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Social determinants of health

Social determinants of health Letters 21 October 2019 Free

The Guttmacher–Lancet Commission on sexual and reproductive health and rights: how does Australia measure up?

To the Editor: The authors of a recent Guttmacher–Lancet Commission article1 point out that Australia is a signatory to the United Nations Sustainable Development Goals, which nominate sexual and reproductive health as rights. The key focus of the article on the Guttmacher–Lancet Commission is around human immunodeficiency virus and sexually transmitted infections, unintended pregnancy, contraception, abortion, and sexual violence.1 These are all important reproductive health rights to address. While the Guttmacher–Lancet Commission also includes maternal and newborn health, there is no mention of reproductive carrier screening. Reproductive carrier screening involves testing prospective parents — before pregnancy, ideally, or in the early stage of pregnancy — for carrier status for autosomal recessive and X‐linked recessive disorders, and giving reproductive choices to people at increased risk of having an affected child. These choices include pre‐implantation genetic diagnosis, prenatal diagnosis by chorionic villus sampling or amniocentesis, donor gametes or embryos, adoption, having no children, or ignoring the risks. Most couples with or at risk of having an affected child have no family history, which is typical for recessively inherited diseases. Reproductive carrier screening is available in Australia, although only through a fee‐for‐service mechanism, but most couples are unaware of its availability. Currently, screening for cystic fibrosis, fragile X syndrome, and spinal muscular atrophy is available,2 and in the future we may be able to screen for a vastly expanded number of diseases. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has recently released a position statement to recommend that all women, either before pregnancy or in the first trimester, should be offered carrier screening for inherited conditions.3 Reproductive carrier screening should be a routine part of pregnancy care and should be considered a health care right.

R John Massie · Martin B Delatycki

Mja2 50350
Medical education Letters 7 October 2019 Free

Flinders medical students pilot free clinic for homeless men

To the Editor: Student‐run clinics (SRCs) empower students to employ logistics, operational management and clinical skills to provide free or affordable health care to underserved populations. SRCs have the dual benefits of student learning and care for underserved patients and promote health equity, interprofessionalism and student leadership.1,2 These clinics are well established in North America but are nascent in Australia. Some sections of the Australian population still face challenges accessing health care, including Aboriginal and Torres Strait Islander people, refugees and rural and homeless populations;3 SRCs not only meet this need but also assist with the growing demand for clinical placements for medical and allied health students.4 In 2012, the first Australian SRC began providing medical, nursing, social work and physiotherapy services in Melbourne,3 and similar clinics have also sprouted in New South Wales and Queensland.2,5 In the same vein, medical students from Flinders University in Adelaide piloted the Flinders Student Run Clinic (FSRC), with the support of faculty and of the Vinnie's Men's Crisis Centre, which provides crisis accommodation, meals, showers and case management for up to 47 homeless and vulnerable men aged over 18 years. From December 2016 to January 2017, student volunteers staffed weekend shifts providing consultations to residents. Clinic days were well subscribed, with about a dozen clients attending each session. Students were surveyed before and after volunteering on aspects of clinical training, preparedness and motivation. Out of 24 medical student volunteers, eight responded to the pre‐survey and six to the post‐survey. Before volunteering, students believed their clinical knowledge and skills would improve and they would be able to manage problems and unexpected events. After volunteering, students were less confident in their abilities and felt less valuable to the clinic, but were more prepared to work with vulnerable individuals, face morally challenging issues and achieve their goals. Volunteering also clarified students’ motivations and values, demystifying primary care with underserved populations, and they were motivated to be involved in similar programs in the future. Feeling less prepared may stem from exposure to responsibilities as primary health care staff on the ground. Further studies can explore expectation‐matching for different parties and the financial impact of similar programs. Furthermore, the use of SRCs in Australia to both teach and serve the community should be encouraged.

Andrew IH Phua · Yvonne K Parry

Environmental health Letters 1 July 2019 Free

Identifying the cultural heritage of patients during clinical handover and in hospital medical records

To the Editor: In the recently published article by Morgan and colleagues1 and associated podcast, the authors raised the issue of future research into the outcomes of identification of Aboriginal and Torres Strait Islander peoples in hospital. The implementation of a visual identification methodology has previously been described2 and was put in place in partnership with the hospital department of Aboriginal health. The purpose of this identification initiative was to encourage all medical professionals who care for Aboriginal and Torres Strait Islander patients to question what they can do to assist them while they are in hospital. We describe here the positive outcomes of this process. In addition to hospital pharmacists,2 the visual alert system is also used by other departments and professionals within the hospital, such as cardiothoracic care, the emergency department (ED), Aboriginal health, and speech pathology, as well as ward‐based nursing and medical staff. The Aboriginal and Torres Strait Islander patients’ identification system is used by health care providers within the hospital to easily identify the patients they need to visit, to provide culturally appropriate resources and services and links to other services, and to enhance the care patients receive and enable them to remain in a caring hospital environment. At ward level, nursing and medical staff use the identification system to highlight the referral process needed to link with Aboriginal health workers — connecting the right resources to the right people. Because of the visual alert,2 staff feel more aware of the cultural needs of the patient before they meet them. Specifically in the ED, there is a system‐wide approach that firstly identifies Aboriginal and Torres Strait Islander patients presenting to the ED using the visual alert at triage, and then implementing initiatives that aim to reduce the level of “did not wait for treatment” episodes. The Heart and Lung Stream at St Vincent's Hospital uses the system to identify Aboriginal and Torres Strait Islander patients early during their admission in order to provide culturally specific education, resources and follow‐up after hospital discharge. We encourage others to explore this initiative in their hospital, together with cultural responsiveness training, to enhance the care of Aboriginal and Torres Strait Islander peoples during and after their hospital visit.

