Australia’s mainstream health services located in rural contexts are mandated to provide health care to the entire local population. However, complex power relations embedded and reflected within the cultures of mainstream generalist health services are excluding the most marginalised residents from health care. This paper argues that unless inclusion in rural, generalist mainstream health services is improved, the health experiences of these residents will not substantially change and Australia will continue to report significant health differentials within its population. The concept of culturally inclusive health care is difficult for Australian mainstream generalist health practitioners to engage with because there is limited understanding of what culture is and how it operates within diverse communities. This makes it challenging for many in mainstream health institutions to begin deconstructing how it is that exclusion occurs. Frequently, ‘culture’ is assigned to ‘Others’, and there is little recognition that all people, including White, mainstream Australians, are cultural beings, and that health disciplines, services and systems have particular cultures that make assumptions about how to be in the world. Consequently, current approaches to the provision of culturally inclusive health care are not shifting the power relations that (re)produce exclusion. In this paper, we outline a new interdisciplinary methodology that operationalises Foucault’s concepts of power, resistance and discourse within a Participatory Action Research (PAR) design and utilises Continuous Quality Improvement (CQI) processes to respond to these power relations and provide health institutions with a process to improve their inclusivity, specifically for Australia’s most marginalised residents. It is suggested that employing this new methodology will promote a different way of thinking and acting in health institutions, producing a deconstructed process for health services to adapt to improve their inclusivity.

BACKGROUND: Ovarian cancer is a metastatic disease and one of the leading causes of gynaecology malignancy-related deaths in women. Cancer stem cells (CSCs) are key contributors of cancer metastasis and relapse. Integrins are a family of cell surface receptors which allow interactions between cells and their surrounding microenvironment and play a fundamental role in promoting metastasis. This study investigates the molecular mechanism which associates CSCs and integrins in ovarian cancer metastasis. METHODS: The expression of Oct4A in high-grade serous ovarian tumors and normal ovaries was determined by immunofluorescence analysis. The functional role of Oct4A was evaluated by generating stable knockdown (KD) of Oct4A clones in an established ovarian cancer cell line HEY using shRNA-mediated silencing. The expression of integrins in cell lines was evaluated by flow cytometry. Spheroid forming ability, adhesion and the activities of matrix metalloproteinases 9/2 (MMP-9/2) was measured by in vitro functional assays and gelatin zymography. These observations were further validated in in vivo mouse models using Balb/c nu/nu mice. RESULTS: We report significantly elevated expression of Oct4A in high-grade serous ovarian tumors compared to normal ovarian tissues. The expression of Oct4A in ovarian cancer cell lines correlated with their CSC-related sphere forming abilities. The suppression of Oct4A in HEY cells resulted in a significant diminution of integrin β1 expression and associated α5 and α2 subunits compared to vector control cells. This was associated with a reduced adhesive ability on collagen and fibronectin and decreased secretion of pro-MMP2 in Oct4A KD cells compared to vector control cells. In vivo, Oct4A knock down (KD) cells produced tumors which were significantly smaller in size and weight compared to tumors derived from vector control cells. Immunohistochemical analyses of Oct4A KD tumor xenografts demonstrated a significant loss of cytokeratin 7 (CK7), Glut-1 as well as CD34 and CD31 compared to vector control cell-derived xenografts. CONCLUSION: The expression of Oct4A may be crucial to promote and sustain integrin-mediated extracellular matrix (ECM) remodeling requisite for tumor metastasis in ovarian cancer patients.

The purpose here is to establish the incidence of respiratory tract colonization with Candida (RT Candida) among ICU patients receiving mechanical ventilation within studies in the literature. Also of interest is its relationship with candidemia and the relative importance of topical antibiotic (TA) use as within studies of selective digestive decontamination (SDD) versus other candidate risk factors towards it. The incidence of RT Candida was extracted from component (control and intervention) groups decanted from studies of various TA and non-TA ICU infection prevention methods with summary estimates derived using random effects. A benchmark RT Candida incidence to provide overarching calibration was derived using (observational) groups from studies without any prevention method under study. A multi-level regression model of group level data was undertaken using generalized estimating equation (GEE) methods. RT Candida data were sourced from 113 studies. The benchmark RT Candida incidence is 1.3; 0.9-1.8 % (mean and 95 % confidence intervals). Membership of a concurrent control group of a study of SDD (p = 0.02), the group-wide presence of candidemia risk factors (p < 0.001), and proportion of trauma admissions (p = 0.004), but neither the year of study publication, nor membership of any other component group, nor the mode of respiratory sampling are predictive of the RT Candida incidence. RT Candida and candidemia incidences are correlated. RT Candida incidence can serve as a basis for benchmarking. Several relationships have been identified. The increased incidence among concurrent control groups of SDD studies cannot be appreciated in any single study examined in isolation.

