Gaps In Service Provision Research Articles

Unfit offenders in NSW: paying the price for gaps in service provision

The Mental Health (Forensic Provisions) Act 1990 (NSW) was amended in 2013 to include section 54 A, enabling an application to be made for the extension of a forensic patient’s status. Thirteen patients were subject to an extension order between 2014 and 30 June 2018. Shared characteristics of these forensic patients were considered with a view to identifying the types of patients involved in these applications and the gaps in service provision that this might reflect. Nine out of the 13 patients subject to an extension order had a background of sexual offences, and all patients had either an intellectual disability and/or complex comorbid disorders, such as severe personality disorder. The extension orders coincide with gaps in the service provision in relation to the management of certain complex mental disorders, intellectual disability and problematic behaviours that lead to justice system involvement. The authors discuss the potential implications that these findings have for future resource allocation, legislative reform and service provision.

Clinical characteristics and care pathways of patients with personality disorder who died by suicide.

It is estimated that 1 in 10 people have a personality disorder. People with emotionally unstable personality disorder are at high risk of suicide. Despite being frequent users of mental health services, there is often no clear pathway for patients to access effective treatments. To describe the characteristics of patients with personality disorder who died by suicide, examine clinical care pathways and explore whether the care adhered to National Institute for Health and Care Excellence guidance. National consecutive case series (1 January 2013 to 31 December 2013). The study examined the health records and serious incident reports of patients with personality disorder who died by suicide in the UK. The majority had a diagnosis of borderline/emotionally unstable or antisocial personality disorder. A high proportion of patients had a history of self-harm (n = 146, 95%) and alcohol (n = 101, 66%) or drug misuse (n = 79, 52%). We found an extensive pattern of service contact in the year before death, with no clear pathway for patients. Care was inconsistent and there were gaps in service provision. In 99 (70%) of the 141 patients with data, the last episode of care followed a crisis. Access to specialised psychological therapies was limited; short-term in-patient admissions was adhered to; however, guidance on short-term prescribing for comorbid conditions was not followed for two-thirds of patients. Continuity and stability of care is required to prevent, rather than respond to individuals in crisis. A comprehensive audit of services for people with personality disorder across the UK is recommended to assess the quality of care provided.

Reducing adverse medication events in mental health: Australian National Survey.

To determine the extent to which evidence-based medication safety practices have been implemented in public and private mental health inpatient units across Australia. The Reducing Adverse Medication Events in Mental Health survey was piloted in Victoria, Australia, in 2015, and rolled out nationally in 2016. In total, 235 mental health inpatient units from all States and Territories in Australia were invited to participate. The survey included questions about the demographics of the mental health unit, evidence-based strategies to improve prescription writing, the administration and dispensing of medicines and pharmacy-led interventions, and also questions relating to consumer engagement in medication management and shared decision-making. The response rate was 45% (N = 106 units). Overall, the survey found that 57% of the mental health units had fully or partially implemented evidence-based medication safety practices. High levels of implementation (80%) were reported for the use of standardized medication charts such as the National Inpatient Medication Chart as a way to improve medication prescription writing. Most (71%) of the units were using standardized forms for recording medication histories, and 56% were using designated forms for Medication Management Plans. However, less than one-fifth of the units had implemented electronic medication management systems, and the majority of units still relied on paper-based documentation systems.Interventions to improve medicine administration and dispensing were not highly utilized. Individual patient-based medication distribution systems were fully implemented in only 9% of the units, with a high reliance (81%) on ward stock or imprest systems. Tall Man lettering for labelling was implemented in only one-third of the units.Pharmacy services were well represented in mental health units, with 80% having access to onsite pharmacist services providing assessments of current medications and clinical review services, adverse drug reaction reporting and management services, patient and carer education and counselling, and medicines information services. However, pharmacists were involved in only half of medical reconciliations. Their involvement in post-discharge follow-up was limited to 4% of units. Gaps in medication safety practices included limited use of individual patient supply systems for medication distribution, a high reliance on ward stock systems and high reliance on paper-based systems for medication prescribing and administration. With regards to service provision, clinical pharmacist involvement in medical reconciliation services, therapeutic drug monitoring and interdisciplinary ward rounds should be increased. Discharge and post-discharge services were major gaps in service provision.

