The domino effect: adolescent girls' response to human papillomavirus vaccination.

OBJECTIVES: To examine the experience of fear, the fear response, and factors affecting fear in adolescents undergoing school-based human papillomavirus (HPV) vaccination. DESIGN, PARTICIPANTS AND SETTING: A purposive sampling strategy and qualitative methods, including observation and face-to-face interviews. Focus groups comprised adolescent girls who were involved in HPV vaccination in 2007 at schools in Sydney, New South Wales. Individual interviews were conducted with parents, teachers and vaccination nurses. RESULTS: Data from observing vaccination days at three schools and from interviewing 130 adolescents in 20 focus groups, 38 parents, 10 teachers and seven nurses were included in the analysis. All participants discussed the issue of fear and distress experienced by adolescent girls in relation to HPV vaccination. Observations corroborated the focus group and interview data. Our results indicated that fear was promoted by witnessing the fear reactions of peers; perceived judgement by peers; lack of information or misinformation; and being vaccinated later in the day. Fear was moderated by procedural factors, the support of peers, appropriate knowledge, and nurses' distraction techniques or approach. Fear also affected acceptance of HPV vaccination. CONCLUSIONS: Fear of HPV vaccination was a near universal experience among adolescents in the school setting and was often associated with significant distress that had an adverse impact on the vaccination process. School vaccination could be improved by proactively managing fear and distress.

"I just signed": Factors influencing decision-making for school-based HPV vaccination of adolescent girls.

OBJECTIVES: Australia was one of the first countries to implement a nationwide program providing HPV vaccination to girls at school. To date, there are no published studies describing decision-making processes and behavior postimplementation of HPV vaccination of adolescents participating in a school-based program. DESIGN: A purposive sample of nine schools was selected to reflect a range of vaccination coverage and school types. Semistructured focus groups with girls and interviews with parents, teachers, and immunization nurses (n = 185) were conducted until saturation was reached. Transcripts were analyzed inductively and emergent themes were subject to constant comparison. MAIN OUTCOME MEASURES: Explanatory model of decision-making in HPV vaccination. RESULTS: An explanatory model of decision-making and behavior was constructed from the data. Five decision-making states emerged across a continuum of vaccination behavior: active decision-vaccinated, passive decision- vaccinated, passive decision- not vaccinated, active decision- not vaccinated, and antivaccination. A range of factors influenced participants in each decision-behavior state. Adolescents were often part of the decision-making process. Where adolescents were not involved, nonagreement sometimes occurred. CONCLUSION: We have presented a variety of paths girls and their parents experience regarding decision-making and behavior in HPV vaccination. Attitudes, past experiences, and worldviews contributed to this process.

Gay men's perceptions of sexually transmissible infections and their experiences of diagnosis: 'part of the way of life' to feeling 'dirty and ashamed'.

BACKGROUND: Gay men are considerably more likely than their heterosexual peers to be diagnosed with a sexually transmissible infection (STI), yet relatively little has been published on gay men's perceptions of STIs other than HIV. METHODS: Drawing on interviews conducted with Sydney gay men, we analysed perceptions of STIs, and men's experiences of testing and diagnosis. RESULTS: Over half the men in the study had ever been diagnosed with an STI. STIs were generally regarded as inconvenient consequences of sexual activity. Viral, recurring STIs were viewed as being more serious than curable, bacterial STIs. However, all STIs were considered as considerably less important than HIV. Condom use and regular STI testing were the most commonly used strategies to manage the risk of STIs. Despite the relative lack of concern attributed to STIs, being diagnosed with an STI could generate feelings of shame, embarrassment and annoyance. For some men, education campaigns appeared to have helped destigmatise STIs and encourage regular testing. CONCLUSIONS: We believe that to maintain high rates of STI testing among gay men, community education efforts should continue to reduce the stigma associated with STIs and greater support should be offered to gay men when they receive an STI diagnosis.

'It's a logistical nightmare!' Recommendations for optimising human papillomavirus school-based vaccination experience.

INTRODUCTION: To date, no published studies examine procedural factors of the school-based human papillomavirus (HPV) vaccination program from the perspective of those involved. This study examines the factors that were perceived to impact optimal vaccination experience. METHODS: Schools across Sydney were selected to reflect a range of vaccination coverage at the school level and different school types to ensure a range of experiences. Semi-structured focus groups were conducted with girls; and one-on-one interviews were undertaken with parents, teachers and nurses until saturation of data in all emergent themes was reached. Focus groups and interviews explored participants' experiences in school-based HPV vaccination. Transcripts were analysed, letting themes emerge. RESULTS: Themes related to participants' experience of the organisational, logistical and procedural aspects of the vaccination program and their perceptions of an optimal process were organised into two categories: (1) preparation for the vaccination program and (2) vaccination day strategies. In (1), themes emerged regarding commitment to the process from those involved, planning time and space for vaccinations, communication within and between agencies, and flexibility. In (2), themes included vaccinating the most anxious girls first, facilitating peer support, use of distraction techniques, minimising waiting time girls, and support staff. DISCUSSION: A range of views exists on what constitutes an optimal school-based program. Several findings were identified that should be considered in the development of guidelines for implementing school-based programs. Future research should evaluate how different approaches to acquiring parental consent, and the use of anxiety and fear reduction strategies impact experience and uptake in the school-based setting.

