Journal articles on the topic '230204 Public services policy advice and analysis'

Policymakers recognize that investments and investment decisions are vitally important to the financial stability of many families. Poor investment advice may result in decisions which may, in a literal sense, financially cripple a family. With the importance of investment decisions in mind, the purpose of this research is to explore the potential efficacy of public policy proposals designed to remedy the problems consumers have with the investment and financial services markets. To accomplish this purpose, this research takes a micro look at how consumers evaluate and choose investment services, a unique perspective for an impact evaluation.

Although considerable weight has been placed on the economist's advice in many areas of public policy, it is suggested that this has not been the case in the pricing of sport and leisure facilities and services. This paper provides an overview of the extent to which economic analysis can be used in the pricing of publicly funded sport and leisure facilities and services. It is reasoned that such facilities and services display both public-good attributes and positive externalities. As such, market pricing is an inappropriate allocation mechanism. Some problems associated with the practical application of economic models to determine user fees in publicly owned sport and leisure facilities are highlighted. An overview of some of the current issues in public facility management and allocation is offered, along with suggestions for further research.

This article focuses to analyze the roots of violence and this article examines at case studies from Indonesia. This article also aims at answering the effectiveness of policy in the conflict management by analysing the critical factors that involved in violent conflicts and briefly seek alternative solution to prevent it to happen in the future. This article aims to answer two central questions, firstly, how effective the Indonesian government policy on security and conflict. Secondly, what are the roles of NGOs to support the effectiveness of the policy on security and conflict. To prevent the future conflicts, there are three effective strategies that can be implemented and it need the collaboration between the policymakers and society. First, to design an effective early warning mechanism which able to inform a potential friction that can escalate to bigger conflict. Second, an effective policy to prevent conflict, to manage conflict, and peace building mechanisms in post-conflict. Third, urge the participation of non-state actors in conflict management. The Indonesian government and house of representatives have passed the bill on social conflict management written as Law No. 7/2012 or known as UU PKS. However, UU PKS arguably leaves plenty of loopholes. Moreover, the activities of NGOs on the conflict management can be divided into two main categories: public engagement and advocacy. Public engagement activities focus on services to the public while on the advocacy focuses to maintain communication and put pressure to the government. In public engagement activities, the NGOs offer the service to provide psychological and legal assistance, consulting the victims rights, consulting, legal advice, psychosocial support to the victims. Moreover, in the advocacy approach, the NGOs maintain the discussion and lobby to the government to ensure the peace and justice in law enforcement.

Purpose – The purpose of this paper is to present a framework integrating theoretical insights, empirical research and practical advice emerging from public service motivation (PSM) and self-determination theory (SDT). It aims at demonstrating that, while PSM shows the relevance of public values for motivation, SDT explains how context affects it. Taking the two theoretical approaches as complementary to one another and by pointing out their “static” and “dynamic” features, the framework provides a theoretical foundation for organizational practices aimed at enhancing motivation in the public services. Design/methodology/approach – The framework is based on a review of PSM and SDT theoretical concepts and empirical studies; the analysis examines the implications and contributions of each approach to the understanding of motivation in the public services. Findings – The paper demonstrates that PSM and SDT are complementary theoretical approaches and that this complementarity can provide clearer guidance to practitioners and widen the understanding of motivation in the public services. Research limitations/implications – The framework considers only a few features pertaining motivation in the public services, such as public values, basic needs satisfaction, prosocial behaviour and socialization. Further research should explore additional factors. Practical implications – The framework provides an explanation of why some practices are likely to enhance motivation in the public services, while others are likely to deplete it. Originality/value – The framework does not limit itself to proposing the theoretical integration of PSM and SDT, but connects this integration to organizational practices.

Abstract Objective To conduct patient and public involvement (PPI) to gain insight into the experience of healthy eating and weight management advice during pregnancy. Design PPI in the planning and development of health interventions, aiming to ensure patient-centred care. Optimum nutrition and weight management are vital for successful pregnancy outcomes, yet many services report poor attendance and engagement. Setting Community venues in Liverpool and Ulster (UK). Participants Two PPI representatives were involved in all aspects of the study: design, interview questions, recruitment and collection/analysis of feedback. Intervention Feedback was collected via note taking during group discussions, two in Liverpool (n = 10 & 5); two in Ulster (n = 7 & 9) and an interview (n = 1, in Ulster). Main Outcome Measures Transcript data were collated and thematic analysis was applied in analysis. Results Thematic analysis identified three themes: (i) weight gain is inevitable in pregnancy; (ii) healthy eating advice is important but currently lacks consistency and depth and (iii) expectations regarding the type of knowledge/support. Conclusions PPI provides opportunity to enhance research design and offers valuable insight towards the needs of healthcare users. Pregnant women want positive health messages, with a focus on what they can/should do, rather than what they should not do. Midwives need to consider their communication with pregnant women, to ensure that their unique relationship is maintained, especially when the topics of diet and weight management are addressed. A well-designed digital intervention could improve access to pregnancy-specific nutrition information; empowering midwives to communicate patient-centred, healthy eating messages with confidence. This has the potential to change dietary and weight management behaviour in pregnant women.

General practitioners and maternal, child and family health nurses have a central role in postpartum primary health care for women and their infants. Positive client-provider relationships are particularly important for women experiencing mental health problems or unsettled infant behaviour. However, little is known about their experiences of postnatal primary health care. The study aimed to describe views of postnatal primary health care among women completing a residential early parenting programme and to identify potential strategies to enhance provider-patient interactions. Participants (n = 138) were women admitted with their infants to a private or a public early parenting service in Melbourne, Australia. Women completed a detailed self-report survey, including open-ended questions about experiences of primary health-care services, and a structured psychiatric interview to diagnose anxiety and depression. Survey responses were analysed thematically. Womens’ experiences of primary health care were influenced by their perceptions of provider competence and the quality of interactions. While similar positive characteristics of doctor and nurse care were valued, medical and nursing practices were judged in different ways. Women described GPs who listened, understood and were thorough as providing good care, and maternal, child and family health nurses were valued for providing support, advice and encouragement. Threats to therapeutic relationships with doctors included feeling rushed during consultations, believing that GPs were not mental health-care providers and the clinician not being ‘good’ with the infant; with nurses, problems included feeling judged or given advice that was inconsistent or lacked an evidence-base. Postpartum primary health care will be improved by unhurried consultations, empathic recognition, encouragement, evidence-informed guidance and absence of criticism.

Assistive technology was once a specialised field of practice, involving products designed for populations with specific impairments or functional goals. In Australia, occupational therapists have, at times, functioned as gatekeepers to public funding, prescribing products from a predefined list. An expanding range of accessible mainstream products available via international and online markets has changed the meaning and application of assistive technology for many people with disability. In the policy context of consumer choice and cost-effectiveness, have occupational therapists been left behind? This paper describes the change in context for access to assistive technology resulting in expanded possibilities for participation and inclusion. A case study of environmental control systems is used to explore the overlap of mainstream and assistive products and the funding and services to support their uptake. The analysis describes a future policy and practice context in which assistive technology includes a spectrum of products decoupled from access to independent advice and support services. A broader scope of occupational therapy practice has potential to enhance the occupational rights of people with disability and the efficiency and effectiveness of assistive technology provision.

The objective of this study was to discuss ideas for improving child health services on the basis of findings of an observational study that was designed to explore the role of child health nurses in supporting parents during the first 6 months following the birth of an infant. As part of a larger study in a child health service in urban Australia, surveys were used to collect data from two independent samples of both parents and nurses at an 8-month interval. Data were condensed using factor analysis; regression analyses were used to determine which aspects of care were most important for the parents, and importance–performance analysis was used to determine which aspects of care needed improvement. While the majority of parents valued support from child health nurses, a need for improvement was identified in empowering parents to make their own decisions, discussing emotional issues with parents, providing continuity of care and giving consistent advice. Organisations should value and provide support for child health nurses in their invisible, non-quantifiable work of supporting families. The structure of child health services should also provide child health nurses continuity of care with the families they support.

Purpose This study aims to outlines the findings of the first qualitative evidence synthesis of empirical research on the impact of the No Recourse to Public Funds (NRPF) rule which prevents most temporary migrants from accessing social security benefits in the UK. Design/methodology/approach The review used the 2020 Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol guidelines. Data were analysed by using Thomas and Harden’s (2008) thematic synthesis methodology. An initial 321 articles were identified from 13 databases, of which 38 studies met the inclusion criteria. Findings The key insights were that NRPF causes destitution and extreme poverty and has a disproportionate impact on racialised women. Studies found that support services were underdeveloped, underfunded, inconsistent and had a culture of mistrust and racism towards migrants. Migrants were often fearful of services due to concerns around deportation, destitution and state intervention around children. Research limitations/implications The review focussed on qualitative research. Future empirical and theoretical research is needed in the following areas: NRPF as a practice of everyday bordering, the role of the Home Office in creating and sustaining the policy; differing gendered experiences of NRPF; and a broader geographical scope which includes all four UK nations and takes an international comparative approach. Originality/value Despite an estimated 1.4 million people in the UK with NRPF (Citizens Advice, 2020), there is little policy or theoretical discussion of the experience of having NRPF or the implications of the rule. This lack of analysis is a significant gap in both our understanding of the landscape of poverty in the UK, and the ways in which immigration policies create extreme poverty. To the best of the authors’ knowledge, this paper is the first systematic qualitative review on NRPF, bringing together the research evidence on how NRPF negatively affects outcomes for migrants, local authority and voluntary sector responses to NRPF and theoretical perspectives on NRPF.

