Experience of Health Leadership in Partnering With University-Based Researchers in Canada - A Call to "Re-imagine" Research.

BACKGROUND: Emerging evidence that meaningful relationships with knowledge users are a key predictor of research use has led to promotion of partnership approaches to health research. However, little is known about health system experiences of collaborations with university-based researchers, particularly with research partnerships in the area of health system design and health service organization. The purpose of the study was to explore the experience and perspectives of senior health managers in health service organizations, with health organization-university research partnerships. METHODS: In-depth, semi-structured interviews (n = 25) were conducted with senior health personnel across Canada to explore their perspectives on health system research; experiences with health organization-university research partnerships; challenges to partnership research; and suggested actions for improving engagement with knowledge users and promoting research utilization. Participants, recruited from organizations with regional responsibilities, were responsible for system-wide planning and support functions. RESULTS: Research is often experienced as unhelpful or irrelevant to decision-making by many within the system. Research, quality improvement (QI) and evaluation are often viewed as separate activities and coordinated by different responsibility areas. Perspectives of senior managers on barriers to partnership differed from those identified in the literature: organizational stress and restructuring, and limitations in readiness of researchers to work in the fast-paced healthcare environment, were identified as major barriers. Although the need for strong executive leadership was emphasized, "multi-system action" is needed for effective partnerships. CONCLUSION: Common approaches to research and knowledge translation are often not appropriate for addressing issues of health service design and health services organization. Nor is the research community providing expertise to many important activities that the healthcare system is taking to improve health services. A radical rethinking of how we prepare health service researchers; position research within the health system; and fund research activities and infrastructure is needed if the potential benefits of research are to be achieved. Lack of response to health system needs may contribute to research and 'evidence-informed' practice being further marginalized from healthcare operations. Interventions to address barriers must respond to the perspectives and experience of health leadership.

Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial.

BACKGROUND: Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates. METHODS: In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16-34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044. FINDINGS: Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16-34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84-1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15-1·65; p=0·0006). INTERPRETATION: Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities. FUNDING: Australian National Health and Medical Research Council.

Perspectives of primary health care staff on the implementation of a sexual health quality improvement program: a qualitative study in remote aboriginal communities in Australia.

BACKGROUND: Young people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes. METHODS: In-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011-2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components. RESULTS: Of the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs. CONCLUSIONS: Across all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these components to be translated directly into clinical activity. To ensure their uptake, CQI programs must acknowledge local clinical guidelines, be compatible with translation into clinical activity and have managerial support. Sexual health CQI needs to align with other CQI activities, engage staff and promote accountability through the provision of clinic specific data and regular face-to-face meetings. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044 . Registered 6/05/2010. Prospectively Registered.

Patient, staffing and health centre factors associated with annual testing for sexually transmissible infections in remote primary health centres.

BACKGROUND: In high-incidence Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) settings, annual re-testing is an important public health strategy. Using baseline laboratory data (2009-10) from a cluster randomised trial in 67 remote Aboriginal communities, the extent of re-testing was determined, along with the associated patient, staffing and health centre factors. METHODS: Annual testing was defined as re-testing in 9-15 months (guideline recommendation) and a broader time period of 5-15 months following an initial negative CT/NG test. Random effects logistic regression was used to determine factors associated with re-testing. RESULTS: Of 10559 individuals aged ≥16 years with an initial negative CT/NG test (median age=25 years), 20.3% had a re-test in 9-15 months (23.6% females vs 15.4% males, P<0.001) and 35.2% in 5-15 months (40.9% females vs 26.5% males, P<0.001). Factors independently associated with re-testing in 9-15 months in both males and females were: younger age (16-19, 20-24 years); and attending a centre that sees predominantly (>90%) Aboriginal people. Additional factors independently associated with re-testing for females were: being aged 25-29 years, attending a centre that used electronic medical records, and for males, attending a health centre that employed Aboriginal health workers and more male staff. CONCLUSIONS: Approximately 20% of people were re-tested within 9-15 months. Re-testing was more common in younger individuals. Findings highlight the importance of recall systems, Aboriginal health workers and male staff to facilitate annual re-testing. Further initiatives may be needed to increase re-testing.

