Equitable Service Delivery Research Articles

Research for Health Priorities in the Northern Cape Province: Fostering Research Capacity to Translate the Identified Research Needs into Action

Background: Over the past decades active community engagement in health research has gained significant attention in people-centered health systems throughout the world. Yet there is little evidence about how best to enhance active community engagement in setting priorities for health research, particularly from low-and middle-income countries (LMICs). This study presents the approaches employed to identify health research priorities and the lesson learnt from the Northern Cape Province in South Africa. Methods: A combination of approaches involving the Essential National Health Research (ENHR), and the World Cafe consultation processes with the support of experts’ ideas used to enhance key stakeholders (n=41) participation towards the identification of health research priorities for the province. A document on the burden of diseases, health systems challenges and population health status indicators was presented and critically reviewed at the workshop. Results: The top ten health research prority areas for the province identified with active community engagement. More than 90% of the prioritised research areas are operational research which are linked to health services delivery challenges including health systems issues, burden of diseases, health program effectiveness, and the social determinants of health. Conclusion: Active community engagement in setting research priorities for health is a necessary first step to improve the delivery of good quality, equitable and accessible healthcare services for all citizens. However, the current limited resource capacities both in terms of funding and human resources for health research is a concern; and may hamper the effective translation of research priorities to actual action.

Strengthening a competent health workforce for the provision of coordinated/ integrated health services

Finding more efficient, innovative and responsive ways of engaging the health workforce to manage patients is key to ensuring integrated care. Systems that are transforming their services to be more integrated must ensure that health professionals are ready to fill the new roles assigned to them in prevention and pro-active patient management, manage health and care rather than disease and cure, work in teams across professions and sectors, work along a continuum of care, protect and advocate the most vulnerable, ensure equitable service delivery, optimize communication that has an emphasis on compassion and empathy and develop more than one vertical expertise.Securing a health workforce that “wants and feels” and has the theoretical knowledge and skills to work more efficiently and effectively is not enough in ensuring integrated health services. What is needed is a guarantee that health professionals who enter the workplace will apply their knowledge and skills with sound judgment (i.e. that they will have competencies) and that they will refine and maintain these over the course of their career (consolidate competencies). To date the focus on competencies has been limited to looking at education institutions (i.e. college and universities) where initial exposure to competencies takes place. Indeed important strides have been taken since the Lancet review on transforming health professional education to be more competency-oriented. The lack of a clear definition on what competencies are, how they are governed and strengthened beyond initial training settings has however resulted in misplacing competencies of the health workforce as merely a problem for training institutions. Without a deeper exploration into what competencies are and how they can be strengthened at both the service and systems level important conversations on the relevance of competencies to health systems have been missed. This has been explored in our paper for the World Health Organization Regional Office for Europe "Strengthening a competent health workforce for the provision of coordinated/ integrated health services" (http://www.euro.who.int/en/health-topics/Health-systems/health-service-delivery/publications/2015/strengthening-a-competent-health-workforce-for-the-provision-of-coordinated-integrated-health-services).A systematic review of the literature was conducted resulting in the identification of 5 core competencies for integrated care. Their consolidation over the course of a health professional's career is conceptualized and a framework proposed that addresses actors and their responsibilities at both the service delivery level and the systems level. 13 important entry points for the assurance and improvement of competencies. Having done this, the paper shows how competencies are the responsibility of a range of stakeholders - service managers, policy makers, regulatory bodies, and patient and professional associations- and how they can work more closely with each other. Most notably the paper proposes that accountability for the consolidation of competencies of the health workforce lies with executives of health services. Without such clarity of roles and responsibilities, governance of the health workforce will continue to be challenged by poor accountability, corruption, limited involvement of communities in policy-making, ineffective management strategies and ultimately poor health outcomes.A workshop is proposed to discuss:- what participants think of the five proposed integrated care competencies listed;- what the participant's experiences with the five proposed integrated care competencies in their individual countries are;- the proposed conceptual framework for competency consolidation and the identified 13 entry points;and- experiences with barriers/facilitators and opportunities for implementation of the competencies and the entry points.The workshop will take a particular focus on the service delivery level and discuss examples and tools for the service-specific entry points for governing competency consolidation.