Outpatient and community care for preventing pressure injuries in spinal cord injury. A qualitative study of service users' and providers' experience.

Qualitative exploratory study. Pressure injuries (PIs) are a major secondary condition occurring after spinal cord injuries (SCI). Optimization of outpatient and community care may be a promising approach to better support community-dwelling individuals with SCI in preventing PIs. The aim of this study was to examine the experiences of individuals with SCI, family caregivers and health professionals (HPs) in using or providing outpatient and community services for early treatment and prevention of PIs in SCI. Switzerland. Semi-structured interviews with a sample of Swiss residents community-dwelling individuals with SCI (n = 20), family caregivers (n = 5) and HPs (n = 22) were analysed using thematic analysis. General practitioners (GPs), home care providers, SCI-specialized outpatient clinics and an SCI-specialized nursing service are involved in the prevention and early treatment of PIs. Our findings show that the needs of individuals with SCI are not fully met: outpatient and community care is often fragmented, mono-professional and non-specialized, while persons with SCI and HPs prefer coordinated, inter-professional and specialized services for preventing and treating PIs. Our findings also highlight the challenges faced by HPs in providing care to individuals with SCI in the community. Although there seems to be a gap in service provision, there is the potential for improvement by better integrating the different providers in a network and structuring their collaborations. Concrete suggestions are: systematizing knowledge transfer to home care providers and GPs; redefining the role of involved HPs and individuals with SCI and reinforcing the role of the SCI-specialized nursing service.

Redressing responses to the treatment gap for people with alcohol problems: The overlooked role of untreated remission from alcohol problems

Abstract. Aims: The “treatment gap” for people with alcohol problems has been identified as very large in the literature. An array of responses to the treatment gap have been focussed upon, including changing the perceptions of untreated people in order to make them want treatment more. A separate approach identifies the treatment system itself as the cause of the treatment gap. The aim of this paper was to consider research on untreated remission from alcohol problems to better understand responses to the treatment gap. Methodology: Three areas of existing published literature were thematically reviewed and synthesised: treatment gap research, untreated remission from alcohol problems research, and treatment planning and system design research. Results: Including rates of untreated remission from alcohol problems reduces the size of the treatment gap considerably. Treatment planning models which estimate unmet demand are better suited than unmet need when identifying gaps in service provision. Responding to the treatment gap requires broadening the treatment system beyond the specialised setting, and the assumptions associated with the process and expected outcomes of remission may need revisiting. Conclusions: Treatment planning models are useful when identifying gaps in service provision, but more sophisticated inclusion of untreated remission data is required. The treatment response may need to be diversified to support the life circumstances and perspectives of people with alcohol problems, with one example (outlined in this paper) being the provision of digital support services.

Is the rise of crowdfunding for medical expenses in the United Kingdom symptomatic of systemic gaps in health and social care?

Crowdfunding for medical care is a new phenomenon but increasingly used by individuals to seek financial help to cover the costs of health care. Ethical concerns have been raised about medical crowdfunding, including implications for equity, resource allocation, medical decision-making, the promotion of non-evidence based therapies, platforms' lack of transparency and corporate interests. Medical crowdfunding efforts may point to shortcomings in health service provision, but they tend to have wider motivations and implications. However, there is no firm evidence base for establishing answers to even the most basic questions, such as who is seeking funds, for what, where and why. In this Essay, we provide an introduction to medical crowdfunding in the United Kingdom (UK). We synthesize what is currently known and the insights that might be gained from an exploratory review of 400 medical crowdfunding campaigns on the GoFundMe UK website: for instance, whether medical crowdfunding occurs in response to gaps in service provision, supports 'queue jumping' and how it relates to 'medical tourism'. We conclude with a call for research on medical crowdfunding in the UK (and elsewhere) as a means to better understand patients' perceived or actual unmet need for health and social care and inform policy development.