High chlamydia and gonorrhoea repeat positivity in remote Aboriginal communities 2009-2011: longitudinal analysis of testing for re-infection at 3 months suggests the need for more frequent screening.

Background Extremely high rates of diagnosis of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) have been recorded in remote communities across northern and central Australia. Re-testing at 3 months, after treatment administered, of CT or NG is recommended to detect repeat infections and prevent morbidity and ongoing transmission. METHODS: Baseline CT and NG laboratory data (2009-2010) from 65 remote health services participating in a cluster randomised trial was used to calculate the proportion of individuals re-tested after an initial CT or NG diagnosis at <2 months (not recommended), 2-4 months (recommended) and 5-12 months and the proportion with repeat positivity on re-test. To assess if there were difference in re-testing and repeat positivity by age group and sex, t-tests were used. RESULTS: There was a total of 2054 people diagnosed with CT and/or NG in the study period; 14.9% were re-tested at 2-4 months, 26.9% at 5-12 months, a total of 41.8% overall. Re-testing was higher in females than in males in both the 2-4-month (16.9% v. 11.5%, P<0.01) and 5-12-month (28.9% v. 23.5%, P=0.01) periods. Women aged 25-29 years had a significantly higher level of re-testing 5-12 months post-diagnosis than females aged 16-19 years (39.8% v. 25.4%, P<0.01). There was a total of 858 people re-tested at 2-12 months and repeat positivity was 26.7%. There was higher repeat NG positivity than repeat CT positivity (28.8% v. 18.1%, P<0.01). CONCLUSIONS: Just under half the individuals diagnosed with CT or NG were re-tested at 2-12 months post-diagnosis; however, only 15% were re-tested in the recommended time period of 2-4 months. The higher NG repeat positivity compared with CT is important, as repeat NG infections have been associated with higher risk of pelvic inflammatory disease-related hospitalisation. Findings have implications for clinical practice in remote community settings and will inform ongoing sexual health quality improvement programs in remote community clinics.

Incidence and predictors of annual chlamydia testing among 15-29 year olds attending Aboriginal primary health care services in New South Wales, Australia.

BACKGROUND: For the past two decades, chlamydia has been the most commonly notified infectious disease among young people (15-29 year olds) in Australia, the United States of America and the United Kingdom and rates have increased annually in these three countries. In Australia, rates of chlamydia are three times higher in Aboriginal compared with non-Aboriginal people. Australian sexually transmissible infection guidelines recommend annual chlamydia testing for 15-29 year old females and males. This analysis will examine the incidence and predictors of annual chlamydia testing in 15-29 year olds attending four Aboriginal Community Controlled Health Services (ACCHS) in Australia. METHODS: From 2009-2011, attendance and chlamydia testing data were extracted from the patient system to calculate the number and proportion of 15-29 year olds that were tested for chlamydia and that tested positive for chlamydia by gender (male, female), age-group (15-19, 20-24, 25-29 years), Aboriginal status (Aboriginal, non-Aboriginal people) and by the four ACCHSs sites (1, 2, 3 and 4). A cohort was created to calculate the incidence rate per 100 person-years (PY) and predictors of an annual chlamydia test (a test within 12-months of a previous test/visit) by the above factors using Cox regression. Unadjusted and adjusted hazard ratios (AHR) and their 95 % confidence intervals (CIs) and p-values were calculated with significance at p < 0.05. RESULTS: From 2009-2011, there were 2896 individuals who attended the four ACCHSs. Overall , 17 % (22 % of females and 10 % of males) were tested for chlamydia and 9 % tested positive (8 % of females and 14 % of males). The median time to an annual chlamydia test was 10.7 months. The cohort included 2318 individuals. Overall the incidence rate of an annual chlamydia test was 9.1 per 100 PY (11.6 in females and 5.8 in males). Predictors of an annual chlamydia test were being female (AHR: 1.7, 95 % CI: 1.2-2.2, p < 0.01), being 15-19 years old (AHR: 1.6, 95 % CI: 1.1-2.3, p < 0.01) and attending ACCHS site 2 (AHR: 3.8, 95 % CI: 1.8-8.0, p < 0.01). CONCLUSIONS: This analysis highlights that opportunistic STI testing strategies are needed to increase annual chlamydia testing in young people; especially males.