The right to education for young people excluded from mainstream in a divided society

This paper offers a rights-based analysis of the equity of educational experience allocated to young people excluded from school in Northern Ireland. Using Tomaševski’s ‘4As scheme’ as a conceptual guide, the availability, accessibility, acceptability and adaptability of alternative education provision is examined. The article begins with a brief overview of the contextual landscape within which the sector operates, alluding to the definitional and procedural difficulties that have hindered the delivery of equitable alternative education services to date, before an examination of the current legal architecture within which the right to education may be given further realisation is detailed. The latter part of the article considers the extent to which the organisation, management and delivery of the EOTAS sector is rights-compliant, before concluding that the right to education, as it stands under domestic and international law, does not extend far enough to ensure and protect the educational entitlements of children excluded from school.

Improving access to primary care for Aboriginal babies in Western Australia: study protocol for a randomized controlled trial.

BackgroundDespite a decade of substantial investments in programs to improve access to primary care for Aboriginal mothers and infants, more than 50 % of Western Australian Aboriginal babies are still not receiving primary and preventative care in the early months of life. Western Australian hospitals now input birth data into the Western Australian electronic clinical management system within 48 hours of birth. However, difficulties have arisen in ensuring that the appropriate primary care providers receive birth notification and clinical information by the time babies are discharged from the hospital. No consistent process exists to ensure that choices about primary care are discussed with Aboriginal families.Methods/DesignWe will undertake a population-based, stepped wedge, cluster randomized controlled trial of an enhanced model of early infant primary care. The intervention is targeted support and care coordination for Aboriginal families with new babies starting as soon as possible during the antenatal period or after birth. Dedicated health professionals and research staff will consult with families about the families’ healthcare needs, provide information about healthcare in the first 3 months of life, offer assistance with birth and Medicare forms, consult with families about their choice for primary care provider, offer to notify the chosen primary care provider about the baby’s health needs, and offer assistance with healthcare coordination at the time of discharge from the hospital.We will evaluate this model of care using a rigorous stepped wedge approach. Our primary outcome measure is a reduced hospitalization rate in infants younger than 3 months of age. Secondary outcome measures include completed Aboriginal and Torres Strait Islander child health screening assessments, immunization coverage, and satisfaction of the families about early infant primary care. We will also assess the cost effectiveness of the model of care.DiscussionThis study will be conducted over a 4-year period in partnership with birthing hospitals and primary care providers including Western Australian Aboriginal Community Controlled Health Services and the new Primary Health Networks. The results of our trial will be used to develop improved primary care models and to improve health outcomes for all Aboriginal infants. These are vital steps toward more equitable health service delivery for the Aboriginal and Torres Strait Islander children in Australia.Trial RegistrationAustralian New Zealand Clinical Trials RegistryRegistration number: ACTRN12615000976583 Date registered: 17 September 2015

World Health Organization Recommends Cost-effective Interventions to Control the Rise in Incidence of Noncommunicable Diseases in Low-resource Settings.

DEAR EDITOR, Worldwide, noncommunicable diseases (NCDs) have emerged as the leading public health threat which accounts for the deaths of 38 million people annually.[1] Even though the problem of NCDs is universal in distribution, nevertheless, low and middle income nations have to bear the maximum toll (viz., 74% of total deaths and 82% of all premature deaths).[1] However, a significant burden of these premature deaths can be minimized by motivating people to adopt healthy lifestyles, delivering universal health care, and strengthening of the primary health care.[2,3] The current costing estimates released by the World Health Organization (WHO) suggest that by mere investment of US$ 1–3/person/year, policy makers can remarkably reduce both morbidity and mortality attributed to NCDs.[1,3] It is very important to understand that multiple cost-effective interventions (namely tools for early detection, strategies for modification of NCD risk factors, and cheap drugs for prophylaxis/therapy) have shown their utility in heterogeneous settings.[4,5] If these measures are implemented in a planned manner and extended even in the remote settings, not only the ever-rising burden of NCDs in low-resource settings will be halted but also a massive reduction in medical expenses and improvement in quality of life of people will be accomplished.[3,4,5] Now, the question arises, if cost-effective interventions are available, what is preventing its implementation, especially in low-resource settings?[4,5] This is predominantly because of the weak health care delivery system, poor utilization of the available resources, no mechanism for continued financial support, limited access to both diagnostic and therapeutic services, low level of awareness among community, poor socioeconomic status, catastrophic expenditure on diseases, and defective referral mechanism.[1,5,6] However, most of these hurdles/challenges can be addressed by the delivery of community-based, sustainable, and equitable health care services via the primary health care.[5] In fact, in an attempt to effectively respond to the NCDs in low-resource setting, the WHO has formulated a package of interventions which can be executed at grass root level.[5] These interventions include prevention, diagnosis, management, and referral services for all major NCDs, essential tools/drugs for management of NCDs, self-care practices, and strategies for creating awareness about healthy lifestyle practices.[5] The rationale behind these interventions is to ensure merging of the NCD strategies within the set-up of primary health care.[5] Most of these advocated interventions are cost-effective, and thus will not only enhance the appropriate utilization of resources but even empower the team of health professionals to play their role in an integrated manner.[5,6] At the same time, it will assist in early diagnosis and management of NCD and its associated complications, so that the nations can proceed ahead in achieving the global NCD targets by the year 2020.[5,6] However, none of the anticipated benefits can be achieved unless sustained political and financial support is warranted.[1,3,6] To conclude, in the global fight against the NCDs, it is high time that all the concerned stakeholders work in a coordinated manner to ensure integration of recommended cost-effective services at the level of primary health care. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