Problem crying in the first few months of life is both common and complex, arising out of multiple interacting and co-evolving factors. Parents whose babies cry and fuss a lot receive conflicting advice as they seek help from multiple health providers and emergency departments, and may be admitted into tertiary residential services. Conflicting advice is costly, and arises out of discipline-specific interpretations of evidence. An integrated, interdisciplinary primary care intervention (‘The Possums Approach’) for cry-fuss problems in the first months of life was developed from available peer-reviewed evidence. This study reports on preliminary evaluation of delivery of the intervention. A total of 20 mothers who had crying babies under 16 weeks of age (average age 6.15 weeks) completed questionnaires, including the Crying Patterns Questionnaire and the Edinburgh Postnatal Depression Scale, before and 3−4 weeks after their first consultation with trained primary care practitioners. Preliminary evaluation is promising. The Crying Patterns Questionnaire showed a significant decrease in crying and fussing duration, by 1 h in the evening (P = 0.001) and 30 min at night (P = 0.009). The median total amount of crying and fussing in a 24-h period was reduced from 6.12 to 3 h. The Edinburgh Postnatal Depression Scale showed a significant improvement in depressive symptoms, with the median score decreasing from 11 to 6 (P = 0.005). These findings are corroborated by an analysis of results for the subset of 16 participants whose babies were under 12 weeks of age (average age 4.71 weeks). These preliminary results demonstrate significantly decreased infant crying in the evening and during the night and improved maternal mood, validating an innovative interdisciplinary clinical intervention for cry-fuss problems in the first few months of life. This intervention, delivered by trained health professionals, has the potential to mitigate the costly problem of health professionals giving discipline-specific and conflicting advice post-birth.

Introduction The objective of this study was to examine the barriers that influence access to and use of mental health services by Black youths in Alberta. Methods We used a youth-led participatory action research (PAR) methodology within a youth empowerment model situated within intersectionality theory to understand access to health care for both Canadian-born and immigrant Black youth in Alberta. The research project was co-led by an advisory committee consisting of 10 youths who provided advice and tangible support to the research. Seven members of the advisory committee also collected data, co-facilitated conversation cafés, analyzed data and helped in the dissemination activities. We conducted in-depth individual interviews and held four conversation café-style focus groups with a total of 129 youth. During the conversation cafés, the youths took the lead in identifying issues of concern and in explaining the impact of these issues on their lives. Through rigorous data coding and thematic analysis as well as reflexivity and member checking we ensured our empirical findings were trustworthy. Results Our findings highlight key barriers that can limit access to and utilization of mental health services by Black youth, including a lack of cultural inclusion and safety, a lack of knowledge/information on mental health services, the cost of mental health services, geographical barriers, stigma and judgmentalism, and limits of resilience. Conclusion Findings confirm diverse/intersecting barriers that collectively perpetuate disproportional access to and uptake of mental health services by Black youths. The results of this study suggest health policy and practice stakeholders should consider the following recommendations to break down barriers: diversify the mental health service workforce; increase the availability and quality of mental health services in Black-dominated neighbourhoods; and embed anti-racist practices and intercultural competencies in mental health service delivery.

Objective: Choices and quality decisions made by consumers in relation to their healthcare have been associated with personal experience of those services, interpersonal engagement and reliance on third-party information, as well as the subsequent satisfaction with the service. The purpose of this research was to understand current information sources, determinants of quality discernment and decision-making factors by consumers in the Australian community in relation to healthcare. Method: Conventional content analysis research was undertaken in the form of a national telephone survey of 200 consumers. Open-ended questions were used to elicit information from the general community. Results: Reputation and other key interpersonal and structural elements are utilised in determining quality of healthcare services as well as in deployment as key factors in decision-making regarding use of healthcare services. While most respondents valued and used key information about provider relationships, outcomes performance and performance rankings, up to 20% of respondents did not know or could not identify ways in which they would assess and evaluate the quality of healthcare services. Conclusion: This research identifies that consumers use a range of information and advice relating to experience, interpersonal engagement and information from third-party sources. If healthcare providers develop clearer communications around their technical, procedural and conduct principles, consumers will be in a better position to evaluate reputation and make decisions about their healthcare needs and the health system.

Patients with oral health problems often attend GPs instead of dentists, particularly in rural areas. There has been little research exploring challenges in providing oral health care in urban general practice. A cross-sectional survey of GPs in Greater Western Sydney explored their experiences, knowledge, confidence, and their oral health educational needs. Descriptive statistics and content analysis was undertaken. Forty-nine GPs reported experience of a wide range of oral health presentations. Approximately 60% were confident to undertake oral health examinations and determine the cause of acute toothache. Although 87% were confident providing preventative oral health advice, most did not include this in routine health assessments. Only 41% were confident explaining eligibility for public dental services. Barriers to providing oral health care were time constraints, lack of equipment and limited oral health training. Our research highlights oral health support and training needs in urban Australian general practice, as well as the need for systems-wide change to oral health training in outer urban settings to tackle health inequity, similar to those advocated in rural Australia.

Modern medicine develops rapidly in the digital direction, and new information and telemedicine technologies are actively introduced in clinical practice. Purpose. To identify the category of cardiac surgical patients interested in the remote dynamic follow-up after the discharge from the hospital, using the Internet services and the factors that affect this. Material and methods. The study was conducted at the base of the department of surgical treatment of interactive pathology of the Bakoulev National Medical Research Center for Cardiovascular Surgery of the Russian Federation. The study was prospective. Before the discharge, patients answered a series of questions combined into an anonymous questionnaire. The questions concerned education, social status of the patient, age, gender, patient interest in remote follow up after discharge, use of the Internet and social networks, satisfaction with the treatment. Results. The study included 652 patients with a mean age of 58±12.5 years. 44% of them were women, 56% were men. More than 85% of patients expressed a positive opinion about such an initiative as using web services for remote consulting. Further analysis was aimed to identify possible differences between those patients who answered positively about remote follow up and those who were not interested. Statistically significant differences were revealed in the following indicators: education, sex, age, frequency of Internet use, use of social networks, place of residence and work status. Conclusions. The study confirms the demand among patients for the availability of services for their remote follow-up, which would perform the function of providing expert advice and the storage of archives of patients’ medical documents. Younger patients who are active Internet users and who have university education are potentially interested in this service. Such services would allow the patient to keep in touch with the doctor of the Department where surgical treatment was carried out, which would undoubtedly increase patients’ adherence to the treatment and recommendations.

BackgroundTreatment-related toxicity and delays in the management of this toxicity can impact the outcomes of patient with cancer. In Scotland, a national cancer helpline was established to provide triage assessment for patients receiving systemic anticancer therapy (SACT) in an attempt to minimise delays in toxicity management. In this article, we describe the use and impact of the helpline in our region over the last 5 years.MethodsPatients who contacted the NHS Tayside cancer helpline between 1 January 2016 and 31 December 2020 were retrospectively identified. Patient demographics as well as the reason and outcome of each call was recorded. A descriptive analysis was performed.Results6562 individual patients received SACT and 8385 calls were recorded during the time period. Median age of callers was 63 years (range 17–98) and 59.2% were women. Use of the helpline increased by 83.6% between 2016 and 2020, driven by an increase in in-hours calls. 41% of calls required review by a healthcare professional only, 24% required review and admission and the remaining 35% telephone advice only. The majority of cases (85%) were either assessed or advised solely by oncology. The proportional use of general practitioner services has decreased.ConclusionsThe helpline provides a way for patients to report symptoms directly to their clinical team and receive appropriate specialist advice at an early stage. We demonstrate that most of these calls can be managed solely by our oncology team. This system can reduce pressure on other parts of the local health system.

Background Analyzing Twitter posts enables rapid access to how issues and experiences are socially shared and constructed among communities of health service users and providers, in ways that traditional qualitative methods may not. Objective To enrich the understanding of mental health crisis care in the United Kingdom, this study explores views on crisis resolution teams (CRTs) expressed on Twitter. We aim to identify the similarities and differences among views expressed on Twitter compared with interviews and focus groups. Methods We used Twitter’s advanced search function to retrieve public tweets on CRTs. A thematic analysis was conducted on 500 randomly selected tweets. The principles of refutational synthesis were applied to compare themes with those identified in a multicenter qualitative interview study. Results The most popular hashtag identified was #CrisisTeamFail, where posts were principally related to poor quality of care and access, particularly for people given a personality disorder diagnosis. Posts about CRTs giving unhelpful self-management advice were common, as were tweets about resource strains on mental health services. This was not identified in the research interviews. Although each source yielded unique themes, there were some overlaps with themes identified via interviews and focus groups, including the importance of rapid access to care. Views expressed on Twitter were generally more critical than those obtained via face-to-face methods. Conclusions Traditional qualitative studies may underrepresent the views of more critical stakeholders by collecting data from participants accessed via mental health services. Research on social media content can complement traditional or face-to-face methods and ensure that a broad spectrum of viewpoints can inform service development and policy.

Aim This exploratory study of commissioning third sector services for older people aimed to explore whether service data was fed back to commissioners and whether this could improve intelligence about the population and hence inform future commissioning decisions. Background Third sector services are provided through charities and non-profit community organizations, and over recent years services have developed that assess and advise people for self-management or provide wellbeing support in the community. Third sector services have an opportunity to reach vulnerable populations and to provide intelligence about them. Some third sector services are state funded (commissioned) in the United Kingdom. While evidence is available about the commissioning of statutory health and social care, as well as private providers, there is limited evidence about how third sector health services are funded. Methods Participants were recruited from commissioner organizations and third sector organizations, both with an interest in supporting the independence, self-management and wellbeing of older people. Organizations were recruited from five purposively selected sites within one region of England (East Midlands). Semi-structured interviews explored the relationships between commissioners and providers and the nature of funding arrangements, including co-production. Interviews also explored collection of data within the service and how data were fed back to commissioners. Focus groups were held with older people with the potential to benefit from wellbeing services. Results Commissioning arrangements were varied, sometimes complex, and often involved co-production with the third sector. Commissioners valued third sector organizations for their engagement with the local community, value for money, outreach services and ability to provide information about the community. Assessing the needs and outcomes of individuals was integral to delivery of support and advice to older people. Diverse approaches were used to assess an individual’s needs and outcomes, although there were concerns that some assessment questionnaires may be too complex for this vulnerable group. Assessment and outcomes data were also used to monitor the service contract and there was potential for the data to be summarized to inform commissioning strategies, but commissioners did not report using assessment data in this way, in practice. While the policy context encouraged partnerships with third sector organizations and their involvement in decision making, the relationship with third sector organizations was not valued within contract arrangements, and may have been made more difficult by the tendering process and the lack of analysis of service data. Conclusion This exploratory study has demonstrated a diversity of commissioning arrangements for third sector services across one region of England. Most commissioners invited co-production; that is, the commissioners sought input from the third sector while specifying details of the service. Service data, including assessments of needs and outcomes, were reported to commissioners, however commissioners did not appear to use this to full advantage to inform future commissioning decisions. This may indicate a need to improve measurement of needs and outcomes in order to improve the credibility of the commissioning process.