A sexual health quality improvement program (SHIMMER) triples chlamydia and gonorrhoea testing rates among young people attending Aboriginal primary health care services in Australia.

BACKGROUND: In Australia, chlamydia is the most commonly notifiable infection and over the past ten years chlamydia and gonorrhoea notification rates have increased. Aboriginal compared with non-Aboriginal Australians have the highest notifications rates of chlamydia and gonorrhoea. Regular testing of young people for chlamydia and gonorrhoea is a key prevention strategy to identify asymptomatic infections early, provide treatment and safe sex education. This study evaluated if a sexual health quality improvement program (QIP) known as SHIMMER could increase chlamydia and gonorrhoea testing among young people attending four Aboriginal primary health care services in regional areas of New South Wales, Australia. METHODS: We calculated the proportion of 15-29 year olds tested and tested positivity for chlamydia and gonorrhoea in a 12-month before period (March 2010-February 2011) compared with a 12-month QIP period (March 2012-February 2013). Logistic regression was used to assess the difference in the proportion tested for chlamydia and gonorrhoea between study periods by gender, age group, Aboriginal status and Aboriginal primary health service. Odds ratios (OR) and their 95 % confidence intervals (CIs) were calculated with significance at p < 0.05. RESULTS: In the before period, 9 % of the 1881 individuals were tested for chlamydia, compared to 22 % of the 2259 individuals in the QIP period (OR): 1.43, 95 % CI: 1.22-1.67). From the before period to the QIP period, increases were observed in females (13 % to 25 %, OR: 1.32, 95 % CI: 1.10-1.59) and males (3 % to 17 %, OR: 1.85, 95 % CI: 1.36-2.52). The highest testing rate in the QIP period was in 15-19 year old females (16 % to 29 %, OR: 1.02, 95 % CI: 0.75-1.37), yet the greatest increase was in 20-24 year olds males (3 % to 19 %, OR: 1.65, 95 % CI: 1.01-2.69). Similar increases were seen in gonorrhoea testing. Overall, there were 70 (11 %) chlamydia diagnoses, increasing from 24 in the before to 46 in the QIP period. Overall, 4 (0.7 %) gonorrhoea tests were positive. CONCLUSIONS: The QIP used in SHIMMER almost tripled chlamydia and gonorrhoea testing in young people and found more than twice as many chlamydia infections. The QIP could be used by other primary health care centres to increase testing among young people.

Attendance patterns and chlamydia and gonorrhoea testing among young people in Aboriginal primary health centres in New South Wales, Australia.

UNLABELLED: Background To inform a sexual health quality improvement program we examined chlamydia and gonorrhoea testing rates among 15-29 year olds attending Aboriginal Community Controlled Health Services (ACCHS) in New South Wales, Australia, and factors associated with chlamydia and gonorrhoea testing. METHODS: From 2009 to 2011, consultation and testing data were extracted from four ACCHS. Over the study period, we calculated the median number of consultations per person and interquartile range (IQR), the proportion attending (overall and annually), the proportion tested for chlamydia and gonorrhoea, and those who tested positive. We examined factors associated with chlamydia and gonorrhoea testing using logistic regression. RESULTS: Overall, 2896 15-29-year-olds attended the ACCHSs, 1223 were male and 1673 were female. The median number of consultations was five (IQR 2-12), four (IQR 1-8) for males and seven (IQR 3-14) for females (P<0.001). Nineteen percent of males and 32% of females attended in each year of the study (P<0.001). Overall, 17% were tested for chlamydia (10% of males and 22% of females, P<0.001), and 7% were tested annually (3% of males and 11% of females, P<0.001). Findings were similar for gonorrhoea testing. In the study period, 10% tested positive for chlamydia (14% of males and 9% of females, P<0.001) and 0.6% for gonorrhoea. Factors independently associated with chlamydia testing were being female (adjusted odds ratio (AOR) 2.64, 95% confidence interval (CI) 2.07-3.36), being 20-24 years old (AOR: 1.58, 95% CI: 1.20-2.08), and having >3 consultations (AOR: 16.97, 95% CI: 10.32-27.92). CONCLUSIONS: More frequent attendance was strongly associated with being tested for chlamydia and gonorrhoea. To increase testing, ACCHS could develop testing strategies and encourage young people to attend more frequently.