P01.05 Equity in aboriginal hiv health care delivers the goods

Introduction Confusion exists with regard to the delivery of equal or equitable services. Far from providing the same care to all our clients we have delivered an enhanced, culturally secure service to a small cohort of Aboriginal people living with HIV. This paper evaluates the impact of this program. Our hypothesis is that this model of care results in improved outcomes. This paper seeks to present this model of HIV care and outline the results as a consequence of this care. Methods Data were collected with regard to the type and number of occasions of service, medication compliance, HIV viral loads, CD4 counts, mortality and pregnancy outcomes. Results From 1994 primary care was provided to the cohort by four doctors, demonstrating low staff turnover for a regional area. All of the current cohort of 16 people are actively engaged with the service. The most common type of service delivered was for follow up with over 350 contacts provided over 12 months. On average there were four contacts per case per month ranging from one to 30. Ninety-four percent are on medication 62.5% with undetectable HIV viral loads, and 62.5% with satisfactory CD4 counts. Since 1994 twelve of the cohort has died and there have been ten new notifications. There have been 30 pregnancies with two positive babies. Conclusion Although challenges in obtaining ideal outcomes persist, a holistic service delivery characterised by the development and continuation of relationships with the service provided has resulted in complete engagement of this cohort and has achieved positive outcomes in 62.5% of cases. This model of care, although labour intensive, delivers results similar or better than those seen internationally in hard to reach populations It demonstrates that equal outcomes can be achieved when equitable services are provided in a culturally appropriate manner. Disclosure of interest statement None No pharmaceutical grants were received in the development of this study.

Suburbanisation of oral cavity cancers: evidence from a geographically-explicit observational study of incidence trends in British Columbia, Canada, 1981-2010.

BackgroundRecent studies have demonstrated an elevated risk of oral cavity cancers (OCC) among socioeconomically deprived populations, whose increasing presence in suburban neighbourhoods poses unique challenges for equitable health service delivery. The majority of studies to date have utilised aspatial methods to identify OCC. In this study, we use high-resolution geographical analyses to identify spatio-temporal trends in OCC incidence, emphasising the value of geospatial methods for public health research.MethodsUsing province-wide population incidence data from the British Columbia Cancer Registry (1981–2009, N = 5473), we classify OCC cases by census-derived neighbourhood types to differentiate between urban, suburban, and rural residents at the time of diagnosis. We map geographical concentrations by decade and contrast trends in age-adjusted incidence rates, comparing the results to an index of socioeconomic deprivation.ResultsSuburban cases were found to comprise a growing proportion of OCC incidence. In effect, OCC concentrations have dispersed from dense urban cores to suburban neighbourhoods in recent decades. Significantly higher age-adjusted oral cancer incidence rates are observed in suburban neighbourhoods from 2006 to 2009, accompanied by rising socioeconomic deprivation in those areas. New suburban concentrations of incidence were found in neighbourhoods with a high proportion of persons aged 65+ and/or born in India, China, or Taiwan.ConclusionsWhile the aging of suburban populations provides some explanation of these trends, we highlight the role of the suburbanisation of socioeconomically deprived and Asia-born populations, known to have higher rates of risk behaviours such as tobacco, alcohol, and betel/areca consumption. Specifically, betel/areca consumption among Asia-born populations is suspected to be a primary driver of the observed geographical shift in incidence from urban cores to suburban neighbourhoods. We suggest that such geographically-informed findings are complementary to potential and existing place-specific cancer control policy and targeting prevention efforts for high-risk sub-populations, and call for the supplementation of epidemiological studies with high-resolution mapping and geospatial analysis.