"Is cancer contagious?": Australian adolescent girls and their parents: making the most of limited information about HPV and HPV vaccination.

INTRODUCTION: Australia has implemented a nation-wide program providing HPV vaccination to girls at school. To date, there are no published studies that explore knowledge about HPV and HPV vaccine post-implementation of the national school-based HPV vaccination program. METHODS: A purposive sample of schools was selected to reflect a range of vaccination coverage (high versus lower uptake), and different school types (Catholic, Independent or Government). Semi-structured focus groups and interviews were conducted with girls and their parents respectively, until saturation was reached. Transcripts were analysed, letting themes emerge from the data. RESULTS: A core theme from both girls and parents was lack of knowledge. Supporting themes were lack of knowledge of HPV, lack of knowledge of vaccine, and realisation of their lack of knowledge. Their lack of knowledge was common in three areas: what HPV is, how HPV is transmitted, and the HPV and cervical cancer connection. The lack of knowledge about HPV vaccination was reflected in what the vaccine protects against, how the vaccine works, HPV vaccination recommendations, the vaccine and Pap smear connection, and myths about HPV vaccination. Both girls and parents wanted more information, had a tendency to defer responsibility, and parents expressed judgment of themselves as parents. DISCUSSION: Low levels of knowledge and understanding about HPV vaccination among adolescents and parents have implications for adolescents' future health practices, including sexual risk behaviour, condom usage, and cervical screening. Reasons for the low levels of knowledge are explored, as are implications for school-based educational interventions.

Effective partnership and adequate investment underpin a successful response: key factors in dealing with HIV increases.

BACKGROUND: Australia has mounted an effective response to HIV and AIDS by investing in evidence-informed policy. Recently, in response to increases in HIV in some states in Australia, the New South Wales Department of Health set up a 'think tank' to examine differences in epidemiological and behavioural data, policies, strategies and community responses in order to account for state-based differences and ensure an effective ongoing response to HIV. METHODS: The National Centre in HIV Social Research undertook key informant interviews with major stakeholders to help understand differences in responses by the three states most affected by HIV in Australia - Queensland, New South Wales and Victoria. In parallel, the Australian Federation of AIDS Organisations completed an analysis of the investments in HIV-prevention activities targeting gay men in all jurisdictions in Australia. The Australian Federation of AIDS Organisations also analysed the strategic contexts and government responses to HIV in the three states. RESULTS: There were significant differences between New South Wales, Queensland and Victoria in the way the HIV partnership functions. Type of prevention strategy and level of financial investment in prevention activities appear to be related to the effectiveness of the ongoing response to HIV. CONCLUSIONS: An active commitment to and adequate resourcing of HIV prevention by all stakeholders in the HIV partnership - government and non-government departments, researchers and gay community organisations - is crucial if Australia is to respond effectively to HIV among gay and other men who have sex with men.

Towards better practice in primary health care settings for young people.

ISSUE ADDRESSED: To identify and describe elements of accessibility and other dimensions of quality of primary health care for Australian young people. METHODS: Five sampling frames identified relevant services and programs across New South Wales (NSW) which were then selected using purposive, convenience or snowball sampling. In-depth interviews were conducted with senior staff members, tape-recorded, transcribed, entered into the qualitative software package NUD*IST and coded under seven theme headings. RESULTS: Interviews with 77 services across five sectors in NSW identified seven principles of better practice in youth health. These were: accessibility, evidence-based practice, youth participation, collaboration, professional development, sustainability and evaluation. Accessibility was the principle most frequently addressed and evaluation was the least frequently addressed. Many seemingly effective programs and services had been minimally evaluated for impact or outcome related to young people's access or health. CONCLUSIONS: Principles of better practice in promoting or delivering adolescent health care have strong face validity across a range of sectors and service types in a heterogeneous primary health care system. These principles are applied to varying degrees in a vast array of health and health promotion programs. Despite this, there is a clear need for impact and outcome evaluation among the majority of programs.

Implementation of a SNAP intervention in two divisions of general practice: a feasibility study.

