.55) and overseas-born women (aOR, 0.61; 95% CI, 0.49-0.77). CONCLUSION: Among women giving birth, there was a significant reduction in HBV prevalence in Indigenous women associated with the introduction of the HBV vaccination program in NSW, although prevalence remains higher than among non-Indigenous Australian-born women, and it also varies by region of residence. Continuing evaluation is needed to ensure that the prevalence of HBV infections continues to fall in Australia.

Human papillomavirus vaccination and genital warts in young Indigenous Australians: national sentinel surveillance data.

OBJECTIVES: To examine the impact of the national human papillomavirus (HPV) vaccination program (available to girls and women [12-26 years] since 2007 and to boys [12-15 years] since 2013) on the number of diagnoses of genital warts in Australian Aboriginal and Torres Strait Islander (Indigenous) people. DESIGN, SETTING, PARTICIPANTS: Analysis of routinely collected data from patients attending 39 sexual health clinics (SHCs) in the Genital Warts Surveillance Network for the first time.Major outcome: The average annual proportion of Indigenous and non-Indigenous SHC patients diagnosed with genital warts during the pre-vaccination (2004-2007) and vaccination periods (2008-2014), stratified by age group and sex. RESULTS: 7.3% of the 215 599 Australian-born patients with known Indigenous status and seen for the first time at participating SHCs during 2004-2014 were Indigenous Australians. The average proportion of female Indigenous patients diagnosed with warts was lower during the vaccination period than during the pre-vaccination period (in those under 21, summary rate ratio [SRR], 0.12; 95% CI, 0.07-0.21; P < 0.001); in 21-30-year olds: SRR, 0.41; 95% CI, 0.27-0.61; P < 0.001); there was no significant difference for women over 30 (SRR, 0.84; 95% CI, 0.51-1.36; P = 0.47). The proportion of male Indigenous heterosexual SHC patients under 21 diagnosed with warts was also lower during the vaccination period (SRR, 0.25; 95% CI, 0.12-0.49; P < 0.001), with no significant changes among older Indigenous men over 30. CONCLUSIONS: There were marked declines in the proportions of diagnoses of genital warts in young Indigenous women and men attending SHCs after the introduction of the HPV vaccination program. If high levels of HPV vaccine coverage are sustained, HPV-related cancer rates should also decline.

Comparison of recording of hepatitis B infection in the NSW Perinatal Data Collection with linked hepatitis B notifications.

OBJECTIVE: Results of routine maternal antenatal hepatitis B (HBV) screening have been recorded in the New South Wales (NSW) Perinatal Data Collection (PDC) since January 2011. We evaluated the accuracy of this reporting in 2012, the first year that comprehensive data were available, by linking the PDC to HBV notifications. METHODS: PDC records of mothers giving birth in 2012 were probabilistically linked to HBV notifications recorded in the NSW Notifiable Conditions Information Management System (NCIMS). Sensitivity and specificity of the PDC record of HBV status were determined using a linked HBV notification from the NCIMS database as the gold standard. Results were also examined according to health service (area health service, hospital level, public or private) and individual factors (maternal age, country of birth, Aboriginality, parity, timing of first antenatal visit). RESULTS: Among 99 510 records of women giving birth in NSW in 2012, positive HBV status was recorded for 0.69% of the women according to the PDC record and 0.90% from linked NCIMS records. The overall sensitivity of the HBV status variable in the PDC data was 65.5% (95% confidence interval [CI] 62.4, 68.7) and positive predictive value was 85.3% (95% CI 82.6, 87.9). In general, the low prevalence of HBV meant we had limited statistical power to assess differences between health service factors and maternal factors; however, sensitivity was significantly lower in PDC data for HBV in Australian-born non-Aboriginal women (37.0%; 95% CI 27.5, 46.7) than in overseas-born women (69.9%; 95% CI 66.6, 73.1; p < 0.001). CONCLUSIONS: PDC records of HBV status for women giving birth in 2012 had high specificity but poor sensitivity. Sensitivity varied across area health services and levels of maternal services, and by various maternal factors. Because the results of maternal HBV screening can be used to monitor HBV prevalence in adults, analysis of the PDC records in subsequent years is necessary to track whether sensitivity improves over time.

Herpes Simplex Virus Type 1 Shedding in Tears and Nasal and Oral Mucosa of Healthy Adults.

BACKGROUND: Herpes simplex virus type 1 (HSV-1) is prevalent worldwide and causes mucocutaneous infections of the oral area. We aimed to define the frequency and anatomic distribution of HSV-1 reactivation in the facial area in persons with a history of oral herpes. METHODS: Eight immunocompetent HSV-1 seropositive adults were evaluated for shedding of HSV-1 from 12 separate orofacial sites (8 from oral mucosa, 2 from nose, and 2 from conjunctiva) 5 days a week and from the oral cavity 7 days a week for approximately 5 consecutive weeks by a HSV DNA PCR assay. Symptoms and lesions were recorded by participants. RESULTS: Herpes simplex virus type 1 was detected at least from 1 site on 77 (26.5%) of 291 days. The most frequent site of shedding was the oral mucosa, with widespread shedding throughout the oral cavity. Lesional shedding rate was 36.4% (4 of 11 days with lesions), and the asymptomatic rate was 27.1% (65 of 240 nonlesional days). In individual participants, the median rate of HSV shedding by HSV PCR was 19.7% of days (range, 11%-63%). CONCLUSIONS: Reactivation of HSV-1 on the oral mucosa is common and usually asymptomatic. However, HSV-1 is rarely found in tears and nasal mucosa. Frequent oral shedding of HSV-1 may increase the risk for transmitting the virus to both oral and genital mucosa of sexual partners.

Hepatitis C enhanced surveillance: results from a southeastern Sydney pilot program.

AIM: Hepatitis C virus (HCV) is a potentially serious bloodborne virus, which persists in the majority of those infected. Long-term sequelae include liver cirrhosis, liver cancer and premature death. Early identification of newly acquired infection is important for protection of public health. Routine surveillance based on laboratory notification of HCV infection is not sufficient to differentiate between newly acquired and chronic infections. Enhanced surveillance systems have been trialled globally in a number of settings. This pilot program aimed to increase identification of newly acquired HCV cases in southeastern Sydney residents and to ascertain the likely mode of transmission. METHODS: All HCV notifications in southeastern Sydney residents with specimen dates from 1 July to 31 December 2012 were included in a pilot program. Demographic data, Australian Indigenous identification and previous laboratory results were collected from electronic medical records, where available. Enhanced surveillance forms were sent to referring doctors to seek information about clinical symptoms and previous hepatitis C pathology. Data were collated to assess, according to Australian national case definitions, whether cases were newly acquired or not, or were unable to be determined on the available information. RESULTS: There were 104 notifications of HCV infection during the surveillance period. Forms were sent to 100 requesting doctors, with 72 forms returned. Six newly acquired cases were identified, a rate of 8%, compared with 1-3% classified by routine surveillance. Twenty cases (28%) were not newly acquired and the status of 46 (64%) was unable to be determined. Of the six newly acquired cases, sexual transmission was deemed to be the likely route of exposure for four cases, and injecting drug use for the remaining two. CONCLUSIONS: Enhanced surveillance increased the rate of identification of newly acquired infections. However, the process was labour-intensive and the status of most cases was unable to be determined. Since identification of newly acquired cases has an important public health benefit in understanding factors in disease transmission, other approaches should be examined.