Testing for sexually transmitted infections in a population-based sexual health survey: development of an acceptable ethical approach

Population-based research is enhanced by biological measures, but biological sampling raises complex ethical issues. The third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3) will estimate the population prevalence of five sexually transmitted infections (STIs) (Chlamydia trachomatis, Neisseria gonorrhoeae, human papillomavirus (HPV), HIV and Mycoplasma genitalium) in a probability sample aged 16-44 years. The present work describes the development of an ethical approach to urine testing for STIs, including the process of reaching consensus on whether to return results. The following issues were considered: (1) testing for some STIs that are treatable and for which appropriate settings to obtain free testing and advice are widely available (Natsal-3 provides all respondents with STI and healthcare access information), (2) limits on test accuracy and timeliness imposed by survey conditions and sample type, (3) testing for some STIs with unknown clinical and public health implications, (4) how a uniform approach is easier to explain and understand, (5) practical difficulties in returning results and cost efficiency, such as enabling wider STI testing by not returning results. The agreed approach, to perform voluntary anonymous testing with specific consent for five STIs without returning results, was approved by stakeholders and a research ethics committee. Overall, this was acceptable to respondents in developmental piloting; 61% (68 of 111) of respondents agreed to provide a sample. The experiences reported here may inform the ethical decision making of researchers, research ethics committees and funders considering population-based biological sampling.     

Reform in Australian medical schools: a collaborative approach to realising Indigenous health potential

The Australian medical education system is at a critical juncture in relation to what and how it delivers for Aboriginal and Torres Strait Islander health. Since 2004, three key organisations concerned with medical education have worked to provide a toolkit for implementation of sustainable reform within medical schools. The aim is a medical workforce trained in Indigenous health, and more Aboriginal and Torres Strait Islander doctors, leading to better health for Australia's Indigenous peoples.     

When the tide goes out: health workforce in rural, remote and Indigenous communities

There is compelling evidence for the success of the "rural pipeline" (rural student recruitment and rurally based education and professional training) in increasing the rural workforce. The nexus between clinical education and training, sustaining the health care workforce, clinical research, and quality and safety needs greater emphasis in regional areas. A "teaching health system" for non-metropolitan Australia requires greater commitment to teaching as core business, as well as provision of infrastructure, including accommodation, and access to the private sector. Workforce flexibility is mostly well accepted in rural and remote areas. There is room for expanding the scope of clinical practice by non-medical clinicians in both an independent codified manner (eg, nurse practitioners) and through flexible local medical delegation (eg, practice nurses, Aboriginal health workers, and therapists). The imbalance between subspecialist and generalist medical training needs to be addressed. Improved training and recognition of Aboriginal health workers, as well as continued investment in Indigenous entry to other health professional programs, remain policy priorities.     

Changes in mental health literacy about depression: South Australia, 1998 to 2004

OBJECTIVE: To identify changes in mental health literacy in regard to depression between 1998 and 2004. DESIGN AND SETTING: Face-to-face interviews with a random and representative sample of the South Australian population in 2004, compared with a similarly conducted survey in 1998 that used the same vignette, questions and methodology. PARTICIPANTS: 3015 randomly selected participants, aged 15 years and over. MAIN OUTCOME MEASURES: Responses to both open-ended and direct questions about symptoms and treatment options for depression. RESULTS: The 3015 interviews conducted represented a response rate of 65.9%. Compared with 1998, in 2004 there was a significant increase in the proportion of people recognising depression in the vignette, acknowledging personal experience of depression, and perceiving professional assistance to be more helpful and less harmful. However, although more people nominated psychiatrists or psychologists as therapists of choice, the difference between 1998 and 2004 was not significant. CONCLUSIONS: There has been a significant increase in mental health literacy, at least as regards depression, in the South Australian community between 1998 and 2004. The lack of significant change in psychiatrists and/or psychologists being perceived as therapists of choice is of concern and suggests that community education about their expertise may be appropriate.     

发展和促进结合医学研究中的公共卫生学方法：来自澳大利亚的范例

目前中国的结合医学研究很大程度上关注于临床和实验研究,这对于确定结合医学治疗手段的疗效和提高结合医学的地位有重要意义。然而,扩展结合医学的研究范围,将公共卫生学领域的研究方法和观点引入结合医学,对于更好地认识临床实践的意义及协助政府和专业机构制定结合医学领域的方针政策会起到重要作用。本文介绍了作者前期研究中将公共卫生学的研究方法应用于补充替代医学的使用与澳大利亚不同地域不同人群的关系的研究当中,以研究范例的形式强调了这些研究方法在结合医学领域研究中的应用价值。     

"Folate before pregnancy": the impact on women and health professionals of a population-based health promotion campaign in South Australia