This study aimed to explore the lived experiences of Kimberley Aboriginal people with type 2 diabetes managed by remote Aboriginal Community Controlled Health Services using phenomenological analysis. Semi-structured interviews formulated by Aboriginal Health Workers, researchers and other clinicians were used to obtain qualitative data from 13 adult Aboriginal patients with type 2 diabetes managed in two remote communities in the Kimberley. Together with expert opinion from local Aboriginal Health Workers and clinicians, the information was used to develop strategies to improve diabetes management. Of 915 regular adult patients in the two communities, 27% had type 2 diabetes; 83% with glycated haemoglobin A >10%. Key qualitative themes included: the need for culturally relevant education and pictorial resources; importance of continuous therapeutic relationships with healthcare staff; lifestyle management advice that takes into account local and cultural factors; and the involvement of Aboriginal community members and families in support roles. Recommendations to improve diabetes management in the remote communities have been made collaboratively with community input. This study provides a framework for culturally relevant recommendations to assist patients with diabetes, for collaborative research, and for communication among patients, Aboriginal Health Workers, community members, researchers and other clinicians. Interventions based on recommendations from this study will be the focus of further collaborative research.

Abstract Introduction Community pharmacy is one of the most accessible sectors in the health service and played a key role in responding to COVID-19 (1). Efforts to tackle COVID-19 have required an immediate response from the community pharmacy workforce. Aim To examine views and experiences of community pharmacists regarding changes in practice/processes in preparation for and response to the COVID-19 pandemic. Methods A telephone questionnaire was conducted across a geographically stratified sample of community pharmacists in Northern Ireland (NI). Based on the total number of pharmacies (N=528) and an anticipated response rate of 30%, up to 433 pharmacies were to be contacted to achieve a target sample size of n=130 (sampling fraction 24%). The questionnaire sections comprised: (1) measures taken to prevent COVID-19 infection; (2) response to the pandemic, i.e. immediate actions taken, effect on service provision and new/innovative ways of working; (3) pandemic preparedness; (4) communication with GPs and patients; (5) professional knowledge; (6) recovery and future outlook. Data were coded, entered into SPSS v27, and analysed descriptively. Free-text comments were summarised using thematic analysis. Results One hundred and thirty community pharmacists (175 approached) completed the questionnaire (74% response rate). Pharmacists responded comprehensively to implementing infection control measures, e.g. management of social distancing in the shop (n=125, 96.2%), making adjustments to premises, e.g. barriers/screens (n=124, 95.4%), while maintaining medicines supply (n=130, 100.0%) and advice to patients (n=121, 93.1%). Patient-facing services such as minor ailments and smoking cessation were initially stopped by 115 (88.5%) and 93 (71.5%) pharmacies respectively during the first wave of the pandemic (March-May 2020); by the second wave (Sep-Dec 2020), modified services had resumed in 121 (93.1%) and 104 (79.9%) pharmacies respectively. Newly commissioned services were provided, e.g. emergency supply service (n=121, 93.1%), flu vaccination for healthcare workers (n=101, 77.7%) and volunteer deliveries to vulnerable people (n=71, 54.6%); new initiatives were developed, e.g. measures to flag/assist patients with sensitive issues (n=73, 56.2%). Pharmacies with a business continuity plan increased from 85 (65.4%) pre-pandemic to 101 (77.7%) during the second wave. Free-text responses indicated how pharmacists adapted practice in the front line to reassure and advise the public and maintain essential medicines supply. Pharmacists were least prepared for the increased workload and patients’ challenging behaviour, but 126 (96.9%) reported that they felt better prepared during the second wave. Telephone was the main method of communication with patients (n=107, 82.3%) and GPs (n=114, 87.7%). Pharmacists felt they had sufficient training resources available (n=113, 86.9%) to maintain professional knowledge. Pharmacists agreed/strongly agreed that they would be able to re-establish normal services (n=114, 87.7%), were willing to administer COVID-19 vaccines (n=105, 80.7%) and provide COVID-19 testing (n=79, 60.8%) in the future. Conclusion The high response rate is a strength of the study, but the impact is limited by not including patients or service commissioners. The pharmacy workforce remained accessible and maintained supply of essential medicines and advice to patients throughout the pandemic. Provision of modified and additional services such as vaccination reinforced the clinical and public health role of pharmacy. Reference (1) Cadogan CA, Hughes CM. On the frontline against COVID-19: Community pharmacists’ contribution during a public health crisis. Res Soc Adm Pharm. 2020; 17: 2032–2035.

Background: Maternal mortality is a major public health issue in developing countries due to its shocking magnitude and lower declining pattern, 295 000 women died of pregnancy or childbirth related complications in 2017. Late initiation of Antenatal Care (ANC) services in most low-income countries like Tanzania has been reported as a major problem which increase maternal mortality rate (MMR). However, different factors for late initiation of antenatal care are not well identified. Therefore, this study aimed to identify factors for late initiation of antenatal care both individual factors and health policy factors as per pregnant women and health care providers opinions in Kahama Municipal, Tanzania. Broad Objective: The study focused on assessment of factors for late initiation of Antenatal Care (ANC) in Kahama Municipal, Tanzania. Materials and Methods: This study was conducted using a qualitative method with exploratory approach which was carried out to explore factors for late initiation of antenatal care in Kahama Municipal. An in-depth interview (IDI) and Focus Group Discussion (FGD) were methods used to collect data. The study comprised of 14 in-depth interviews (IDIs) with pregnant women with age range of 18 years to 49 years attending antenatal care clinics in two health facilities and 4 in-depth interviews (IDIs) with health care providers attending pregnant women during antenatal care clinic visit. Furthermore, two Focus Group Discussions (FGDs), one from each health facility with pregnant women were conducted. Data Analysis: Thematic analysis was conducted through use of inductive approach. The audio recordings were conducted using the Swahili language then transcribed and translated into the English language where themes were obtained after translation. Results: Findings obtained from this study were factors for late initiation of antenatal care as reported by both pregnant women and health care providers. Factors for late initiation of antenatal care were under guidance of Health Behavioral Modal (HBM): Factors mentioned by pregnant women included pregnant women education level, negligence of pregnant women to attend clinic, unplanned pregnancy among couples, distance from pregnant women settlement to the facility, pregnant women misconceptions related to antenatal care services, use of local herbs, pregnancy complications, , unfriendly services and unequal gender power relation within a family. Factors mentioned by health care providers based on health policy and managerial factors such as Partner accompanying policy, distant allocation of health facility from people’s settlement and unfriendly services provided by health care providers. Conclusion: This study focused on assessing factors for late initiation of antenatal care in Kahama municipal council in Shinyanga, Tanzania. Different factors for late initiation of antenatal care were reported which included pregnant women and health care providers. Pregnant women education level, negligence of pregnant women to attend clinic, unplanned pregnancy among couples, and distance from pregnant women settlement to the facility, pregnant women misconceptions related to antenatal care services, use of local herbs, pregnancy complications. Health policy and managerial related factors were partner accompanying policy, unfriendly services, and allocation of health facility. Recommendation: However different improvement made on maternal health services in Tanzania but still some of pregnant women are not utilizing it efficiently because of different obstacles like distance from people’s settlement to the health facility, Partner accompanying policy and unfriendly services provided by health care providers. Through such obstacles as a policy maker, I would like to advice Government through Ministry of Health to allocate health facility nearby people’s settlement, providing outreach program to educate the community about antenatal care rather than relying on partner accompanying policy and lastly is provision of refresher training related to client’s rights during health care services provision to all staff.

Background: Training courses in integrated management of childhood illness (IMCI) have been conducted for health workers for nearly one and half decades in Afghanistan. The objective of the training courses is to improve quality of care in terms of health workers communication skills and clinical performance when they provide health services for under-5 children in public healthcare facilities. This paper presents our findings on the effects of IMCI training courses on quality of care in public primary healthcare facilities in Afghanistan. Methods: We used a cross-sectional post-intervention design with regression-adjusted difference-in-differences (DiD) analysis, and included 2 groups of health workers (treatment and control). The treatment group were those who have received training in IMCI recently (in the last 12 months), and the control group were those who have never received training in IMCI. The assessment method was direct observation of health workers during patient-provider interaction. We used data, collected over a period of 3 years (2015–2017) from primary healthcare facilities, and investigated training effects on quality of care. The outcome variables were 4 indices of quality care related to history taking, information sharing, counseling/medical advice, and physical examination. Each index was formed as a composite score, composed of several inter-related tasks of quality of care carried out by health workers during patient-provider interaction for under-5 children. Results: Data were collected from 733 primary healthcare facilities with 5818 patients. Quality of care was assessed at the level of patient-provider interaction. Findings from the regression-adjusted DiD multivariate analysis showed significant effects of IMCI training on 2 indices of quality care in 2016, and on 4 indices of quality care in 2017. In 2016 two indices of quality care showed improvement. There was an increase of 8.1% in counseling/medical advice index, and 8.7% in physical examination index. In 2017, there was an increase of 5.7% in history taking index, 8.0% in information sharing index, 10.9% in counseling/medical advice index, and 17.2% in physical examination index. Conclusion: Conducting regular IMCI training courses for health workers can improve quality of care for under-5 children in primary healthcare facilities in Afghanistan. Findings from our study have the potential to influence policy and strategic decisions on IMCI programs in developing countries.