Physician perspectives on care of individuals with severe mobility impairments in primary care in Southwestern Ontario, Canada.

Despite the high health risks associated with severe mobility impairments, individuals with physical disabilities are less likely to receive the same level of primary care as able-bodied persons. This study explores family physicians' perspectives on primary care for individuals with mobility impairments to identify and better understand the challenges that prevent equitable service delivery to this group of patients. Semi-structured interviews were conducted in the autumn of 2012 with a purposeful sample of 20 family physicians practising in Southwestern Ontario to gather their perspectives of the personal and professional barriers to healthcare delivery for individuals with mobility impairments, including perceptions of challenges, contributing reasons and possible improvements. A thematic analysis was conducted on the transcripts generated from the interviews to identify perceptions of existing barriers and gaps in care, needs and existing opportunities for improving primary care for this patient population. Eight themes emerged from the interviews that contributed to understanding the perceived challenges of providing care to patients with mobility impairments: transportation barriers, knowledge gaps and practice constraints resulting in episodic care rather than preventive care, incongruence between perceived and actual accessibility to care, emergency departments used as centres for primary care, inattention to mobility issues among specialist and community services, lack of easily accessible practice tools, low patient volumes impact decision-making regarding building decreased motivation to expand clinical capacity due to low patient volume, and lastly, remuneration issues. Despite this patient population presenting with high healthcare needs and significant barriers and care gaps in primary care, low prevalence rates negatively impact the acquisition of necessary equipment and knowledge required to optimally care for these patients in typical primary care settings. Novel approaches to address inequitable healthcare practices for this vulnerable group are needed.

A qualitative analysis of health professionals’ job descriptions for surgical service delivery in Uganda

BackgroundThe ever increasing demand for surgical services in sub-Saharan Africa is creating a need to increase the number of health workers able to provide surgical care. This calls for the optimisation of all available human resources to provide universal access to essential and emergency surgical services. One way of optimising already scarce human resources for health is by clarifying job descriptions to guide the scope of practice, measuring rewards/benefits for the health workers providing surgical care, and informing education and training for health professionals. This study set out to determine the scope of the mandate to perform surgical procedures in current job descriptions of surgical care health professionals in Uganda.MethodsA document review was conducted of job descriptions for the health professionals responsible for surgical service delivery in the Ugandan Health care system. The job descriptions were extracted and subjected to a qualitative content data analysis approach using a text based RQDA package of the open source R statistical computing software.ResultsIt was observed that there was no explicit mention of assignment of delivery of surgical services to a particular cadre. Instead the bulk of direct patient related care, including surgical attention, was assigned to the lower cadres, in particular the medical officer. Senior cadres were assigned to perform predominantly advisory and managerial roles in the health care system. In addition, a no cost opportunity to task shift surgical service delivery to the senior clinical officers was identified.ConclusionsThere is a need to specifically assign the mandate to provide surgical care tasks, according to degree of complexity, to adequately trained cadres of health workers. Health professionals’ current job descriptions are not explicit, and therefore do not adequately support proper training, deployment, defined scope of practice, and remuneration for equitable surgical service delivery in Uganda. Such deliberate assignment of mandates will provide a means of increasing surgical service delivery through further optimisation of the available human resources for health.