OBJECTIVES: To evaluate a South Australian campaign to promote and implement knowledge that taking adequate folate/folic acid in the periconceptional period can reduce the risk of having a baby with a neural tube defect. DESIGN AND SETTING: The campaign, conducted in October 1994--August 1995, targeted women of reproductive age and health professionals. Evaluation was by computer-assisted telephone interviews undertaken by random dialling throughout the State before and after the campaign, and by self-administered questionnaires to health professionals and women in the postnatal period. PARTICIPANTS: Women of reproductive age and four groups of health professionals. MAIN OUTCOME MEASURES: Knowledge about folate, folate-rich foods and the periconceptional period; participation of health professionals in advising women about folate; use of periconceptional folic acid supplements; sales of folic acid tablets; and prevalence of neural tube defects. RESULTS: Significant increases in knowledge about folate followed the campaign. Health professionals and women in the postnatal period had higher initial levels of knowledge about folate, which also increased significantly. The proportions of women taking periconceptional folic acid supplements, and of health professionals advising women planning a pregnancy about folate, also increased significantly, and folic acid tablet sales doubled. Total prevalence of neural tube defects declined between 1966 and 1999 from a baseline of 2.0 per 1,000 births to 1.1 per 1,000 births (Poisson regression, P= 0.03; average decline of 1.0% per year). CONCLUSIONS: A short educational campaign with a limited budget ($40,000) can promote folate successfully, but alternative strategies such as food fortification are likely to be needed to achieve adequate periconceptional folate intake for a very high proportion of women.     

Attitudes and behaviours of young Indigenous people in Townsville concerning relationships, sex and contraception: the "U Mob Yarn Up" project

OBJECTIVE: To gain some understanding of the attitudes and behaviours of Indigenous young people in Townsville concerning relationships, contraception and safe sex. DESIGN: Cross-sectional study using a computer-assisted self-administered survey and single-sex focus group discussions designed by a Young Mums' Group operating on participatory action principles and acting as peer interviewers. PARTICIPANTS AND SETTING: 171 Indigenous students in Years 9-11 at three high schools and 15 residents of a homeless youth shelter in Townsville, Queensland, 27 April - 8 December 2004. MAIN OUTCOME MEASURES: Self-reported attitudes and behaviour about relationships, sexual intercourse and contraception. RESULTS: 84/183 participants (45.9%) reported past sexual intercourse, with 56.1% commencing intercourse at age 13-14 years. The likelihood of having had sex increased with being male (P=0.001), increasing age, increased perceived sexual activity of peer group (both P=0.000), and drinking alcohol at least weekly (P=0.015). Young women were more likely to report unwanted sexual touching (P=0.031), and less likely to report enjoying sexual intercourse (P=0.001). The main qualitative themes concerned females' reputations, coercion, and denial of female desire. Only 49/80 participants (61.3%) reported always using condoms. The main reasons for not using contraception were "just not thinking about it", shame, and problems with access. Despite having reasonable knowledge about contraception, most lacked the confidence and negotiation skills to communicate with partners about condom use. CONCLUSIONS: Like teenagers elsewhere, Indigenous teenagers in Townsville are becoming sexually active at a young age, and not practising safe sex reliably. The need to protect their reputations puts young women at risk by not being prepared for safe sex by carrying condoms.     

Enhancing humanistic skills: an experiential approach to learning about ethical issues in health care.

An outstanding feature of the study of nursing ethics is that it raises questions concerning moral virtue, conscience, consistency and character. A considerable section of the literature is devoted to ideas of how best to teach ethics to health professionals. It has been shown that when faced with ethical dilemmas nurses tended to rely on intuition and instinct to resolve them, with little systematic analysis to help the process. Nurses who have been in practice for a number of years may experience particular difficulties in resolving ethical dilemmas, for although they may be able easily to identify ethical problems they may feel powerless to behave appropriately through lack of theoretical background and/or confidence in participating in informed debate. An educational programme was designed to meet the needs of mature registered nurses who were undertaking a post-qualification part-time honours degree in nursing studies. A variety of teaching methods were employed in teaching the nurses. These included discussion, student-led seminars, structured debate and role play. A session which dealt with sudden death and organ donation is described in some detail. Because the topic involved communication between professionals and patients and/or relatives and was linked with ethics, role play was used to explore the dynamics in these areas. The participants were invited to act out the situation as they felt it might occur. Role play highlighted the stress and shock attached to such an experience. Before working through the dynamics of a situation the nurses were conscious of being part of decision-making 'in the cold' and 'in isolation'. As a result of the experiential learning they felt more able to reflect analytically and to participate in discussions in an informed and articulate way.