Susan A Welch · Sonia Robinson · Tamra Langley · Pauline Deweerd

Health occupations Letters 18 February 2019 Free

Increasing registrations on the Australian Organ Donor Register

To the Editor: Many people are aware that Australia has an opt‐in system for recording organ donation decisions; and many are also aware that, historically, donation decisions were recorded on the driver's licence. What is not well known is that, in 2000, the Australian Organ Donor Register (AODR) was introduced as a register of consent (or objection), and that, between 2005 and 2012, the recording of donation decisions (except for South Australia) was transitioned from the driver's licence to registration on the national register, the AODR.1 Five years on, 53% of the people we surveyed in New South Wales (n = 802) were unaware that donation decisions were no longer recorded on the driver's licence,2 and less than a third of eligible Australians had registered their decision on the AODR.3 The implications of this are profound. Consent to donate by the next‐of‐kin in the intensive care unit is 90% when decisions are registered on the AODR, but only 44% when the decision is unknown.4 We have responded to the need to increase registration rates by developing5 an immediate registration opportunity, which combines the opportunity to discuss donation in a face to face interaction with the opportunity to register on the AODR immediately.2 Participants’ concerns, fears and questions about donation are prompted through a brief survey about organ donation beliefs, which facilitates discussion and allows misconceptions to be addressed. The participants are then asked if they would like to register on the AODR. This initiative has been successful in increasing AODR registrations among the general public at a range of locations in NSW in 2017,2 and we had even higher success rates when we rolled this out in two NSW hospital‐based settings (Box). Integral to the success of the immediate registration opportunity is the consistent finding that the public and health care staff simultaneously hold positive beliefs and negative concerns about organ donation. Addressing the tension created by these dichotomous beliefs through face to face interaction, coupled with the ease and immediacy of on‐the‐spot registration, facilitates the registration decision. We believe that offering the immediate registration opportunity nationally in hospital‐based settings and in the community has the potential to increase registrations in the AODR dramatically. Box – Percentage of participants who registered on the day at the public and private hospitals from particpants who had not yet registered and were eligible to do so

Gail Moloney · Michael Sutherland · Maddison Norton · Alison Bowling · Iain Walker

Mja2 50000
Health services administration Letters 19 November 2018 Free

Health protection and Australian prisons, 2018

To the Editor: In 2007 and again in 2012, we highlighted in the Medical Journal of Australia1,2 the limited access Australian prisoners had to essential health protection measures. Six years on, we can only report that progress has been minimal (Box). In August 2012, the Australian Capital Territory Chief Minister announced the implementation of a needle exchange program for prisoners in the ACT; 6 years later, the ACT government retracted its commitment. Canada has recently agreed to a pilot prison-based needle exchange, with a commitment to national implementation in 2019. Human immunodeficiency virus (HIV) is still not a concern in Australian prisons, although bleach provision and condoms are still severely restricted in Queensland and the Northern Territory, and effectively not available in Victoria and Tasmania. Hepatitis B immunisation coverage continues to improve, and chronic hepatitis B infection is not increasing among Aboriginal and Torres Strait Islander prisoners.3 The availability of direct-acting antiviral treatments for hepatitis C infection for all Australians, including prisoners, has some Australian prisons already reporting treatment achievements commensurate to international treatment targets for 20304 — the term “micro-elimination” has been applied to facility by facility reduction of burden of this infection. However, despite reductions in hepatitis C in Australian prisons, the risk of transmission is ever present.5 The predictors of successful return to the community include housing, employment and maintenance of relationships;6 yet, private family (conjugal) visits are only allowed in some Victorian prisons and in one South Australian prison farm. Visits are definitely not available to ACT prisoners, since previous enabling policy was repealed in 2014. Safer sex is still an elusive aspiration for the majority of Australian prisoners and their families. Tattoo and body piercing programs are being implemented in prisons in Luxembourg and Catalonia, Spain. Despite this activity being successfully regulated in the community, there are still no verifiable reports of sanctioned programs in Australian prisons. In 2012, we questioned Australia’s commitment to protecting the health of prisoners.2 With changes in prison harm reduction programs internationally (notably, Canada) underpinned by legal challenges, we foresee that similar proceedings could have a place in finally driving reform in Australia. Box – Progress in Australian prisoners’ access to essential health protection measures Jurisdiction Changes since 2012 Australian Capital Territory Bleach available in single unit sachets; micro-elimination of hepatitis C from the only prison; private family visits ceased; support for a prison needle exchange program withdrawn New South Wales Micro-elimination of hepatitis C from several prisons Northern Territory No notable changes Queensland Still considering opiate replacement therapy; micro-elimination of hepatitis C from one prison South Australia Private visits available at one prison farm Tasmania Micro-elimination of hepatitis C from one prison Victoria Micro-elimination of hepatitis C from several prisons Western Australia Poor uptake of hepatitis C treatment

Michael H Levy · Carla J Treloar

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