"SNAP" is a model for the general practice management of four common behavioural risk factors: smoking, nutrition, alcohol and physical activity. The SNAP program was developed for the Australian Government in 2002. In 2003 and 2004, a feasibility study was conducted in one urban and one rural division of general practice (DGP) in NSW, in partnership with their local area health services. Information technology support and referral directories were developed, based on an initial needs assessment, SNAP guidelines, a clinical summary chart, patient education materials, and general practitioner and staff training. GPs reported that the SNAP approach fitted general practice consultations well. After its implementation, they were more confident in using motivational interviewing and SNAP interventions and referred more frequently. The impact and sustainability of the SNAP program were limited by a lack of effective practice teamwork, poor linkages with referral services, and the lack of a business model to support SNAP in the practices. DGPs could play an important role in providing practice visits and resources to improve communication, education and collaboration to support SNAP programs.

Access to health care among Australian adolescents young people's perspectives and their sociodemographic distribution.

PURPOSE: To identify the health concerns for which adolescent residents in New South Wales, Australia, do not receive health care, and the associated factors, including their sociodemographic distribution. METHODS: Purposive sampling was used to recruit school students who were stratified by gender and age (12-14, 14-16 and 16-17 years), from schools stratified by socioeconomic status and urban/rural location. Out-of-school young people were recruited through youth health services. Qualitative methods were used to collect and analyze data. RESULTS: Eighty-one focus groups were conducted. Most young people defined health solely in terms of their physical well-being, but still identified a broad range of situations, conditions, or behaviors which they believed might affect their health. One-third of females and two-thirds of males said they would not seek help for their health concerns, and when they did, were most likely to seek help from family, friends, or others they trusted. When professional help was sought, young people again preferred someone they knew and trusted. The three groups of barriers to accessing health care were: concerns about confidentiality, knowledge of services and discomfort in disclosing health concerns, and accessibility and characteristics of services. Factors related to use of health care services were associated with age, gender, and location, but rarely with socioeconomic status. CONCLUSIONS: The majority of these young people in New South Wales (particularly males) do not seek health care despite identifying a broad range of issues that affect their health.

Access to primary health care for Australian adolescents: how congruent are the perspectives of health service providers and young people, and does it matter?

OBJECTIVE: To explore the extent of congruence between the views of service providers and young people (on adolescents' health concerns, barriers to accessing health services and ideal service model) in order to improve and increase the appropriateness, quality and usage of primary health care services. METHODS: A qualitative data collection technique was used. During 2001/02, focus groups were conducted in urban and rural locations with adolescents (in and out of mainstream education), general practitioners, community health staff and youth health workers. RESULTS: Service providers and young people identified a similar range of health concerns for young people, with young people adding additional issues of great importance to them that service providers felt were not in their 'domain of treatment'. There was reasonable congruence in regard to 'ideal service model' with some differences relating to methods of information delivery. However, for 'barriers to accessing services' there were major discrepancies. CONCLUSIONS: While there is some common understanding between young people and service providers on certain aspects of health services, there are clearly areas where perceptions differ. This discrepancy matters because it may adversely affect the quality of provider-adolescent interaction and the willingness of adolescents to access services. IMPLICATIONS: To deliver optimal health services to young people, the differences in understanding regarding services need to be addressed. Strategies could include promotion to, and encouragement of, young people to seek help, continuing professional education of providers and changes in remuneration policies.

Access to primary health care for Australian young people: service provider perspectives.

BACKGROUND: To adequately address the complex health needs of young people, their access to services, and the quality of services received, must be improved. AIMS: To explore the barriers to service provision for young people and to identify the training needs of primary healthcare service providers in New South Wales (NSW), Australia. DESIGN OF STUDY: A cross-sectional, qualitative study of the perspectives of a range of health service providers. SETTING: A range of primary healthcare organisations across NSW. METHODS: Samples of general practitioners (GPs), youth health workers, youth health coordinators, and community health centre staff were drawn from urban and rural clusters across NSW. Focus groups and interviews were used to identify barriers to service provision and the training needs of service providers. Data were tape recorded, transcribed, and analysed. RESULTS: Barriers to service provision among GPs and community health centre staff included inadequate time, flexibility, skills, and confidence in working with young people, and poor linkages with other relevant services. Training needs included better knowledge of and skills in adolescent health requirements, working with adolescents, and working with other services. Barriers to service provision for youth health workers and coordinators included lack of financial resources and infrastructure. There were few linkages between groups of service providers. CONCLUSION: Models of service provision that allow stronger linkages between service providers, sufficient time for consultation with young people, adequate training and support of health professionals, and flexibility of service provision, including outreach, should be explored and evaluated.