Mental and physical health in service member and veteran students who identify as American Indians and Alaskan natives

Objective The purpose of this study was to explore (a) current utilization rates of university mental health services among American Indian/Alaskan Native/Native Hawaiian (AI/AN/NH) student veterans and (b) predictors of mental health service utilization among AI/AN student veterans. Participants: Data for this cross-sectional study were obtained from the American College Health Association (ACHA)’s 2011–2014 National College Health Assessment II (n = 103). Methods: University mental health service utilization rates were calculated as a percentage for AI/AN/NH student veterans. Multivariable logistic regression was used to determine predictors of mental health service utilization. Results: Results showed that 14% of AI/AN/NH student veterans have used university mental health services. Predictors of mental health service utilization in this population included financial stress, lack of deployment during service, suicidal ideation, and a diagnosis of depression, model (13) = 162. 128, p < 0.001, Nagelkerke R 2 = 0.130. Conclusion: This research identified gaps in service provision for AI/AN service member and veteran students on college campuses and provided possible models for intervention development.

Utilisation of Medical Services and Outcomes at Adult Rape Clinic at Parirenyatwa Group of Hospitals, Zimbabwe.

Sexual violence is a major public health problem due to the associated risk of acquiring sexually transmitted infections, behavioural disorders and risk of committing suicide. The Adult Rape Clinic (ARC) was established at Parirenyatwa Hospital, Harare in 2009 with the objective of providing medical and support services for survivors of sexual violence in a safe and private environment. The data collected had never been analysed since the establishment of the clinic. We described the clients' profile and the services offered at the clinic to identify gaps in service provision and areas of improvement. A retrospective record review of data was carried out from the ARC collected from February 2009 to December 2017. We analyzed 2343 affidavits that were available. Out of 2343 records analysed, (2190) 93.5% were female and 6.5 % (153) were male. The median age was 23years (Q1=21; Q3= 29) for males and 19 years (Q1= 17; Q2=25) for females. Among the clients, 2164 (92.4%) received a baseline HIV test, and 263 females and 6 males tested positive. From 2010 to 2017, six clients' seroconversion was recorded. Only 863(36.8%) clients presented within 3 days after the sexual assault. About 40% of male victims were assaulted by someone they knew and 27% were married. The study recommends further research on the determinants of late presentation after sexual assault.

ESPO/BEHAVIORAL AND SOCIAL SCIENCES: SOCIAL RELATIONSHIPS, ISOLATION, AND WELL-BEING

The purpose of this symposium is twofold: (1) To present innovative research linking social relationships, isolation, and well-being among older adults, and (2) To highlight new and emerging scholars in the Behavioral and Social Sciences section of GSA. The papers in this symposium examine the repercussions of numerous relationships for well-being in later life. Huo and colleagues examine the impacts of contact with close and not-close social partners on physical activity, highlighting differences by gender. Polenick and colleagues focus on perhaps the closest of relationships in later life: marriage, analyzing longitudinal associations between discordant chronic conditions and depressive symptoms among older couples. Upenieks takes an intergenerational perspective, examining the embeddedness of adult children in older adults’ networks in the context of both depression onset and chronically high depressive symptomology. This paper also highlights the consequences of well-being for older adults’ social isolation, and not merely the reverse. Hladek and colleagues explore the subjective side of isolation among older adults with chronic disease, noting links between loneliness and self-efficacy that may have clinical and interventional significance. Lastly, Meinertz and Gilligan explore potential gaps in service provision that may increase rural older adults’ risk of isolation and abuse. Taken together, these five papers underscore the importance of various social relationships for older adults’ well-being, and suggest implications for how best to promote healthy aging. As discussant, Thomas will assess the strengths and limitations of these papers, and consider the contributions these studies – and new scholars – can make to the field.

MIND THE GAP: FINDINGS FROM THE AGE-FRIENDLY OXFORD COMMUNITY NEEDS ASSESSMENT

In November 2017, Oxford, OH joined the AARP network of Age-Friendly Communities (AFCs). The first step in building an action plan through the AARP process is conducting a community needs assessment. Scripps Gerontology Center adapted the AARP Community Survey Questionnaire and mailed surveys to a random sample of 700 Oxford residents aged 50 years and older. The response rate was 46.8%. For seven of the eight domains of livability, individuals were asked how important is it to have particular services in the community (Likert scale) and whether the community provides the services (response options: yes, no, not sure). The responses to these questions were used to calculate a perceived gap score. The purpose of this project was to identify which domains had the largest perceived gaps, then further analyze individual item gaps. The three domains with the largest gaps were transportation (50.6%), housing (47.7%), and health (46.2%). Further analysis of the 60 individual domain items provided information about the type of gap. For example, 84% of respondents found the item “affordable public transportation” important. However, of those who said it is important, 73% perceived a gap in service provision, and 64% of the gap was due to not knowing if Oxford provides it. Communities may interpret a “not sure” gap as an opportunity to restructure how they promote services to older individuals. Implications of this research include proposing different ways of analyzing needs assessment data so AFCs can make efficient and effective changes for older adults to age in place.