The limited access to oral care for older people living in residential aged care facilities (RACFs) has been noted repeatedly in the literature. The aim of this study was to explore RACF staff perspectives on how to engage dental professionals in the provision of oral care for RACF residents. Semi-structured interviews were conducted with 30 staff from six purposively selected RACFs located in high socioeconomic areas to gain understanding of the multidimensional issues that influenced the engagement of dental professionals from a carer perspective. Analysis revealed that staff perceived tensions regarding affordability, availability, accessibility and flexibility of dental professionals as significant barriers to better oral care for their residents. Participants raised a series of options for how to better engage dental professionals and reduce these barriers. Their ideas included: the engagement of RACF staff in collaborative discussions with representatives of public and private dental services, dental associations, corporate partners and academics; the use of hygienists/oral health therapists to educate and motivate RACF staff; the promotion of oral health information for troubleshooting and advice on how to deal with residents’ dental pain while waiting for support; the encouragement of onsite training for dental professionals; and the importance of gerodontology (geriatric dentistry). Findings highlighted the need to explore alternative approaches to delivering oral care that transcend the model of private clinical practice to focus instead on the needs of RACFs and take into account quality of end-of-life oral care.

Although the benefits of breastfeeding are widely recognized, only 14% of mothers in Thailand exclusively breastfed their children during the first six months of their lives in 2019, which dropped from 23% in 2016. This study aimed to assess the prevalence of exclusive breastfeeding (EBF) up to six months, current breastfeeding patterns, and key determinants that influence six-month EBF among mothers residing in Bangkok, Thailand. A cross-sectional study was conducted using a self-administered questionnaire survey. In total, 676 healthy mothers living in Bangkok, whose most recent child was between 6 and 18 months old, were recruited. Descriptive statistics, univariable analysis by Chi-square test, and multivariable logistic regression were performed to assess the association between six-month EBF and maternal characteristics and experiences of using maternal health services. The prevalence of six-month EBF of infants in Bangkok was 41%. The key determinants that influenced six-month EBF included: maternal age of more than 30 years; higher education level; higher maternal income; multi-parity; exposure to breastfeeding advice during pregnancy; intention to breastfeed for a long duration (≥6 months) during pregnancy; experience of six-month EBF in the previous child. This study draws health professionals’ and policy makers’ attention to further promote breastfeeding in particular types of mothers.

Vascular disease is a leading cause of death and disability. While it is preventable, little is known about the feasibility or acceptability of implementing interventions to prevent vascular disease in Australian primary health care. We conducted a cluster randomised controlled trial assessing prevention of vascular disease in patients aged 40–65 by providing a lifestyle modification program in general practice. Interviews with 13 general practices in the intervention arm of this trial examined their views on implementing the lifestyle modification program in general practice settings. Qualitative study, involving thematic analysis of semi-structured interviews with 11 general practitioners, four practice nurses and five allied health providers between October 2009 and April 2010. Providing brief lifestyle intervention fitted well with routine health-check consultations; however, acceptance and referral to the program was dependent on the level of facilitation provided by program coordinators. Respondents reported that patients engaged with the advice and strategies provided in the program, which helped them make lifestyle changes. Practice nurse involvement was important to sustaining implementation in general practice, while the lack of referral services for people at risk of developing vascular disease threatens maintenance of lifestyle changes as few respondents thought patients would continue lifestyle changes without long-term follow up. Lifestyle modification programs to prevent vascular disease are feasible in general practice but must be provided in a flexible format, such as being offered out of hours to facilitate uptake, with ongoing support and follow up to assist maintenance. The newly formed Medicare Locals may have an important role in facilitating lifestyle modification programs for this target group.

BackgroundOver the life of the NHS, hospital services have been subject to continued reconfiguration. Yet it is rare for the reconfiguration of clinical services to be evaluated, leaving a deficit in the evidence to guide local reconfiguration of services.ObjectivesThe objectives of this research are to determine the current pressures for reconfiguration within the NHS in England and the solutions proposed. We also investigate the quality of evidence used in making the case for change, any key evidence gaps, and the opportunities to strengthen the clinical case for change and how it is made.MethodsWe have drawn on two key sources of evidence. First, we reviewed the reports produced by the National Clinical Advisory Team (NCAT) documenting its reviews of reconfiguration proposals. An in-depth multilevel qualitative analysis was conducted of 123 NCAT reviews published between 2007 and 2012. Second, we carried out a search and synthesis of the literature to identify the key evidence available to support reconfiguration decisions. The findings from this literature search were integrated with the analysis of the reviews to develop a narrative for each specialty and the process of reconfiguration as a whole.ResultsThe evidence from the NCAT reviews shows significant pressure to reconfigure services within the NHS in England. We found that the majority of reconfiguration proposals are driving an increasing concentration of hospital services, with some accompanying decentralisation and, for some specialist services, the development of supporting clinical networks. The primary drivers of reconfiguration have been workforce (in particular the medical workforce) and finance. Improving outcomes and safety issues have been subsidiary drivers, though many make the link between staffing and clinical safety. Policy has also been a notable driver. Access has been notable by its absence as a driver. Despite significant pressures to reconfigure services, many proposals fail to be implemented owing to public and/or clinical opposition. We found strong evidence that some specialist service reconfiguration including vascular surgery and major trauma can significantly improve clinical outcomes. However, there are notable evidence gaps. The most significant is the absence of evidence that service reconfiguration can deliver significant savings. There is also an absence of evidence about safe staffing models and the interplay between staff numbers, skill mix and outcomes. We found that the advice provided by the NCAT reflects the current evidence, but one of the NCAT’s most valuable contributions has been to encourage greater clinical engagement in service change.ConclusionsThe NHS is continuing to concentrate many district general hospital services to resolve financial and workforce pressures. However, many proposals are not implemented owing to public opposition. We also found no evidence to suggest that this will deliver the savings anticipated. There is a significant gap in the evidence about safe staffing models and the appropriate balance of junior and senior medical as well as other clinical staff. There is an urgent need to carry out research that will help to fill the current evidence gap. There is also a need to retain some national clinical expertise to work alongside Clinical Senates in supporting local service reconfiguration.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Abstract Introduction This study aimed assessed the prescribing quality of progesterone-only pills (POP) to determine whether online asynchronous algorithmic assisted consultations alone could help women or whether enhanced remote consultations still need to be performed. Our digital service follows Faculty of Sexual and Reproductive Healthcare FSRH clinical guidance, patients who have conditions that fall in category of UKMEC 3 and 4 would be signposted to other methods.1,2 The service works by patients completing an online consultation which is supported by algorithm-assisted consultations. The algorithm is written by doctors and pulls out the relevant information for the clinician to suggest whether it safe to prescribe. Asynchronized consultations using algorithms can identify patients for whom POP is not suitable to prescribe. As this is safe and scalable, it has the potential to improve access to contraception for women. For those women where technology identifies that POP is not suitable, there is still an important place for remote interaction to ensure that women are able to make an informed and safe contraceptive choice. Aim To review patients who met a Faculty of Sexual and Reproductive Healthcare (FSRH) exclusion for POP to determine adherence to FSRH clinical guidance on signposting these patients to in-person services where appropriate,1.2 and to review patients’ medical records, who were initially declined POP after completing an online consultation to identify the outcome and potential pathway improvement. Methods A retrospective case-note review of 362 patients, who met a FSRH exclusion criteria for POP, using a large digital sexual health service for POP (Cerelle, Cerazette, Norgeston, Noriday) between 1.3.21-25.5.22. Those patients who were not prescribed POP were then identified, to see how they were managed; how many were signposted to the clinic and how many were managed remotely and subsequently prescribed POP. The data underwent descriptive statistical analysis. Ethical approval was not required as this was a service evaluation. Results Of the 362 patients who met the FSRH exclusion criteria (100% female, aged 18-51), 288 (80%) patients were declined from POP treatment and signposted to in-persons services, 74 (20%) were prescribed POP after clinician review. Of the 288 who were initially declined POP, 110 (38%) patients sought further advice with a clinician remotely, resulting in 83 being prescribed POP and 27 being declined. Overall clinicians correctly followed guidance for 99% (284/288) of POP consultations who met the FSRH exclusion criteria.2 Of these 4 patients reported potential exclusion criteria for POP and were prescribed. Upon reflection, clinicians felt the potential exclusion criteria could have been explored further before prescribing. Discussion/Conclusion Asynchronous consultations bring lots of efficiencies, assists clinicians in triaging and managing the majority of patients. We’ve developed a pathway where patients can undertake a further discussion with a clinician remotely, which resulted in provision of remote contraception. This is convenient for patients and has the potential or may ease pressure off in-person services. References 1. Faculty of Sexual & Reproductive Healthcare (FSRH). Clinical Effectiveness Unit. FSRH Guidance – Progesterone-only pills. March 2015. Amended April 2019. Royal College of Obstetricians & Gynaecologists Website www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-pop-mar-2015 Accessed May 2022 2. Faculty of Sexual & Reproductive Healthcare (FSRH). UK Medical Eligibility Criteria (UKMEC) Summery sheets for contraceptive use. April 2016. Amended September 2019. Website www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets Accessed May 2022