PURPOSE: To estimate the direct and indirect (contextual) effects of the factorized constituents of selective digestive decontamination and selective oropharyngeal decontamination (SDD/SOD), being topical antibiotic (TA) and protocolized antifungal prophylaxis (PAFP), on ICU-acquired candidemia. METHODS: A broad range of ICU candidemia incidence studies were sourced to serve as points of reference. The candidemia incidence was extracted from component (control and intervention) groups decanted from studies of various designs (concurrent or non-concurrent) and whether investigating SDD/SOD versus non-TA methods of ICU infection prevention. The candidemia incidences were summarized in regression models using generalized estimating equation (GEE) methods. Groups derived from observational studies (no prevention method under study) provided an overarching external benchmark candidemia incidence for calibration. RESULTS: Within studies investigating SDD/SOD, the mean (and 95% confidence interval) candidemia incidence among concurrent component groups (40 control; 2.4%; 1.7-3.2% and 43 intervention groups; 2.4%; 1.6-3.1%), but not non-concurrent control groups (11 groups; 1.6%; 0.1-2.7%), is higher than that of the benchmark candidemia incidence derived from 54 observational groups (1.5%; 1.2-1.9%). The TA constituent within SDD/SOD has significant direct and indirect (contextual) effects in GEE models even after adjusting for the publication year and the group-wide presence of either candidemia risk factors or PAFP use. CONCLUSION: The TA constituent of SDD/SOD is associated with a contextual effect on candidemia incidence which is similar in magnitude to that of the conventional candidemia risk factors and against which PAFP partially attenuates. This increase is inapparent within individual SDD/SOD studies examined in isolation.

BACKGROUND: Medical termination of pregnancy (MToP) is a safe and acceptable abortion option. Depending on country context, MToP can be administered by general practitioners and mid-level healthcare providers in the first and second trimesters of pregnancy. Like other high-income countries, a range of social and structural barriers to MToP service provision exist in Australia. To counter some of these barriers, geographic decentralization of MToP was undertaken in rural Victoria, Australia, through training service providers about MToP to increase service delivery opportunities. The aim of this study was to investigate the factors that enabled and challenged the decentralization process. METHODS: Face-to-face and telephone interviews were undertaken between April and June 2016 with a purposeful sample of six training providers and 13 general practitioners (GP) and nurse training participants. Study participants were asked about their perceptions of motivations, enablers and challenges to MToP provision. A published conceptual framework of synergies between decentralization and service delivery was used to analyse the study findings. RESULTS: Three key themes emerged from the study findings. First, the effort to decentralize MToP was primarily supported by motivations related to making service access more equitable as well as the willingness of training providers to devolve their informal power, in the form of MToP medical expertise, to training participants. Next, the enablers for MToP decentralization included changes in the regulatory environment relating to decriminalization of abortion and availability of required medication, formation of partnerships to deliver training, provision of MToP clinical resources and local collegial support. Finally, challenges to MToP decentralization were few but significant. These included a lack of a state-wide strategy for service provision, provider concerns about coping with service demand, and provider stigma in the form of perceived negative community or collegial attitudes. These were significant enough to create caution for GPs and nurses considering service provision. CONCLUSIONS: Decentralization concepts offer an innovative way for reframing and tackling issues associated with improving MToP service delivery. There is scope for more research about MToP decentralization in other country contexts. These findings are important for informing future rural MToP service expansion efforts that improve equity in service access.