ADDRESSING OLDER ADULT SOCIAL ISOLATION AND ABUSE THROUGH RURAL OUTREACH AND INTER-ORGANIZATIONAL COLLABORATION

Elder abuse is commonly linked with social isolation and in a rural state, such as Iowa, older adults may be at increased risk of social isolation and elder abuse. A community-based needs assessment aimed to record the first-hand perspectives of service providers regarding the needs of older adults in rural areas across the state of Iowa, covering 54 of the 99 counties. Through a survey (N=202) and focus groups (N=24), service providers, including direct care, Area Agencies on Aging, law enforcement, and attorneys, offered ways in which to address the gaps in service provision and prevention of elder abuse. Based on survey and focus groups, suggestions included ways to decrease social isolation among older adults by improving service outreach, provider training, and inter-organization communication. Discussion will outline gaps in service outreach and address future inter-organizational collaboration and strategies to prevent social isolation and elder abuse in rural communities.

Delivering on the Sustainable Development Goals through long-term infrastructure planning

Through the provision of a range of essential services, infrastructure systems profoundly influence development. At a time of increasing global investment in infrastructure, there is a need to support practitioners in making informed choices in order to achieve progress toward sustainable development objectives. Using the 2030 Agenda for Sustainable Development (the SDGs) as a framework to structure infrastructure decision-making and trade-offs, this analysis develops a performance indicator system that assesses the potential development implications of a portfolio of infrastructure investments and policies. We develop metrics to assess the performance of infrastructure-linked targets. We then embed these metrics in a systems model that allows for the quantification of future infrastructure needs and the assessment of portfolios of infrastructure investments and policies that contribute to meeting these needs. These methods are applied to the small-island country of Curaçao, demonstrating the potential for meeting the SDGs through adoption of strategies of cross-sectoral infrastructure investments and policies in the energy, water, wastewater and solid waste sectors. In the face of growing demands for infrastructure services, we find that inaction with regard to infrastructure supply and demand will lead to a 28% decrease in average SDG achievement across these targets by 2030. We assemble a portfolio of interventions that provide infrastructure services across these four sectors that enable achievement of 19 SDG targets directly linked to infrastructure. These interventions imply scaling up of infrastructure where there are gaps in service provision, ranging from an overall 10% increase in the water sector to a 368% increase in waste sector infrastructure from current capacities by 2030. Achieving the SDGs does not necessarily imply more infrastructure: in the energy sector the sustainable policy implies demand reductions of 32% from current levels. Nearly 50% of the assessed targets require intervention in more than one sector, emphasising the interdependent nature of the infrastructure system. The analysis addresses future uncertainties around the key drivers of residential population and tourism growth on the island by modelling infrastructure needs for alternate scenario projections. Averaged across the four sectors, these needs range from −14% (low) to +5% (high) in relation to the moderate projection. The analysis provides the first step towards a practical means of utilising infrastructure to deliver the SDGs, using quantitative indicators to underpin effective decision-making.

Remembering the forgotten victims: Child-Related themes in domestic violence fatality reviews