Abstract Introduction Research active healthcare organisations and staff have been shown to significantly improve performance and patient outcomes1. Undertaking research is a core element of the pharmacist role, however many pharmacists report not having the skills, knowledge and/or resources to take part2. There are many opportunities for the delivery of transformational research within primary care, however pharmacy team engagement is lacking. Aim To explore the barriers and facilitators to research engagement within a Clinical Commissioning Group (CCG) Medicines Optimisation team. Methods Twelve focus groups, guided by a semi-structured topic guide, were held over MS Teams between October 2021 and February 2022. 37 participants (pharmacists, pharmacy technicians and administrative support roles) attended and discussed topics relating to their experiences of engaging with research, as well as what helped or hindered them. Detailed notes were taken and analysed using Thematic Analysis. Following this inductive analysis, which aimed to capture all themes arising from the data, the Consolidated Framework for Implementation Research (CFIR)3 was applied. This helped to categorise the barriers and facilitators into domains which influence to what extent research is undertaken. The analysis was validated by the CCG team. This study was deemed to be service evaluation and therefore no ethical approval was needed. Results Three core themes emerged: People, Place and Practicalities. Individuals felt they had limited knowledge and capabilities in the field of research, despite having an internal motivation to engage in research activity. The perception of research was often linked in peoples’ thoughts to academia or secondary care/ acute Trusts or lab-based, and therefore not really something they would engage with in their current role. A lack of research culture, leadership and visibility of projects were all thought to hinder the team. A clear need for training and education in research (what it is, how it can be done, and available tools) was expressed, as well as appropriate resource allocation. Mapping to the CFIR illustrated that most barriers fell within the inner setting (i.e. the organisation itself) and with the process of conducting research, such as limited time, lack of encouragement from champions and poor feedback from projects. Enablers were also identified which included advice offered by external organisations, dissemination about work conducted in other primary care organisations and beliefs about the benefits of being research active. Discussion/Conclusion Participants perceived there to be many more barriers to research engagement than enablers, and these ranged from challenges with the individual projects, the process of conducting research within the organisation, things about the person themselves, their organisation or the wider setting of primary care. Areas for improvement were identified, mainly through increased training, visibility of projects and interested people, development of champions and role models, and stronger links with academia. This study was conducted with only one CCG and therefore further work needs to explore the experience within other integrated care boards and across secondary and community practice. References 1. Hanney, S., Boaz, A., Soper, B. and Jones, T. Engagement in research: an innovative three-stage review of the benefits for health-care performance. Health Services and Delivery Research, 2013;1(8). ISSN (print) 2050-4349 2. Crilly P, Patel N, Ogunrinde A, Berko D, Kayyali R. Community Pharmacists’ Involvement in Research in the United Kingdom. Pharmacy. 2017;5(3):48. https://doi.org/10.3390/pharmacy5030048 3. Damschroder, L.J., Aron, D.C., Keith, R.E. et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Sci 2009;4:50. https://doi.org/10.1186/1748-5908-4-50

Abstract Introduction Significant alterations occur in human physiology and the way medications function in space (1). Understanding the efficacy and pitfalls of pharmacological intervention and developing space-related pharmacy services is therefore integral to ensuring a sustained presence for human spaceflight. In contemporary society, the pharmacist plays a significant role in a person’s health. However, pharmacist input towards the spaceflight participant’s health is minimal to nil. Aim: T o explore stakeholder perspectives towards the role of Astropharmacy in the space sector. Methods Pharmacists (n = 18) across the globe and space sector participants (n = 18) from governmental, commercial, and space tourism sectors participated, via 27 qualitative interviews and three focus groups. Participants were recruited via purposive and snowball sampling. A six-step thematic analysis was used and mapped into the Job Characteristics Model (JCM). JCM is a theory within work design, aiming to promote work experiences and personal outcomes. There are five job dimensions – skill variety, task identity, task significance, autonomy, and feedback which influence three psychological states required for a well-designed job. The three psychological states are meaningfulness, responsibility, and knowledge of work results, which lead to positive work and personal experiences (2). Results Three key themes were generated: medication management, medication research, and regulation/licensing. Medication management encompassed safeguarding the space traveller’s health, like space tourists, by conducting medication reviews (pre-and post-flight), medication advice (digital astro-telepharmacy information services during spaceflight) and developing personalised medication. Medication management also included ensuring shelf-life and continuous medication supply for deep space exploration. Medication research included novel drug development, innovative manufacturing, and understanding clinical applications of the pharmacokinetic and pharmacodynamic changes of medications in space. Innovative manufacturing like 3-D printing raises questions regarding the need for regulations/licensing of medications use and manufacturing in space. Based on the JCM our findings indicate that Astropharmacy possesses diverse duties eliciting meaningfulness, with clear responsibility and observable workplace results promoting task significance, and both the medication and patient focus promoting task identity. Autonomy was blurred within Astropharmacy as a degree of autonomy is needed due to the field’s novelty, but workforce regulations by governmental space agencies are expected. Lastly, workplace feedback can be achieved in Astropharmacy through performance reviews. Conclusion The Astropharmacy role is perceived to involve medication management, medication research and regulation/licensing of medications for space. The work design of astropharmacy is well-reflected in the JCM, implying that a novel and energising opportunity for the pharmacy profession is forthcoming. Although the data generated by qualitative research are not generalizable to other settings, these themes represent the first study to investigate the space sector qualitatively in the context of pharmacy, providing rich foundational data for future research. Consequently, the amalgamation of two previously distinct workplace domains may be a conceivable reality for the future of pharmacy practice. References 1. Blue RS, Bayuse TM et al. Supplying a pharmacy for NASA exploration spaceflight: challenges and current understanding. Npj Microgravity. 2019;5(1):1–12. 2. Hackman RJ, Oldham G. Motivation through the design of work: Test of a theory. Organizational Behavior and Human Performance. 1976;16(2):250–279.

BackgroundAsthma episodes and deaths are known to be seasonal. A number of reports have shown peaks in asthma episodes in school-aged children associated with the return to school following the summer vacation. A fall in prescription collection in the month of August has been observed, and was associated with an increase in the number of unscheduled contacts after the return to school in September.ObjectiveThe primary objective of the study was to assess whether or not a NHS-delivered public health intervention reduces the September peak in unscheduled medical contacts.DesignCluster randomised trial, with the unit of randomisation being 142 NHS general practices, and trial-based economic evaluation.SettingPrimary care.InterventionA letter sent (n = 70 practices) in July from their general practitioner (GP) to parents/carers of school-aged children with asthma to remind them of the importance of taking their medication, and to ensure that they have sufficient medication prior to the start of the new school year in September. The control group received usual care.Main outcome measuresThe primary outcome measure was the proportion of children aged 5–16 years who had an unscheduled medical contact in September 2013. Supporting end points included the proportion of children who collected prescriptions in August 2013 and unscheduled contacts through the following 12 months. Economic end points were quality-adjusted life-years (QALYs) gained and costs from an NHS and Personal Social Services perspective.ResultsThere is no evidence of effect in terms of unscheduled contacts in September. Among children aged 5–16 years, the odds ratio (OR) was 1.09 [95% confidence interval (CI) 0.96 to 1.25] against the intervention. The intervention did increase the proportion of children collecting a prescription in August (OR 1.43, 95% CI 1.24 to 1.64) as well as scheduled contacts in the same month (OR 1.13, 95% CI 0.84 to 1.52). For the wider time intervals (September–December 2013 and September–August 2014), there is weak evidence of the intervention reducing unscheduled contacts. The intervention did not reduce unscheduled care in September, although it succeeded in increasing the proportion of children collecting prescriptions in August as well as having scheduled contacts in the same month. These unscheduled contacts in September could be a result of the intervention, as GPs may have wanted to see patients before issuing a prescription. The economic analysis estimated a high probability that the intervention was cost-saving, for baseline-adjusted costs, across both base-case and sensitivity analyses. There was no increase in QALYs.LimitationThe use of routine data led to uncertainty in the coding of medical contacts. The uncertainty was mitigated by advice from a GP adjudication panel.ConclusionsThe intervention did not reduce unscheduled care in September, although it succeeded in increasing the proportion of children both collecting prescriptions and having scheduled contacts in August. After September there is weak evidence in favour of the intervention. The intervention had a favourable impact on costs but did not demonstrate any impact on QALYs. The results of the trial indicate that further work is required on assessing and understanding adherence, both in terms of using routine data to make quantitative assessments, and through additional qualitative interviews with key stakeholders such as practice nurses, GPs and a wider group of children with asthma.Trial registrationCurrent Controlled Trials ISRCTN03000938.Funding detailsThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 93. See the HTA programme website for further project information.