We Finally Learnt to Demand: Consumers’ Access to Rehabilitation Following Traumatic Brain Injury

Clinical care guidelines exist internationally recommending the appropriate standards of care for adults following brain injury. These guidelines recommend a care pathway including acute, inpatient and outpatient rehabilitation and community-based care. However, if and how these guidelines are implemented is largely unknown. The aim of this study was to explore the recollected continuum of care experienced by 202 adults with moderate to severe traumatic brain injury (TBI) in Victoria, Australia. The experiences of participants in this study were investigated using a mixed methods research approach (surveys and in-depth interviews). The results indicated that only 20% of participants in this study recollected receiving care in line with recommendations made in clinical care guidelines. Reasons they identified for their problematic access to services included: a lack of information about the services available, the absence of an advocate and services being restricted by limited funding. The findings of this study indicate that while guidelines provide recommendations regarding standards of care and can serve as a benchmark to improve the quality of services, they do not ensure the equitable delivery of services. Clinicians using these guidelines need to be aware of the factors that restrict clients’ access to services and take these into account when planning the delivery of services.

Empowering patients and strengthening communities for real health workforce and funding targets

The setting of ambitious targets for expanding the health work force and improving its quality, efficiency and equitable service delivery is a task long overdue. It has been nearly one decade since the minimum needed density of physicians, nurses and skilled midwives – 2.28 workers per 1000 inhabitants – was established, but without attention to other health worker cadres. Furthermore, the estimate was based on only two areas of health worker activity – skilled birth attendance and measles immunization – that represent a minuscule fraction of people’s health-care needs. 1 As a result, it grossly underestimated the health workforce needed in low- and middle-income countries to respond effectively to the pandemics of human immunode ficiency virus infection (HIV), tuberculosis and malaria; the burden of neglected tropical diseases; unmet needs in child, maternal and sexual and reproductive health; and the growing prevalence of noncommunicable diseases. In addition to being unsuitable for responding to epidemiological trends and other contextual variables, the established worker density target was minimalistic and non-dynamic, for it conveyed the impression that meeting only the most rudimentary needs of health systems would suffice to alleviate the crisis in the area of human resources for health. No aspirational goals were set for progressively expanding and strengthening a health workforce to meet a population’s broad-spectrum health needs. Cometto & Witter 2 are correct in asserting that much has been learnt about the value of properly trained mid-level 3 and community health workers 4 in improving health service coverage and efficiency. Work is still being conducted to determine the best skill mixes and workforce ratios for different countries and to establish good practice models for health workforce training, task sharing and teamwork. Although simplification, combined with equity and quality, is the overall goal, the path is laborious given the headwinds of bureaucratic intransigence, chronic underfunding and persistent brain drain. To overcome these headwinds, it is crucial that health workers be paid living wages and given incentives to work in neglected areas. 5

Patterns of primary care service use by families with young children

In the UK, early years policy emphasizes that all families should have access to support tailored to their individual needs. Knowledge of the determinants of health service use should help to inform rational and equitable planning and delivery of services to parents. We seek to investigate the determinants of primary care service use in families with preschool children. Determinants of service use in two population cohorts (families with children aged 0-1 and 2-3 years) from the Growing Up in Scotland study are presented. Services related to use of the family doctor or health visitor for information on the child's health or behaviour in the last year. A range of socio-demographic determinants were significant predictors of service use on multivariate analysis. Determinants of service use differed between the health visitor and family doctor. The analysis provides an insight into the determinants and patterns of health service use by families with young children at two stages of development. While some of our findings are expected or supported by previous research, others highlight areas that require further investigation.

Incorporating Lesbian and Bisexual Women into Women Veterans’ Health Priorities

ABSTRACTRelative to the general population, lesbian and bisexual (LB) women are overrepresented in the military and are significantly more likely to have a history of military service compared to all adult women. Due to institutional policies and stigma associated with a gay or lesbian identity, very little empirical research has been done on this group of women veterans. Available data suggest that compared to heterosexual women veterans, LB women veterans are likely to experience heightened levels of prejudice and discrimination, victimization, including greater incidence of rape, as well as adverse health and substance use disorders. They are also likely to encounter a host of unique issues when accessing health care, including fears of insensitive care and difficulty disclosing sexual orientation to Veterans Health Administration (VHA) providers. Training of staff and providers, education efforts, outreach activities, and research on this subpopulation are critical to ensure equitable and high quality service delivery.