Reasons for delays in treatment of bacterial sexually transmissible infections in remote Aboriginal communities in Australia: a qualitative study of healthcentre staff.

UNLABELLED: Background Remote Aboriginal communities in Australia experience high rates of bacterial sexually transmissible infections (STIs). To control the transmission and decrease the risk of complications, frequent STI testing combined with timely treatment is required, yet significant delays in treatment have been reported. Perceived barriers to timely treatment for asymptomatic patients in remote communities were explored. METHODS: A qualitative study was undertaken as part of the STRIVE (STIs in Remote communities, ImproVed and Enhanced primary health care) project; a cluster randomised controlled trial of a sexual health quality improvement program. During 2012, we conducted 36 in-depth interviews with staff in 22 clinics in remote Australia. RESULTS: Participants included registered nurses (72%) and Aboriginal health practitioners (28%). A key barrier to timely treatment was infrequent transportation of specimens to laboratories often hundreds of kilometres away from clinics. Within clinics, there were delays checking and actioning test results, and under-utilisation of systems to recall patients. Participants also described difficulties in physically locating patients due to: (i) high mobility between communities; and (ii) low levels of community knowledge created by high staff turnover. Participants also suggested strategies to overcome some barriers such as dedicated clinical time to follow-up recalls and taking treatment out to patients. CONCLUSIONS: Participants identified barriers to timely STI treatment in remote Aboriginal communities, and systems to address some of the barriers. Innovative strategies such as point-of-care testing or increased support for actioning results, coupled with incentives to individual patients to attend for results, may also assist in decreasing the time to treatment.

Barriers and facilitators of sexually transmissible infection testing in remote Australian Aboriginal communities: results from the Sexually Transmitted Infections in Remote Communities, Improved and Enhanced Primary Health Care (STRIVE) Study.

UNLABELLED: Background Remote Australian Aboriginal communities experience high rates of bacterial sexually transmissible infections (STI). A key strategy to reduce STIs is to increase testing in primary health care centres. The current study aimed to explore barriers to offering and conducting STI testing in this setting. METHODS: A qualitative study was undertaken as part of the STI in Remote communities, Improved and Enhanced Primary Health Care (STRIVE) project; a large cluster randomised controlled trial of a sexual health quality improvement program. We conducted 36 in-depth interviews in 22 participating health centres across four regions in northern and central Australia. RESULTS: Participants identified barriers including Aboriginal cultural norms that require the separation of genders and traditional kinship systems that prevent some staff and patients from interacting, both of which were exacerbated by a lack of male staff. Other common barriers were concerns about client confidentiality (lack of private consulting space and living in small communities), staff capacity to offer testing impacted by the competing demands for staff time, and high staff turnover resulting in poor understanding of clinic systems. Many participants also expressed concerns about managing positive test results. To address some of these barriers, participants revealed informal strategies, such as team work, testing outside the clinic and using adult health checks. CONCLUSIONS: Results identify cultural, structural and health system issues as barriers to offering STI testing in remote communities, some of which were overcome through the creativity and enthusiasm of individuals rather than formal systems. Many of these barriers can be readily addressed through strengthening existing systems of cultural and clinical orientation and educating staff to view STI in a population health framework. However others, particularly issues in relation to culture, kinship ties and living in small communities, may require testing modalities that do not rely on direct contact with health staff or the clinic environment.

Coinfection with Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis: a cross-sectional analysis of positivity and risk factors in remote Australian Aboriginal communities.