Abstract Introduction Independent Prescribing Pharmacists (IPPs) can prescribe autonomously within their scope of practice. Their role is increasing within the community setting (1). The Welsh Pharmaceutical Committee has a vision to have at least one IPP in every community pharmacy by 2030 (1). In 2020, an Independent Prescribers’ Service (IPS) pilot was delivered in 13 pharmacies across six of the seven Health Boards in Wales (2), via Choose Pharmacy (CP), an IT platform that provides access to patients’ General Practitioner (GP) medical record. IPS allowed patients to access advice, and, where relevant, be treated in the community pharmacy setting, rather than the GP surgery. The consultation is recorded on CP and the patient’s GP informed of the outcome. As the IPS is a recent development there is little research on this service. Aim To explore the views of community IPPs delivering the IPS. Methods A qualitative methodology was utilised with semi-structured interviews, via telephone or MS Teams. Only thirteen pharmacies were commissioned to deliver the service. Purposive sampling was used to identify IPPs in these premises, who had completed at least one IPS consultation. Participants were informed of the study and written; informed consent obtained. An interview schedule utilised open questions to explore participants’ experiences of the service. Interviews were recorded, transcribed and analysed via deductive and inductive thematic analysis. Analysis was quality assured through discussion with the research team. All identifiable information in the transcripts were removed to ensure anonymity. Results Nine interviews were conducted, including participants from all Health Boards in the pilot. Interviewees had varied prescribing experience with some only prescribing since the roll out of the pilot. The IPPs’ scope of practice included acute minor ailments, contraception, urinary tract infections and asthma. Four themes were identified: 1.Impact of the IPS: Participants believed the service had impacted on the wider healthcare setting, patients and themselves. Patients had improved convenience and accessibility to a healthcare professional to manage their condition. Patient safety was of a high standard with access to patient notes ensuring informed, appropriate clinical decisions. 2.Relationship with GP: Positive relationships with local GPs was believed to be critical to the pilot’s success. 3.Future delivery: This will rely on support, funding, and ongoing review. A ‘blended approach’ whereby patients are seen with or without an appointment was believed to provide the flexibility that patients want. 4.Remote consultations: Can have an impact on patient safety, making non-verbal communication and language barriers more challenging. After nine interviews, no new information was gathered. Conclusion Participants were supportive of the service which will potentially benefit IPPs, patients and GPs, and improve patient care. Pharmacists, by providing a high quality, accessible service, ensures that forward thinking healthcare is delivered in a manner which makes use of the skills of those working in the community. The study, albeit small scale, explored the thoughts of the majority of IPPs conducting the IPS service at that time. More information is needed to understand the impact of the service and effect on practice, from the practitioner and patient perspective. References (1) Walsh A. All Welsh pharmacies to have independent prescribers. Wales; 2019 [accessed 5 February 2021]. Available from: http://www.pharmacymagazine.co.uk/all-welsh-pharmacies-to-have-independent-prescribers (2) NHS Wales Informatics Service. Choose Pharmacy. Wales; 2021 [accessed 5 Feb 2021]. Available from: http://www.nwis.nhs.wales/systems-and-services/in-the-community/choose-pharmacy/

PurposeThis study explores how career training with mentoring (CTM) programs work in Nigerian higher education (HE) institutions to foster students' career development and employability of graduates. It also explores how Nigerian HE curriculum can be adequately used to facilitate CTM as well as possible constraints to effective implementation of CTM programs in Nigerian HE institutions.Design/methodology/approachThe study draws on interviews with well-qualified and experienced experts from six Nigerian public universities (each from the 6 geo-political zones of Nigeria), and 20 industries also within the same 6 geo-political zones of Nigeria that were selected for this study using a purposeful sampling technique. The study interviewed 33 experts comprising 21 senior academics at Nigerian universities and 12 industry executives to reveal substantial information about CTM programs in Nigerian HE institutions.FindingsDrawing on the three key themes that emerged during the thematic analysis and linked to social cognitive career theory, it is clear that participants are convinced that CTM can enhance clarity about students' career ambitions, career interests, personal development plans and employability. Findings show that there are some career-related programs or activities that Nigerian HE students are presented with, but the programs have not been effective as to offer graduates quality career guidance and employability skills that employers demand. Acknowledging these, participants recommend establishing CTM centres in all Nigerian HE institutions to provide students with the opportunity to receive quality career advice, coaching and mentoring services while schooling.Practical implicationsThe findings of this study shed light on varying resources required to cope with the demands of labour market in terms of supply of competent workforce that can contribute to Nigeria's economic growth and development. The findings are highly relevant for Nigeria and other developing countries' policy and research initiatives that aim to promote social inclusion and equity and improve better working conditions for all. The findings also have implications for career development and employability of HE graduates in developing world context.Originality/valueUnderstanding the role that CTM programs can play in facilitating career development and graduate employability can arguably be of importance within the developing world context. This study, therefore, provides significant suggestions on how to build sustained HEIs and labour market partnership to foster career development and employability of HE graduates through establishing CTM centres in every Nigerian HE institutions.