Decentralization and delivery of public services in Asia

Impact of decentralization on public service delivery is mixed. A meta-analysis of the studies suggests that impact of decentralization on public service delivery is contingent on factors such as the design of the decentralization policy; implementation bottlenecks and diluting the model of decentralization for accommodating the dissenting segments of stakeholders including employees; and participatory governance. In particular decentralization has resulted in improvements in delivery of local services where devolution as a mode of decentralization is accompanied by sound financial resource base of local governments, full autonomy to local governments in HRM matters, regular capacity building of local officials, performance based incentive structures, and participatory governance. In contrast where either truncated model of decentralization is adopted or the original model is diluted in favour of centralisation particularly in the form of imposition of central personnel policies, thus burdening local governments financially and in the process delivery of public services suffered. Rampant corruption and elite capture in the decentralized bodies have also hampered the equitable delivery of services.

Structural and Organizational Characteristics Associated With Performance of Essential Public Health Services in Small Jurisdictions

This study examined jurisdictional, organizational, and structural characteristics associated with capacity to deliver 10 essential public health services (EPHS) in Massachusetts, a state where a majority of local public health departments serve small municipalities. A survey was administered to local health directors or board of health chairs. The main outcome of the study was capacity to perform EPHS, measured by a 25-item screening tool. Seventy percent of the 351 boards of health in Massachusetts participated in the study. Greatest capacity was demonstrated in EPHS 2 (Diagnose and Investigate Health Problems) and EPHS 6 (Enforce Laws and Regulations). The capacity to perform the 8 other essential services was limited. Bivariate analysis indicates that overall capacity to perform EPHS is significantly associated with population size, poverty rate, annual municipal budget, and perceived understanding of the roles and responsibilities of local boards of health among elected municipal officials. The latter was the strongest predictor of overall capacity in multivariate analysis. Findings are aligned with studies examining factors associated with capacity to perform EPHS in large public health jurisdictions. The results suggest that one strategy for improving capacity to perform EPHS in smaller jurisdictions is to educate elected municipal leaders about the responsibilities of local health officials. Clarification regarding the role small jurisdictions with limited resources can play to ensure the equitable delivery of essential public health services and a strategy for measuring their contributions is important, especially as the national public health accreditation program gains momentum in the United States.

Transition in South African water governance: Insights from a perspective on power

After apartheid, South Africa has stepped up to the challenge of reforming an inequitable water service delivery system to meet the needs of all citizens. We frame this systematic societal change as a transition in water governance. We argue that when evaluating this pathway of transition, we should not only look at the changes in water legislation and number with improved access, but also analyze the quality of the water service delivery in terms of different payment schemes, participation by local citizens and conflicts around equality of water provision. By analyzing power in transition studies, we explore the power dynamics at play in two regions of Johannesburg, namely Alexandra and Soweto. The paper highlights the need to explicate the politics of water service delivery and suggests opportunities to break the negative patterns in order to achieve equitable and sustainable water service delivery in South Africa.

Cost of providing sustainable water, sanitation and hygiene (WASH) services: an initial assessment of a life-cycle cost approach (LCCA) in rural Andhra Pradesh, India

Water, sanitation and hygiene (WASH) service levels remain stubbornly low in rural India despite high levels of public expenditure recently. In many areas, this is because service levels have slipped back for reasons including inadequate protection of water sources (quantity and quality) and more attention given to capital expenditure than expenditure on operational and capital maintenance. This paper argues that adoption of a life-cycle cost approach (LCCA) could play a significant role in rectifying this by providing a framework for identifying and plugging gaps in the present pattern of expenditure. It is argued that LCCA will provide a sound basis for implementing the WASH Guidelines released by the Rajiv Gandhi National Drinking Water Mission in 2010. These guidelines signal a shift away from viewing the provision of WASH services as primarily an engineering challenge to one that requires activities that include source protection, institution building and long-term support and pro-poor planning, all of which need to be budgeted for by WASH service providers and/or users. Preliminary findings indicate that LCCA can be used to assess actual life-cycle costs of sustainable, equitable and efficient WASH service delivery. The challenge now is to investigate how best LCCA can be mainstreamed into WASH planning and other governance processes.