OBJECTIVES: To determine the co-occurrence and epidemiological relationships of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) in a high-prevalence setting in Australia. METHODS: In the context of a cluster randomised trial in 68 remote Aboriginal communities, we obtained laboratory reports on simultaneous testing for CT, NG and TV by nucleic acid amplification tests in individuals aged ≥16 years and examined relationships between age and sex and the coinfection positivity. ORs were used to determine which infections were more likely to co-occur by demographic category. RESULTS: Of 13 480 patients (median age: 30 years; men: 37%) tested for all three infections during the study period, 33.3% of women and 21.3% of men had at least one of them, highest in patients aged 16-19 years (48.9% in women, 33.4% in men). The most frequent combination was CT/NG (2.0% of women, 4.1% of men), and 1.8% of women and 0.5% of men had all three. In all co-combinations, coinfection positivity was highest in patients aged 16-19 years. CT and NG were highly predictive of each other's presence, and TV was associated with each of the other two infections, but much more so with NG than CT, and its associations were much stronger in women than in men. CONCLUSIONS: In this remote high-prevalence area, nearly half the patients aged 16-19 years had one or more sexually transmitted infections. CT and NG were more common dual infections. TV was more strongly associated with NG coinfections than with CT. These findings confirm the need for increased simultaneous screening for CT, NG and TV, and enhanced control strategies. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044.

Incidence of curable sexually transmissible infections among adolescents and young adults in remote Australian Aboriginal communities: analysis of longitudinal clinical service data.

OBJECTIVES: To undertake the first comprehensive analysis of the incidence of three curable sexually transmissible infections (STIs) within remote Australian Aboriginal populations and provide a basis for developing new control initiatives. METHODS: We obtained all results for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) testing conducted during 2009-2011 in individuals aged ≥16 years attending 65 primary health services across central and northern Australia. Baseline prevalence and incidence of all three infections was calculated by sex and age group. RESULTS: A total of 17 849 individuals were tested over 35 months. Baseline prevalence was 11.1%, 9.5% and 17.6% for CT, NG and TV, respectively. During the study period, 7171, 7439 and 4946 initially negative individuals had a repeat test for CT, NG and TV, respectively; these were followed for 6852, 6981 and 6621 person-years and 651 CT, 609 NG and 486 TV incident cases were detected. Incidence of all three STIs was highest in 16-year-olds to 19-year-olds compared with 35+ year olds (incident rate ratio: CT 10.9; NG 11.9; TV 2.5). In the youngest age group there were 23.4 new CT infections per 100 person-years for men and 29.2 for women; and 26.1 and 23.4 new NG infections per 100 person-years in men and women, respectively. TV incidence in this age group for women was also high, at 19.8 per 100 person-years but was much lower in men at 3.6 per 100 person-years. CONCLUSIONS: This study, the largest ever reported on the age and sex specific incidence of any one of these three curable infections, has identified extremely high rates of new infection in young people. Sexual health is a priority for remote communities, but will clearly need new approaches, at least intensification of existing approaches, if a reduction in rates is to be achieved.

STI in remote communities: improved and enhanced primary health care (STRIVE) study protocol: a cluster randomised controlled trial comparing 'usual practice' STI care to enhanced care in remote primary health care services in Australia.

BACKGROUND: Despite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population. METHODS/DESIGN: STRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16-34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia. DISCUSSION: STRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12610000358044.

Frequent occurrence of undiagnosed pelvic inflammatory disease in remote communities of central Australia.

OBJECTIVE: To assess the extent of diagnosed and undiagnosed pelvic inflammatory disease (PID) in Aboriginal women in remote central Australia. DESIGN, SETTING AND SUBJECTS: Retrospective cross-sectional study in five remote central Australian primary health care centres. Medical records of all resident Aboriginal women aged 14-34 years were examined. Data were from presentations with documented lower abdominal pain, excluding other causes, for 2007-2008. MAIN OUTCOME MEASURES: PID investigations undertaken, PID diagnoses made, recommended treatment, and presentations meeting the guideline criteria for diagnosing PID based on pelvic examination, symptom profile or history. RESULTS: Of 655 medical records reviewed, 119 women (18%) presented 224 times with lower abdominal pain. Recommended investigations to diagnose PID were infrequently undertaken: bimanual examination (15 cases [7%]); testing for gonorrhoea and chlamydia (78 [35%]); and history taking for vaginal discharge (59 [26%]), intermenstrual bleeding (27 [12%]) and dyspareunia (17 [8%]). There were 95 presentations (42%) consistent with guidelines to diagnose PID, most (87 [39%]) based on symptom profile and history. Of these, practitioners made 15 diagnoses of PID, and none had the recommended treatment documented. CONCLUSION: Pelvic inflammatory disease occurred frequently among Aboriginal women in central Australia during the study period but was vastly underdiagnosed and poorly treated. Undiagnosed or inadequately treated PID leads to poorer reproductive health outcomes in the long term. Increased awareness of PID symptoms, diagnosis and treatment and a revision of the guidelines is needed to improve detection and management of PID in this high-risk setting.