BackgroundThe needs of children exposed to domestic violence have been historically overlooked. One way in which service provision for children exposed to this violence can be explored is through an examination of Domestic Violence Fatality Review Teams (DVFRT's), who review cases of fatal domestic violence to identify possible areas for improvement. ObjectiveThis study explored key themes relative to children exposed to domestic violence and homicide published by DVFRT's in order to identify the services that exist for children exposed to domestic violence, barriers to providing these services, and recommendations for improvement. Participants and SettingThis study reviewed annual reports from three DVFRT jurisdictions with regular annual reports from 2004 to 2016. MethodsA generic thematic analysis was performed by the primary author, in consultation with the second author, in order to identify dominant themes present in the DVFRT annual reports. The analysis utilized a codebook that was created beforehand in order to capture pertinent information within the reports. Trustworthiness of the data was established through a consistent application and thorough reporting of the coding procedures. ResultsThe analysis highlighted key barriers to child-specific service provision among agencies involved (e.g., lack of professional training and public awareness), recommendations for enhanced intervention (e.g., enhanced child-specific services) and promising practices (e.g., policy and legislation development). ConclusionsThe three DVFRTs identified several gaps in service provision for children affected by fatal domestic violence that will require increased engagement and resources targeting these vulnerable children.

Online Social anxiety Cognitive therapy for Adolescents (OSCA): protocol for a randomised controlled trial

BackgroundAdolescent social anxiety disorder (SAD) is common, impairing and persistent. There is a need to intervene early to avert its long-term consequences. Cognitive Therapy for SAD is the leading treatment for adults and shows promise for adolescents. However, given the scale of the problem of adolescent SAD and the limited availability of psychological therapists in child and adolescent mental health services, there is a substantial gap in service provision. Delivering therapy via the Internet may provide part of the solution to this problem. An Internet version of adult Cognitive Therapy for SAD has been developed, with outcomes similar to face-to-face therapy. We have recently adapted this treatment for use with adolescents with SAD. Here, we describe a randomised controlled trial designed to test the efficacy of Internet Cognitive Therapy for adolescent SAD compared to waitlist.Methods/designForty adolescents aged 14–18 years with a diagnosis of SAD will be recruited via schools. Participants will be randomly allocated to Internet Cognitive Therapy or to waitlist. All participants will be assessed three times during the study—at baseline (pretreatment/wait), midtreatment/wait (week 8) and posttreatment/wait (week 15). Participants in the experimental arm will also complete weekly measures as part of the online program and they will be assessed at 3 and 6 months. Postwait, participants in the waitlist arm will be offered Internet Cognitive Therapy, and weekly and posttreatment data will also be collected for them. The trial aims to test whether Internet Cognitive Therapy is superior to waitlist in reducing social anxiety symptoms and in reducing the proportion of adolescents meeting criteria for SAD. Other outcomes of interest include depression and general anxiety symptoms. Acceptability of the online treatment will also be evaluated.DiscussionThis randomised controlled trial will provide preliminary evidence on whether this intervention, requiring relatively low levels of therapist input, is safe and clinically effective. If this is shown to be the case, Internet Cognitive Therapy for adolescents has the potential to provide a service to the large population of adolescents with untreated SAD.Trial registrationISRCTN Registry, ISRCTN15079139. Version 1 registered on 06/02/2019.

Improving the quality of communication during handover in a Paediatric Emergency Department: a qualitative pilot study.

SummaryIntroductionThere is a dearth of literature that specifically addresses the handover reporting process among healthcare staff working in children’s Emergency Department (ED). Widespread gaps in service provision, such as gaps in communication in handover reports to ambulance staff have been noted in the general literature on the topic. There are also improvements observed in handover when a structured mnemonic was encouraged. Structured reports improve communication, safety and may reduce medication errors. Thus, the improvement of handover reporting in children’s ED has important implications for children’s healthcare practice. However, little is known about communication processes during handover reports in Italian children’s ED or its consequences for errors or risks.MethodsA qualitative description methodology was used. Semi-structured interviews were used to collect data from five children’s ED nurses. Thematic content analysis was used to identify common themes.ResultsEmergent themes were: interpersonal influences on handover; structural issues; and local contextual factors.ConclusionsThe findings of this pilot study prompted the need for a standardized tool that improves communication during handover. As such, standardizing the communication process during handover could be effectively resolved by using a mnemonic tool adapted for handover in a paediatric emergency department.