Travelling all over the countryside: Travel‐related burden and financial difficulties reported by cancer patients in New South Wales and Victoria

To describe travel burden and travel-related financial burden experienced by cancer patients over the first year after diagnosis. Population-based longitudinal cohort of recent adult cancer patients diagnosed with the eight most incident cancers recruited from New South Wales and Victorian Cancer Registries. Self-report survey data were collected at 6 and 12 months after diagnosis from 1410 participants (city: n = 890; regional/remote: n = 520). Travel time to cancer treatment, living away from home for treatment, travel-related treatment decisions, extent of financial issues, unmet need for financial help. During the first 12 months after diagnosis, outer regional/remote residents had the greatest travel burden; 61% (n = 79) travelled at least 2 hours one way to receive treatment, and 49% (n = 66) lived away from home to receive treatment. Strongest associates of travel burden were living in regional/remote areas (odds ratio (OR) = 18.9-135.7), having received surgery (OR = 6.7) or radiotherapy (OR = 3.6). Between 6 and 12 months after diagnosis, 2% (n = 24) of patients declined cancer treatment because of the time it would take to get to treatment. Patients who travelled more than 2 hours or lived away for treatment reported significantly greater financial difficulties (38%; 40%) than those who did not (12%; 14%), even after adjusting for covariates. Travel burden is greatest for rural patients, and is associated with greater financial burden. Appropriate and adequate provision of travel and accommodation assistance schemes remains paramount to achieving equitable delivery of cancer services.

Preventive Care in Relation to Obesity: An Analysis of a Large, National Survey

Reports from the 1990s observed lower receipt of preventive care services among obese individuals, but a few recent studies in older adults and Department of Veterans Affairs (VA) patients have failed to do so. Additional studies, using population-based samples, are needed to understand whether disparities in care by obesity continue to exist in the U.S. To investigate whether receipt of preventive care services varies in relation to BMI. This study used data from the 2008 and 2009 Behavioral Risk Factor Surveillance System (analyzed in 2011), a state-based national telephone survey of non-institutionalized U.S. adults, to examine associations between receipt of preventive services (influenza and pneumococcal vaccination; cholesterol and HIV screening; fecal occult blood test; colonoscopy/sigmoidoscopy, mammogram, and Pap) and BMI category (normal, 18.5-24.9; overweight, 25-29.9; obese Class I, 30-34.9; obese Class II, 35-39.9; and obese Class III, ≥40), after adjusting for confounding factors. Receipt was lower for mammography and Pap testing (6.1 and 5.6 percentage points, respectively, relative to normal weight women) in obese Class III women. For immunizations, cholesterol screening, and colon cancer screening, receipt was similar or greater in overweight and obese individuals. This study suggests that for most services, obese individuals received as much if not more preventive health care as normal-weight individuals. Although these findings are reassuring, the evidence for disparities for cervical and breast cancer screening in obese women demonstrates that efforts to ensure more equitable service delivery are still needed.

Youth Justice: Challenges in Responding to Young People Convicted of Sexual Offences

The clinical and criminological literature on adolescents who have committed sexual offences indicates that the pathologisation of young people and a labelling or overly punitive response is likely to be more harmful than rehabilitative. Accordingly, therapeutic counselling and diversionary schemes are seen as preferable to custodial terms in most instances. For adolescents convicted of sex offences, clinicians identify the benefits of comprehensive therapeutic care which involves family and is sensitive to the young person’s context and culture. The benefits of this approach are documented and, although data are limited, indications are that recidivism is reduced where adolescents are provided with specialised counselling to encourage positive and non-abusive behaviours. In Australia, each state and territory has provisions for youth justice clients serving custodial or community orders for sexually abusive behaviours. Yet each jurisdiction experiences challenges in ensuring the delivery of equitable and comprehensive therapeutic services, particularly to regionally and remotely located youth. This paper draws on data from a national study of the therapeutic services to children and adolescents with sexualised or sexual offending behaviours. With attention to the difficulties in providing services to regionally and remotely located adolescents, this paper highlights challenges around lengthy remand terms, the provision of pre-offence diversionary programs, and the provision of specialised supervision for young people serving community orders. For example, jurisdictions with the largest geographic service areas face enormous difficulties in providing specialised supervision for community-based orders. At present, there are several jurisdictions where regionally and remotely located adolescents may serve the duration of a youth justice order without receiving specialised counselling to assist them in modifying their behaviours. The paper identifies the risks where specialised counselling cannot be provided, but also identifies specific initiatives designed to fill these gaps in service provision to youth justice clients.