Covid 19 – living the experience As I sit at my desk at home in suburban Brisbane, following the dictates on self-isolation shared with so many around the world, I am forced to contemplate the limits of human prediction. I look out on a world which few could have predicted six months ago. My thoughts at that time were all about 2020 as a metaphor for perfect vision and a plea for it to herald a new period of clarity which would arm us in resolving the whole host of false divisions that surrounded us. False, because so many appear to be generated by the use of polarised labelling strategies which sought to categorise humans by a whole range of identities, while losing the essential humanity and individuality which we all share. This was a troublesome trend and one which seemed reminiscent of the biblical tale concerning the tower of Babel, when a single unified language was what we needed to create harmony in a globalising world. However, yesterday’s concerns have, at least for the moment, been overshadowed by a more urgent and unifying concern with humanity’s health and wellbeing. For now, this concern has created a world which we would not have recognised in 2019. We rely more than ever on our various forms of electronic media to beam instant shots of the streets of London, New York, Berlin, Paris, Hong Kong etc. These centres of our worldly activity normally characterised by hustle and bustle, are now serenely peaceful and ordered. Their magnificent buildings have become foregrounded, assuming a dignity and presence that is more commonly overshadowed by the mad ceaseless scramble of humanity all around them. From there however the cameras can jump to some of the less fortunate areas of the globe. These streets are still teeming with people in close confined areas. There is little hope here of following frequent extended hand washing practices, let alone achieving the social distance prescribed to those of us in the global North. From this desk top perspective, it has been interesting to chart the mood as the crisis has unfolded. It has moved from a slightly distant sense of superiority as the news slowly unfolded about events in remote Wuhan. The explanation that the origins were from a live market, where customs unfamiliar to our hygienic pre-packaged approach to food consumption were practised, added to this sense of separateness and exoticism surrounding the source and initial development of the virus. However, this changed to a growing sense of concern as its growth and transmission slowly began to reveal the vulnerability of all cultures to its spread. At this early stage, countries who took steps to limit travel from infected areas seemed to gain some advantage. Australia, as just one example banned flights from China and required all Chinese students coming to study in Australia to self-isolate for two weeks in a third intermediate port. It was a step that had considerable economic costs associated with it. One that was vociferously resisted at the time by the university sector increasingly dependent on the revenue generated by servicing Chinese students. But it was when the epicentre moved to northern Italy, that the entire messaging around the event began to change internationally. At this time the tone became increasingly fearful, anxious and urgent as reports of overwhelmed hospitals and mass burials began to dominate the news. Consequently, governments attracted little criticism but were rather widely supported in the action of radically closing down their countries in order to limit human interaction. The debate had become one around the choice between health and economic wellbeing. The fact that the decision has been overwhelmingly for health, has been encouraging. It has not however stopped the pressure from those who believe that economic well-being is a determinant of human well-being, questioning the decisions of politicians and the advice of public health scientists that have dominated the responses to date. At this stage, the lives versus livelihoods debate has a long way still to run. Of some particular interest has been the musings of the opinion writers who have predicted that the events of these last months will change our world forever. Some of these predictions have included the idea that rather than piling into common office spaces working remotely from home and other advantageous locations will be here to stay. Schools and universities will become centres of learning more conveniently accessed on-line rather than face to face. Many shopping centres will become redundant and goods will increasingly be delivered via collection centres or couriers direct to the home. Social distancing will impact our consumption of entertainment at common venues and lifestyle events such as dining out. At the macro level, it has been predicted that globalisation in its present form will be reversed. The pandemic has led to actions being taken at national levels and movement being controlled by the strengthening and increased control of physical borders. Tourism has ground to a halt and may not resume on its current scale or in its present form as unnecessary travel, at least across borders, will become permanently reduced. Advocates of change have pointed to some of the unpredicted benefits that have been occurring. These include a drop in air pollution: increased interaction within families; more reading undertaken by younger adults; more systematic incorporation of exercise into daily life, and; a rediscovered sense of community with many initiatives paying tribute to the health and essential services workers who have been placed at the forefront of this latest struggle with nature. Of course, for all those who point to benefits in the forced lifestyle changes we have been experiencing, there are those who would tell a contrary tale. Demonstrations in the US have led the push by those who just want things to get back to normal as quickly as possible. For this group, confinement at home creates more problems. These may be a function of the proximity of modern cramped living quarters, today’s crowded city life, dysfunctional relationships, the boredom of self-entertainment or simply the anxiety that comes with an insecure livelihood and an unclear future. Personally however, I am left with two significant questions about our future stimulated by the events that have been ushered in by 2020. The first is how is it that the world has been caught so unprepared by this pandemic? The second is to what extent do we have the ability to recalibrate our current practices and view an alternative future? In considering the first, it has been enlightening to observe the extent to which politicians have turned to scientific expertise in order to determine their actions. Terms like ‘flattening the curve’, ‘community transmission rates’, have become part of our daily lexicon as the statistical modellers advance their predictions as to how the disease will spread and impact on our health systems. The fact that scientists are presented as the acceptable and credible authority and the basis for our actions reflects a growing dependency on data and modelling that has infused our society generally. This acceptance has been used to strengthen the actions on behalf of the human lives first and foremost position. For those who pursue the livelihoods argument even bigger figures are available to be thrown about. These relate to concepts such as numbers of jobless, increase in national debt, growth in domestic violence, rise in mental illness etc. However, given that they are more clearly estimates and based on less certain assumptions and variables, they do not at this stage seem to carry the impact of the data produced by public health experts. This is not surprising but perhaps not justifiable when we consider the failure of the public health lobby to adequately prepare or forewarn us of the current crisis in the first place. Statistical predictive models are built around historical data, yet their accuracy depends upon the quality of those data. Their robustness for extrapolation to new settings for example will differ as these differ in a multitude of subtle ways from the contexts in which they were initially gathered. Our often uncritical dependence upon ‘scientific’ processes has become worrying, given that as humans, even when guided by such useful tools, we still tend to repeat mistakes or ignore warnings. At such a time it is an opportunity for us to return to the reservoir of human wisdom to be found in places such as our great literature. Works such as The Plague by Albert Camus make fascinating and educative reading for us at this time. As the writer observes Everybody knows that pestilences have a way of recurring in the world, yet somehow, we find it hard to believe in ones that crash down on our heads from a blue sky. There have been as many plagues as wars in history, yet always plagues and wars take people equally by surprise. So it is that we constantly fail to study let alone learn the lessons of history. Yet 2020 mirrors 1919, as at that time the world was reeling with the impact of the Spanish ‘Flu, which infected 500 million people and killed an estimated 50 million. This was more than the 40 million casualties of the four years of the preceding Great War. There have of course been other pestilences since then and much more recently. Is our stubborn failure to learn because we fail to value history and the knowledge of our forebears? Yet we can accept with so little question the accuracy of predictions based on numbers, even with varying and unquestioned levels of validity and reliability. As to the second question, many writers have been observing some beneficial changes in our behaviour and our environment, which have emerged in association with this sudden break in our normal patterns of activity. It has given us the excuse to reevaluate some of our practices and identify some clear benefits that have been occurring. As Australian newspaper columnist Bernard Salt observes in an article titled “the end of narcissism?” I think we’ve been re-evaluating the entire contribution/reward equation since the summer bushfires and now, with the added experience of the pandemic, we can see the shallowness of the so-called glamour professions – the celebrities, the influencers. We appreciate the selflessness of volunteer firefighters, of healthcare workers and supermarket staff. From the pandemic’s earliest days, glib forays into social media by celebrities seeking attention and yet further adulation have been met with stony disapproval. Perhaps it is best that they stay offline while our real heroes do the heavy lifting. To this sad unquestioning adherence to both scientism and narcissism, we can add and stir the framing of the climate rebellion and a myriad of familiar ‘first world’ problems which have caused dissension and disharmony in our communities. Now with an external threat on which to focus our attention, there has been a short lull in the endless bickering and petty point scoring that has characterised our western liberal democracies in the last decade. As Camus observed: The one way of making people hang together is to give ‘em a spell of the plague. So, the ceaseless din of the topics that have driven us apart has miraculously paused for at least a moment. Does this then provide a unique opportunity for us together to review our habitual postures and adopt a more conciliatory and harmonious communication style, take stock, critically evaluate and retune our approach to life – as individuals, as nations, as a species? It is not too difficult to hypothesise futures driven by the major issues that have driven us apart. Now, in our attempts to resist the virus, we have given ourselves a glimpse of some of the very things the climate change activists have wished to happen. With few planes in the air and the majority of cars off the roads, we have already witnessed clearer and cleaner air. Working at home has freed up the commuter driven traffic and left many people with more time to spend with their family. Freed from the continuing throng of tourists, cities like Venice are regenerating and cleansing themselves. This small preview of what a less travelled world might start to look like surely has some attraction. But of course, it does not come without cost. With the lack of tourism and the need to work at home, jobs and livelihoods have started to change. As with any revolution there are both winners and losers. The lockdown has distinguished starkly between essential and non-essential workers. That represents a useful starting point from which to assess what is truly of value in our way of life and what is peripheral as Salt made clear. This is a question that I would encourage readers to explore and to take forward with them through the resolution of the current situation. However, on the basis that educators are seen as providing essential services, now is the time to turn to the content of our current volume. Once again, I direct you to the truly international range of our contributors. They come from five different continents yet share a common focus on one of the most popular of shared cultural experiences – sport. Unsurprisingly three of our reviewed papers bring different insights to the world’s most widely shared sport of all – football, or as it would be more easily recognised in some parts of the globe - soccer. Leading these offerings is a comparison of fandom in Australia and China. The story presented by Knijnk highlights the rise of the fanatical supporters known as the ultras. The origin of the movement is traced to Italy, but it is one that claims allegiances now around the world. Kniijnk identifies the movement’s progression into Australia and China and, in pointing to its stance against the commercialisation of their sport by the scions of big business, argues for its deeper political significance and its commitment to the democratic ownership of sport. Reflecting the increasing availability and use of data in our modern societies, Karadog, Parim and Cene apply some of the immense data collected on and around the FIFA World Cup to the task of selecting the best team from the 2018 tournament held in Russia, a task more usually undertaken by panels of experts. Mindful of the value of using data in ways that can assist future decision making, rather than just in terms of summarising past events, they also use the statistics available to undertake a second task. The second task was the selection of the team with the greatest future potential by limiting eligibility to those at an early stage in their careers, namely younger than 28 and who arguably had still to attain their prime as well as having a longer career still ahead of them. The results for both selections confirm how membership of the wealthy European based teams holds the path to success and recognition at the global level no matter what the national origins of players might be. Thirdly, taking links between the sport and the world of finance a step further, Gomez-Martinez, Marques-Bogliani and Paule-Vianez report on an interesting study designed to test the hypothesis that sporting success within a community is reflected in positive economic outcomes for members of that community. They make a bold attempt to test their hypothesis by examining the relationship of the performance of three world leading clubs in Europe - Bayern Munich, Juventus and Paris Saint Germain and the performance of their local stock markets. Their findings make for some interesting thoughts about the significance of sport in the global economy and beyond into the political landscape of our interconnected world. Our final paper comes from Africa but for its subject matter looks to a different sport, one that rules the subcontinent of India - cricket. Norrbhai questions the traditional coaching of batting in cricket by examining the backlift techniques of the top players in the Indian Premier league. His findings suggest that even in this most traditional of sports, technique will develop and change in response to the changing context provided by the game itself. In this case the context is the short form of the game, introduced to provide faster paced entertainment in an easily consumable time span. It provides a useful reminder how in sport, techniques will not be static but will continue to evolve as the game that provides the context for the skilled performance also evolves. To conclude our pages, I must apologise that our usual book review has fallen prey to the current world disruption. In its place I would like to draw your attention to the announcement of a new publication which would make a worthy addition to the bookshelf of any international sports scholar. “Softpower, Soccer, Supremacy – The Chinese Dream” represents a unique and timely analysis of the movement of the most popular and influential game in the world – Association Football, commonly abbreviated to soccer - into the mainstream of Chinese national policy. The editorial team led by one of sports histories most recognised scholars, Professor J A Mangan, has assembled a who’s who of current scholars in sport in Asia. Together they provide a perspective that takes in, not just the Chinese view of these important current developments but also, the view of others in the geographical region. From Japan, Korea and Australia, they bring with them significant experience to not just the beautiful game, but sport in general in that dynamic and fast-growing part of the world. Particularly in the light of the European dominance identified in the Karog, Parim and Cene paper this work raises the question as to whether we can expect to see a change in the world order sooner rather than later. It remains for me to make one important acknowledgement. In my last editorial I alerted you to the sorts of decisions we as an editorial and publication team were facing with regard to ensuring the future of the journal. Debates as to how best to proceed while staying true to our vision and goals are still proceeding. However, I am pleased to acknowledge the sponsorship provided by The University of Macao for volume 42 and recognise the invaluable contribution made by ISCPES former president Walter Ho to this process. Sponsorship can provide an important input to the ongoing existence and strength of this journal and we would be interested in talking to other institutions or groups who might also be interested in supporting our work, particularly where their goals align closely with ours. May I therefore commend to you the works of our international scholars and encourage your future involvement in sharing your interest in and expertise with others in the world of comparative and international sport studies, John Saunders, Brisbane, May 2020

High-quality policy analysis and advice is critical to good governance. Teaching public policy for the Australia and New Zealand School of Government (ANZSOG) provides a welcome opportunity to discuss challenges and opportunities for the public sector advisory system with experienced practitioners from Australia and New Zealand. Public sector advisers in many jurisdictions recognize the existence of competition for these services from others, leading to some reflection on the comparative advantage the public sector can bring to its role (Bardach, 2000; Weimer and Vining, 1999; Radin, 2000).

Abstract Background Community pharmacy professionals have great potential to deliver various public health services aimed at improving service access, particularly in countries with a shortage of health professionals. However, little is known about their involvement in child health service provision in Ethiopia. Objective The purpose of this study was to evaluate the level of involvement of community pharmacy professionals in child health service provision within Ethiopia. Methods A multi-center cross-sectional survey was conducted among 238 community pharmacy professionals from March to July 2020 in Amhara regional state of Ethiopia. Independent samples t-test and one way Analysis of Variance (ANOVA) was used to test the mean difference. Results Most community pharmacy professionals were ‘involved’ in providing child health services related to ‘advice about vitamins/supplements’ (46.6%), ‘advice about infant milk/formulas’ (47.1%) and ‘responding to minor symptoms’ (50.8%) for children. The survey revealed that, community pharmacy professionals were less frequently involved in providing childhood ‘vaccination’ services. Further, level of involvement of community pharmacy professionals differed according to participants’ licensure level, setting type, responsibility in the facility and previous training experience in child health services. Conclusion Community pharmacy professionals have been delivering various levels of child health services, demonstrating ability and capacity in improving access to child health services in Ethiopia. However, there is a need for training and government support to optimize pharmacist engagement and contribution to service delivery.