Asking women about disabilities during maternity care (the ABLE study): Exploring how women with a disability are identified, and what percentage of women identify as having a disability

people with learning disabilities (LD) are increasingly likely to become parents and are entitled to have access to the right support to be able to be suitable parents. However, access to such support is affected by limited resources, attitudes towards people with LD becoming parents, and lack of training regarding caring for parents with learning disabilities for midwives. A learning disability (LD) is defined as a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), reduced skills to cope independently with everyday life, has an impact on most areas of a person’s life and the difficulties started in early childhood. Little research has explored health professionals’ experiences of their support of people with LD during their journey to become parents. Midwives are often the first professionals pregnant women come into contact with and therefore are key professionals in the support system for parents with LD. The principle objective of the current research is to develop an understanding of midwives’ experiences of caring for women with a LD.the study explored midwives׳ experiences of caring for women with LD using an Interpretative Phenomenological Approach (IPA).nine qualified midwives employed by a single NHS trust participated in the study.a semi-structured interview schedule was utilised during one-to-one interviews with the midwives. The interview transcripts were analysed using IPA stages. Four superordinate themes were identified.The midwives reported receiving a lack of LD training and faced significant time constraints, which left them feeling that they could not spend the necessary time with the women to meet their pregnancy needs. The midwives felt unsupported in their attempts to deliver adequate midwifery care, speaking about a lack of accessible support for pregnant women with LD. They were left feeling responsible to fill the gaps in service provision. The midwives were dedicated in delivering adequate care to help give women with LD a positive experience of childbearing. They felt a safeguarding process (child protection) was an inevitable part of women with LD’s pregnancy experience yet were aware that the right support at the right time could improve parenting capacity.it is recommended that training on working with and providing services for people with LD is made available to qualified and student midwives as well as accessible resources, professional support and supervision.

A Qualitative Study on the Transition Support Needs of Indigenous Australians Following Traumatic Brain Injury

AbstractObjective:A growing body of qualitative literature globally describes post-hospital experiences during early recovery from a traumatic brain injury. For Indigenous Australians, however, little published information is available. This study aimed to understand the lived experiences of Indigenous Australians during the 6 months post-discharge, identify the help and supports accessed during transition and understand the gaps in service provision or difficulties experienced.Methods and Procedure:Semi-structured interviews were conducted at 6 months after hospital discharge to gain an understanding of the needs and lived experiences of 11 Aboriginal and Torres Strait Islander Australians who had suffered traumatic brain injury in Queensland and Northern Territory, Australia. Data were analysed using thematic analysis.Results:Five major themes were identified within the data. These were labelled ‘hospital experiences’, ‘engaging with medical and community-based supports’, ‘health and wellbeing impacts from the injury’, ‘everyday living’ and ‘family adjustments post-injury’.Conclusions:While some of the transition experiences for Indigenous Australians were similar to those found in other populations, the transition period for Indigenous Australians is influenced by additional factors in hospital and during their recovery process. Lack of meaningful interaction with treating clinicians in hospital, challenges managing direct contact with multiple service providers and the injury-related psychological impacts are some of the factors that could prevent Indigenous Australians from receiving the supports they require to achieve their best possible health outcomes in the long term. A holistic approach to care, with an individualised, coordinated transition support, may reduce the risks for re-admission with further head injuries.

The chiropractic workforce: a global review

BackgroundThe world is faced with a chronic shortage of health workers, and the World Health Organization (WHO) has estimated a global shortage of 7.2 million health workers resulting in large gaps in service provision for people with disability. The magnitude of the unmet needs, especially within musculoskeletal conditions, is not well established as global data on health work resources are scarce.MethodsWe conducted an international, cross-sectional survey of all 193 United Nation member countries and seven dependencies to describe the global chiropractic workforce in terms of the availability (numbers and where they are practising), quality (education and licensing), accessibility (entry and reimbursement), and acceptability (scope of practice and legal rights). An electronic survey was issued to contact persons of constituent member associations of the World Federation of Chiropractic (WFC). In addition, data were collected from government websites, personal communication and internet searches. Data were analysed using descriptive statistics. Worldwide density maps of the distribution of numbers of chiropractors and providers of chiropractic education were graphically presented.ResultsInformation was available from 90 countries in which at least one chiropractor was present. The total number of chiropractors worldwide was 103,469. The number of chiropractors per country ranged from 1 to 77,000 (median = 10; IQR = [4–113]). Chiropractic education was offered in 48 institutions in 19 countries. Direct access to chiropractic services was available in 81 (90%) countries, and services were partially or fully covered by government and/or private health schemes in 46 (51.1%) countries. The practice of chiropractic was legally recognized in 68 (75.6%) of the 90 countries. It was explicitly illegal in 12 (13.3%) countries.ConclusionWe have provided information about the global chiropractic workforce. The profession is represented in 90 countries, but the distribution of chiropractors and chiropractic educational institutions, and governing legislations and regulations largely favour high-income countries. There is a large under-representation in low- and middle-income countries in terms of provision of services, education and legislative and regulatory frameworks, and the available data from these countries are limited.