Studies examining the association between muscle size, muscle strength, and bone mineral density (BMD) are limited. Thus, this study aimed to describe the association between hip muscles cross-sectional area (CSA), muscle strength, and BMD of the hip and spine. A total of 321 subjects from the Tasmanian Older Adult Cohort study with a right hip MRI scan conducted between 2004 and 2006 were included. Hip muscles were measured on MR images by OsiriX (Geneva) software measuring maximum muscle CSA (cm(2)) of gluteus maximus, obturator externus, gemelli, quadratus femoris, piriformis, pectineus, sartorius, and iliopsoas. Dual-energy X-ray absorptiometry measured total hip, femoral neck, and spine BMD, and lower limb muscle strength was assessed by dynamometer. Muscle CSA of the hip flexors (pectineus, sartorius, and iliopsoas) and the hip rotators, obturator externus, and quadratus femoris were associated with both total hip and femoral neck BMD (all p < 0.05). The associations between CSA of pectineus and sartorius and BMD were stronger in women (p = 0.01-0.001) compared to men (p = 0.12-0.54). Additionally, only gemelli CSA was associated with BMD of the spine (p = 0.002). Gluteus maximus and piriformis showed no relationship with BMD. CSA of most hip muscles (except gluteus maximus and gemelli) were positively associated with leg strength (p = 0.02 to <0.001). Lastly, leg strength was weakly associated with BMD (p = 0.11-0.007). Hip muscle CSA, and to a lesser extent muscle strength, were positively associated with hip BMD. These data suggest that both higher muscle mass and strength may contribute to the maintenance of bone mass and prevention of disease progression in older adults.

The Deaf usually do not see themselves as having a disability; however, discourses and social stereotyping continue to portray the Deaf rather negatively. These discourses may lead to misconceptions, prejudice and possibly discrimination. A study was conducted to identify the challenges members of the Deaf community experience accessing quality health care in a small Island state of Australia. Using a qualitative approach, semi-structured interviews and focus groups were conducted with service providers and the Deaf community. Audist discourses of deafness as deficiency, disability and disease remain dominant in contemporary society and are inconsistency with the Deaf community’s own perception of their reality. Despite the dominant constructions of deafness and their affect on the Deaf’s experience of health service provision, many Deaf have developed skills, confidence and resilience to live in the hearing world. The Deaf were pushing back on discourses that construct deafness as a disempowering impairment.

BACKGROUND: Although many pregnant women report fear related to the approaching birth, no consensus exists on how fear of birth should be handled in clinical care. OBJECTIVE: This randomized controlled trial aimed to compare the efficacy of a guided internet-based self-help program based on cognitive behavioral therapy (guided ICBT) with standard care on the levels of fear of birth in a sample of pregnant women reporting fear of birth. METHODS: This nonblinded, multicenter randomized controlled trial with a parallel design was conducted at three study centers (hospitals) in Sweden. Recruitment commenced at the ultrasound screening examination during gestational weeks 17-20. The therapist-guided ICBT intervention was inspired by the Unified protocol for transdiagnostic treatment of emotional disorders and consisted of 8 treatment modules and 1 module for postpartum follow-up. The aim was to help participants observe and understand their fear of birth and find new ways of coping with difficult thoughts and emotions. Standard care was offered in the three different study regions. The primary outcome was self-assessed levels of fear of birth, measured using the Fear of Birth Scale. RESULTS: We included 258 pregnant women reporting clinically significant levels of fear of birth (guided ICBT group, 127; standard care group, 131). Of the 127 women randomized to the guided ICBT group, 103 (81%) commenced treatment, 60 (47%) moved on to the second module, and only 13 (10%) finished ≥4 modules. The levels of fear of birth did not differ between the intervention groups postintervention. At 1-year postpartum follow-up, participants in the guided ICBT group exhibited significantly lower levels of fear of birth (U=3674.00, z=-1.97, P=.049, Cohen d=0.28, 95% CI -0.01 to 0.57). Using the linear mixed models analysis, an overall decrease in the levels of fear of birth over time was found (P≤ .001), along with a significant interaction between time and intervention, showing a larger reduction in fear of birth in the guided ICBT group over time (F1,192.538=4.96, P=.03). CONCLUSIONS: Fear of birth decreased over time in both intervention groups; while the decrease was slightly larger in the guided ICBT group, the main effect of time alone, regardless of treatment allocation, was most evident. Poor treatment adherence to guided ICBT implies low feasibility and acceptance of this treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT02306434; https://clinicaltrials.gov/ct2/show/NCT02306434 (Archived by WebCite at http://www.webcitation.org/70sj83qat).