Improving adherence to guidelines for the diagnosis and management of pelvic inflammatory disease: a systematic review.

BACKGROUND: Evidence suggests adherence to clinical guidelines for pelvic inflammatory disease (PID) diagnosis and management is suboptimal. We systematically reviewed the literature for studies describing strategies to improve the adherence to PID clinical guidelines. METHODS: The databases MEDLINE and EMBASE, and reference lists of review articles were searched from January 2000 to April 2012. Only studies with a control group were included. RESULTS: An interrupted time-series study and two randomised controlled trials (RCTs) were included. The interrupted time-series found that following a multifaceted patient and practitioner intervention (practice protocol, provision of antibiotics on-site, written instructions for patients, and active followup), more patients received the recommended antibiotics and attended for followup. One RCT found a patient video on PID self-care did not improve medication compliance and followup. Another RCT found an abbreviated PID treatment guideline for health-practitioners improved their management of PID in hypothetical case scenarios but not their diagnosis of PID. CONCLUSION: There is limited research on what strategies can improve practitioner and patient adherence to PID diagnosis and management guidelines. Interventions that make managing PID more convenient, such as summary guidelines and provision of treatment on-site, appear to lead to better adherence but further empirical evidence is necessary.

Epidemiology of syphilis in Australia: moving toward elimination of infectious syphilis from remote Aboriginal and Torres Strait Islander communities?

OBJECTIVE: To describe the epidemiology of infectious syphilis among Aboriginal and Torres Strait Islander (Indigenous) people in Australia. DESIGN AND SETTING: We assessed trends in national infectious syphilis notification rates from 2005 to 2009 using Poisson regression, with a focus on geographic and demographic differences by Indigenous status. We compared Indigenous and non-Indigenous rate ratios over the study period and summarised the annual changes (summary rate ratio). MAIN OUTCOME MEASURES: Crude notification rates and summary rate ratios by Indigenous status, jurisdiction, sex, age group and area of residence. RESULTS: From 2005 to 2009, in the Indigenous population, there was a substantial decline in the notification rate for infectious syphilis nationally; as well as in the following subgroups: females, 15-29 year olds, and people living in outer regional and remote areas in the Northern Territory and Queensland. In contrast, there was a significant (P < 0.001) upward trend in the notification rate in the non-Indigenous population nationally; as well as in males, in people aged 20 years and over, and in residents of metropolitan and regional areas, New South Wales, Queensland, South Australia, Victoria and Western Australia. The highest summary rate ratios were seen in remote/very remote areas (86.33; 95% CI, 57.45-129.74), in 15-19 year olds (64.65; 95% CI, 51.12-81.78), in females (24.59; 95% CI, 19.73-30.65), and in Western Australia (23.89; 95% CI, 19.82-28.82). CONCLUSION: These data demonstrate that Australia has two distinct patterns of infectious syphilis: a substantially declining occurrence in Indigenous remote communities and an increasing incidence in males residing in urban and regional areas. Given the decline in notification rates in Indigenous remote communities, now might be the right time to move toward eliminating infectious syphilis from Indigenous communities.

A microsphere-based vaccine prevents and reverses new-onset autoimmune diabetes.