Strengthening the scale-up and uptake of effective interventions for sex workers for population impact in Zimbabwe.

Introduction UNAIDS’ goal of ending AIDS by 2030 is unreachable without better targeting of testing, prevention and care. Female sex workers (FSW) in Zimbabwe are at high risk of HIV acquisition and transmission. Here, we report on collated programme and research data from Zimbabwe's national sex work programme. We also assess the potential for wider population impact of FSW programmes by modelling the impact on HIV incidence of eliminating transmission through FSW (i.e. calculate the population attributable fraction of incidence attributable to sex work).MethodsDescriptive analyses of individual‐level programme data collected from FSW between 2009 and June 2018 are triangulated with data collected through 37 respondent driven sampling surveys from 19 sites in Zimbabwe 2011 to 2017. We describe programme coverage, uptake, retention and patterns of sex work behaviour and gaps in service provision. An individual‐level stochastic simulation model is used to reconstruct the epidemic and then the incidence compared with the counter‐factual trend in incidence from 2010 had transmission through sex work been eliminated from that date.ResultsSisters has reached >67,000 FSW since 2009, increasing attendance as number of sites, programme staff and peer educators were increased. Over 57% of all FSW estimated to be working in Zimbabwe in 2017 (n = 40,000) attended the programme at least once. The proportion of young FSW reached has increased with introduction of the “Young Sisters programme.” There are no clear differences in pattern of sex work across settings. Almost all women report condom use with clients at last sex (95%); however, consistent condom use with clients in the last month varies from 52% to 95% by site. Knowledge of HIV‐positive status has increased from 48 to 78% between 2011 and 2016, as has prevalence of ART use among diagnosed women (29 to 67%). Although subject to uncertainty, modelling suggests that 70% (90% range: 32%, 93%) of all new infections in Zimbabwe from 2010 are directly or indirectly attributable to transmission via sex work.ConclusionsIt is feasible to increase coverage and impact of sex work programming through community‐led scale‐up of evidence‐based interventions. Eliminating transmission through commercial sex would likely have a substantial impact on new infections occurring more widely across Zimbabwe.

Using co-creation and multi-criteria decision analysis to close service gaps for underserved populations.

BackgroundNavigating treatment pathways remains a challenge for populations with complex needs due to bottlenecks, service gaps and access barriers. The application of novel methods may be required to identify and remedy such problems.ObjectiveTo demonstrate a novel approach to identifying persistent service gaps, generating potential solutions and prioritizing action.DesignCo‐creation and multi‐criteria decision analysis in the context of a larger, mixed methods study.Setting and participantsCommunity‐dwelling sample of older women living alone (OWLA), residing in Melbourne, Australia (n = 13‐37). Convenience sample of (n = 11) representatives from providers and patient organizations.InterventionsNovel interventions co‐created to support health, well‐being and independence for OWLA and bridge missing links in pathways to care.Main outcome measuresPerformance criteria, criterion weights , performance ratings, summary scores and ranks reflecting the relative value of interventions to OWLA.ResultsThe co‐creation process generated a list of ten interventions. Both OWLA and stakeholders considered a broad range of criteria when evaluating the relative merits of these ten interventions and a “Do Nothing” alternative. Combining criterion weights with performance ratings yielded a consistent set of high priority interventions, with “Handy Help,” “Volunteer Drivers” and “Exercise Buddies” most highly ranked by both OWLA and stakeholder samples.Discussion and conclusionsThe present study described and demonstrated the use of multi‐criteria decision analysis to prioritize a set of novel interventions generated via a co‐creation process. Application of this approach can add community voice to the policy debate and begin to bridge the gap in service provision for underserved populations.