Objective: To classify a rural community sample by their modifiable health behaviours and identify the prevalence of chronic conditions, poor self-rated health, obesity and hospital use. Method: Secondary analysis of a cross- sectional self-report questionnaire in the Hume region of Victoria, Australia. Cluster analysis using the two-step method was applied to responses to health behaviour items. Results: 1,259 questionnaires were completed. Overall 63% were overweight or obese. Three groups were identified: 'Healthy Lifestyle' (63%), 'Non Smoking, Unhealthy Lifestyle' (25%) and 'Smokers' (12%). 'Healthy lifestyle' were older and more highly educated than the other two groups while 'Non Smoking, Unhealthy Lifestyle' were more likely to be obese. 'Smokers' had the highest rate of poor self-rated health. Prevalence of chronic conditions was similar in each group (>20%). 'Smokers' were twice as likely to have had two or more visits to hospital in the preceding year even after adjustment for age, gender and education. Conclusion: High rates of overweight and obesity were identified but 'Smokers' were at the greatest risk for poor self-rated health and hospitalisation. Implications for Public Health: Within an environment of high rates of chronic ill health and obesity, primary care clinicians and public health policy makers must maintain their vigilance in encouraging people to quit smoking.

BACKGROUND: Engagement is essential in trials research but is rarely embedded across all stages of the research continuum. The development, use, effectiveness and value of engagement in trials research is poorly researched and understood, and models of engagement are rarely informed by theory. This article describes an innovative methodological approach for the development and application of a relational model of engagement in a stepped wedge designed cluster randomised controlled trial (RCT), the CORE study. The purpose of the model is to embed engagement across the continuum of the trial which will test if an experience-based co-design intervention improves psychosocial recovery for people affected by severe mental illness. METHODS: The model was developed in three stages and used a structured iterative approach. A context mapping assessment of trial sites was followed by a literature review on recruitment and retention of hard-to-reach groups in complex interventions and RCTs. Relevant theoretical and philosophical underpinnings were identified by an additional review of literature to inform model development and enactment of engagement activities. RESULTS: Policy, organisational and service user data combined with evidence from the literature on barriers to recruitment provided contextual information. Four perspectives support the theoretical framework of the relational model of engagement and this is organised around two facets: the relational and continuous. The relational facet is underpinned by relational ethical theories and participatory action research principles. The continuous facet is supported by systems thinking and translation theories. These combine to enact an ethics of engagement and evoke knowledge mobilisation to reach the higher order goals of the model. CONCLUSIONS: Engagement models are invaluable for trials research, but there are opportunities to advance their theoretical development and application, particularly within stepped wedge designed studies where there may be a significant waiting period between enrolment in a study and receipt of an intervention.

BACKGROUND: Acinetobacter species such as Acinetobacter baumanii are of increasing concern in association with ventilator associated pneumonia (VAP). In the ICU, Acinetobacter infections are known to be subject to seasonal variation but the extent of geographic variation is unclear. The objective here is to define the extent and possible reasons for geographic variation for Acinetobacter associated VAP whether or not these isolates are reported as Acinetobacter baumanii. METHODS: A meta-regression model of VAP associated Acinetobacter incidence within the published literature was undertaken using random effects methods. This model incorporated group level factors such as proportion of trauma admissions, year of publication and reporting practices for Acinetobacter infection. RESULTS: The search identified 117 studies from seven worldwide regions over 29 years. There is significant variation in Acinetobacter species associated VAP incidence among seven world-wide regions. The highest incidence is amongst reports from the Middle East (mean; 95 % confidence interval; 8.8; 6 · 2-12 · 7 per 1000 mechanical ventilation days) versus that from North American ICU's (1 · 2; 0 · 8-2 · 1). There is a similar geographic related disparity in incidence among studies reporting specifically as Acinetobacter baumanii. The incidence in ICU's with a majority of admission being for trauma is >2.5 times that of other ICU's. CONCLUSION: There is greater than fivefold variation in Acinetobacter associated VAP among reports from various geographic regions worldwide. This variation is not explainable by variations in rates of VAP overall, admissions for trauma, publication year or Acinetobacter reporting practices as group level variables.