OBJECTIVE: This study was aimed at ascertaining the efficacy of antisense oligonucleotide-formulated microspheres to prevent type 1 diabetes and to reverse new-onset disease. RESEARCH DESIGN AND METHODS: Microspheres carrying antisense oligonucleotides to CD40, CD80, and CD86 were delivered into NOD mice. Glycemia was monitored to determine disease prevention and reversal. In recipients that remained and/or became diabetes free, spleen and lymph node T-cells were enriched to determine the prevalence of Foxp3(+) putative regulatory T-cells (Treg cells). Splenocytes from diabetes-free microsphere-treated recipients were adoptively cotransferred with splenocytes from diabetic NOD mice into NOD-scid recipients. Live-animal in vivo imaging measured the microsphere accumulation pattern. To rule out nonspecific systemic immunosuppression, splenocytes from successfully treated recipients were pulsed with beta-cell antigen or ovalbumin or cocultured with allogeneic splenocytes. RESULTS: The microspheres prevented type 1 diabetes and, most importantly, exhibited a capacity to reverse clinical hyperglycemia, suggesting reversal of new-onset disease. The microspheres augmented Foxp3(+) Treg cells and induced hyporesponsiveness to NOD-derived pancreatic beta-cell antigen, without compromising global immune responses to alloantigens and nominal antigens. T-cells from successfully treated mice suppressed adoptive transfer of disease by diabetogenic splenocytes into secondary immunodeficient recipients. Finally, microspheres accumulated within the pancreas and the spleen after either intraperitoneal or subcutaneous injection. Dendritic cells from spleen of the microsphere-treated mice exhibit decreased cell surface CD40, CD80, and CD86. CONCLUSIONS: This novel microsphere formulation represents the first diabetes-suppressive and reversing nucleic acid vaccine that confers an immunoregulatory phenotype to endogenous dendritic cells.

Evaluation of self-collected samples in contrast to practitioner-collected samples for detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis by polymerase chain reaction among women living in remote areas.

BACKGROUND: Self-collected samples have been shown to be an acceptable and sensitive method for the detection by polymerase chain reaction (PCR) of sexually transmitted infections (STIs) among women. GOAL The goal of the study was to compare self-collected sampling methods to conventional practitioner endocervical sampling for the PCR detection of Chlamydia trachomatis and Neisseria gonorrhoeae to compare two self-collected sampling methods for the detection of T vaginalis by PCR. STUDY DESIGN: Women (n = 318) from urban and remote areas of central Australia participated in the study when attending their health clinic for a check-up. They each provided a FVU sample, self-collected vaginal swab specimen, and tampon specimen. This was followed by a clinical examination by a practitioner, with collection of endocervical and high vaginal swabs for testing by conventional microscopy and culture for N gonorrhoeae and T vaginalis, respectively. The FVU, self-collected vaginal swab, tampon, and endocervical swab specimens were tested by Roche Cobas Amplicor for C trachomatis and N gonorrhoeae. The self-collected vaginal swab and tampon specimens were also tested by an in-house PCR method for the detection of T vaginalis. RESULTS: In toto, C trachomatis was detected by PCR in 11.5%, N gonorrhoeae in 11.8%, and T vaginalis in 24.6%. Molecular diagnostics for N gonorrhoeae and T vaginalis were significantly more sensitive than traditional assays with microscopy and culture. For the detection of C trachomatis by PCR, tampons were the most sensitive (100.0%) and urine the least sensitive (72.7%) specimens ( = 0.01). For the detection of by PCR, the self-collected tampon was the most sensitive specimen, followed by the endocervical swab, self-collected swab, and urine specimen, with sensitivities of 97.2%, 92.6%, 71.9%, and 31.2%, respectively. For detection of N gonorrhoeae, statistically significant differences were detected for urine versus tampon ( < 0.0001), endocervical swab ( < 0.001), and self-collected swab ( = 0.01) and for self-collected swab versus tampon ( = 0.01). Subsequent data collection showed that sensitivity of urine PCR for detection of N gonorrhoeae improved with freezing of urine specimens and shorter transport time. Tampons were also more sensitive than self-collected swabs for detection of T vaginalis (sensitivity of 100% versus 87.7%). CONCLUSION: Self-collected specimens offer women in remote communities an acceptable and sensitive alternative method of testing for STIs. The low sensitivity of N gonorrhoeae PCR of urine specimens may reflect poor transport and storage conditions, which we have shown can be improved by freezing urine specimens and reducing transport delays.