The emergence of COVID-19 has brought a demographic shift in the usage of health services. Patients used to physically visit healthcare facilities but today many of them utilize technology to get advice from doctors. As a result, technology is becoming more widely used and accepted in the healthcare industry. Using the technological acceptance model as a base, this study aims to identify the critical factors that impact patients' adoption of telehealth services. This study found that the intention to adopt technology is dependent on reliability, social norms, schemes, offers, hedonic motivation, convenience, and affordability. These factors comprise 67% of the total variance. Analysis using structural equation modelling revealed that reliability, convenience, and affordability at (β =0.22, p=***), (β =0.31, p=***), (β =0.33, p=***) shows positive intention by consumers to adopt telehealth services. As a result, the hypotheses H1 (Reliability has a positive influence on the adoption intention of telehealth services), H5 (Convenience has a positive influence on the adoption intention of telehealth services), and H6 (Affordability has a positive influence on the adoption intention of telehealth services) are accepted. The path coefficient for social norms, hedonic motivation, schemes, and offers was negative and non-significant. Therefore, hypotheses H2 (Social Norms have a positive influence on the adoption intention of telehealth services), H3 (Social Norms have a positive influence on the adoption intention of telehealth services), and H4 (Hedonic Motivation has a positive influence on the adoption intention of telehealth services) were rejected. The findings also demonstrated that telehealth service adoption intentions positively impacted usage behavior. *(The paper presented at the 7th International Conference on Embracing Change & Transformation Innovation and Creativity 26-28 May 2022)

Abstract Background The Ecology of medical care was first published in 1961. The graphical square model showed that 75% of the population in the US and England experience a feeling of illness during a given month, 25% seek medical help and only one percent are hospitalized. In 2001, Green and colleagues found the same findings despite the many changes that occurred over the past decades. The frequency of illness, the desire for assistance and the frequency of seeking and getting medical assistance may differ in different populations due to cultural, economic, social, demographic background and local Health policy. This work describes the ecology of medical care consumption in Israel for the first time and examines the socio-demographic effects on consumption. Methods This is a Nationwide cross-sectional study. A telephone survey was conducted among a representative sample of the adult population (> 15 years) in Israel. Subjective morbidity rate in the preceding month, the rate of those considering medical assistance and those who got assistance were calculated. Correlation between socio-demographic variables and patterns of morbidity and medical care consumption was examined using a t-test and chi square for continuous quantitative and categorical variables. Logistic regression was used for multivariate analysis. Results A total of 1862 people participated; 49.5% reported having symptoms in the previous month, 45% considered seeking medical advice, 35.2% sought out medical assistance and only 1.5% were hospitalized. The vast majority chose to contact their family physician (58%) and the primary care setting provided their needs in 80% of the cases; Subjective morbidity and medical care consumption differed significantly between Israeli Jews and Arabs. Gaps in the availability of medical services were observed as residents of the periphery forewent medical services significantly more than others (OR = 1.42, p = 0.026). Conclusions Subjective morbidity is less common in Israel than in other countries, but paradoxically consumption of medical services is higher. An Israeli who feels ill will usually consider receiving assistance and will indeed receive assistance in most cases. However, a greater tendency to forego medical services in the periphery indicates barriers and inequality in the provision of health services. Different cultural perceptions, lack of knowledge and low accessibility to medical services in the periphery probably contribute to the contrast shown between low consumption of medical services and high prevalence of chronic illness in Arab society. The prevailing preference for family medicine and its ability to deal with most requests for assistance suggest that strengthening family medicine in the periphery may reduce those barriers and inequalities.

Abstract Background The use of medications is the most common intervention in healthcare. However, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. A Virtual Clinical Pharmacy Service (VCPS) was introduced in rural and remote New South Wales public hospitals to support safe and effective use of medications. In this model clinical pharmacy services are delivered via a telehealth cart at the patient’s bedside and through electronic medical and pharmaceutical record systems. The aim of this research was to understand healthcare staff perspectives of the VCPS and identify areas for improvement. Methods A qualitative approach informed by Appreciative Inquiry was used to investigate healthcare staff perceptions of the VCPS. Focus group discussions (n = 15) with hospital staff and medical officers were conducted via videoconference at each study site. Focus groups explored issues, benefits and barriers 3 months after service implementation. Transcribed data were analysed using thematic analysis and team discussion to synthesise themes. Results Focus group participants identified the value of the VCPS to patients, to the health service and to themselves. They also identified enhancements to increase value for each of these groups. Perceived benefits to patients included access to specialist medication advice and improved medication knowledge. Staff valued access to an additional, trusted workforce who provided back-up and guidance. Staff also reported confidence in improved patient safety and identification of medication errors. Enhanced compliance with antimicrobial stewardship and hospital accreditation standards were beneficial to the health service. Suggested improvements included extending virtual service hours and widening patient eligibility to include aged care patients. Conclusions The VCPS brought a positive, collegiate culture regarding medications. Healthcare staff perceived the VCPS was effective and an efficient way for the health service to supply pharmacy services to smaller hospitals. The ease of use, model of delivery, availability, local knowledge and responsiveness of highly skilled pharmacists was the key to user satisfaction. Trial registration ANZCTR ACTRN12619001757101, 11/12/2019.

The calculation of the community satisfaction index is carried out by the relevant agencies on a regular basis to determine the progress of the unit's performance in the services of government agencies, which can be used as a separate policy material to further improve the quality of service. . Public. Service At the same time, the aim of this study is to measure SMI's satisfaction with its customers, to understand what needs to be improved and how to increase people's satisfaction. PermenpanRB No. 14 of 2017 Indicators of Community Satisfaction Measurement are System Requirements, Mechanisms and Procedures, Completion Time, Costs/Tariffs, Product Specifications by Type of Service, Implementation Capacity, Implementation Behavior, Facilities and Infrastructure, and Complaints, Advice and Feedback Handling. In addition, this study aims to find out how satisfied SMIs are with their customers and what can be done to make them more satisfied. The Community Satisfaction Index (IKM) based on the One Stop Integrated Service and Investment Indicator (DPMPTSP) Medan takes into account factors such as system requirements, mechanisms and procedures. Community Satisfaction (SKM) is 80.43 with a range of 76.61-88.30. The results are still among the good grades. The service elements that are considered the most satisfactory are cost/task points and complaint handling with an average of 3.6, while the lowest points are service hours and permit issuance procedures, with an average of 2.85.

Abstract Objectives Some community pharmacies in England provide free chlamydia testing to young people, yet testing activity in the setting is low. This study aims to increase understanding of why that is, by investigating community pharmacists’ perceptions of barriers to delivering the service, and the reasons why some do not offer testing. Methods Semi-structured interviews were conducted with 22 community pharmacists in North East England between November 2018 and May 2019. The sample comprised both those who provided and did not provide chlamydia testing at the time of the interview. Data were subjected to thematic analysis, utilising the constructs of the normalisation process theory. Key findings Pharmacists found it challenging to sustain delivery of chlamydia testing, as very few young people either requested the test or accepted it when it was offered during consultations on other sexual health services. Pharmacists were cautious about offering the test, having concerns about making clients feel uncomfortable. They identified the value of training to enable them to communicate confidently with clients about testing. Pharmacists supported the suggestion that treatment for chlamydia be offered as part of a ‘test and treat’ package, as they felt that it aligned to their role in the provision of medicines advice. Conclusions Community pharmacies are well-placed to deliver chlamydia testing but are not operating as effectively as they might do. The provision of training on communicating with young people, integrating testing with more sexual health services, and providing ‘test and treatment’ for chlamydia could contribute to greater testing activity.

Abstract While debts are widely used financial tools, few longitudinal studies investigating potential causal links between debts and mental wellbeing exist among older adults. Older adults, particularly those not employed, are less likely to have increasing incomes to help them pay off their debts. This study investigates whether older adults with non-mortgage debts in three different labour market states have lower mental wellbeing and, separately, whether it is likely that reducing their debts helps to improve mental wellbeing. Using the English Longitudinal Study of Ageing, the study focuses on the English context, which is particularly interesting due to the high levels of, and a unique policy approach to, private indebtedness. The results indicate that people with debts have lower mental wellbeing (more depressive symptoms and lower quality of life) in all categories, but the mental pain linked to debts is stronger for people who are jobless (not working, not retired). The analysis from a causal perspective suggests that getting rid of debts may reduce depressive symptoms among people who are jobless but may also improve quality of life among the retired and employed. Both these findings suggest that mental health services should work closely with debt advice when needed.

Abstract Background Persons with disabilities have a higher risk for and poorer outcomes of type 2 diabetes. Primary health care providers face several challenges in providing primary diabetes care for them. This study was conducted to explore the challenges faced by primary health care providers in delivering primary diabetes services to persons with disabilities. Methods We performed a qualitative research study by conducting in-depth interviews among 13 primary health care providers including medical officers, staff nurses, community health workers and a physiotherapist. We adopted a descriptive qualitative research approach to data collection and analysis. Results Primary health care providers often could only prescribe medications to persons with diabetes by proxy due to poor accessibility of the facilities. They felt that these patients also had poor compliance to treatment. They felt that the lack of standard guidelines for diet and exercise for persons with disabilities prevented them from giving them appropriate advice on the same and even if they did, persons with disabilities would find it very difficult to adopt dietary changes and physical activity as they were dependent on others for even their daily activities. They also felt that they couldn’t perform annual screening tests due to lack of accessibility to higher facilities. Some primary care providers did local innovations such as formation of peer support groups, utilization of resources of other programs to reach out to persons with disabilities and innovative physical activity techniques to care for persons with disabilities. They recommended that there is a need for specific guidelines for management of diabetes among persons with disabilities, treatment of chronic diseases among persons with disabilities must be incentivized and there must be intersectoral coordination between social welfare department and health department to achieve the goal of care for persons with disabilities. Conclusions Primary health care providers faced substantial challenges in providing primary diabetes care for persons with disabilities. There is a need for an effective public health policy to address these challenges.

China’s ecological compensation (EC) is based on the property rights structure of public ownership of natural resources, which should be based on the spatial planning, which is defined by local government as the boundary of property right management and the distribution of development power. This study combined spatial planning and ecosystem service value (ESV) accounting to design a decision-making framework of EC, which includes “Subject choice, Value accounting, Priority evaluation, Policy supply”. We selected 32 counties (districts) in the Yangtze River Delta region as the research object with the consideration of spatial planning and expert advice, and found that the implementation of EC slowed down the urbanization process and promoted the increase of ecological space. We conducted an accounting and sensitivity analysis on the spatial and temporal changes of ESV in the region from 2000 to 2019, and finally determined the amount and priority of accepting EC. The research results show that the ESV in the study area shows a general trend of increasing and then decreasing in time, and a spatial pattern of high in the south and low in the north and high in the east and low in the west. Forestland and water area are the main providers of ESV in the study area. The sensitivity coefficients of each type of ESV do not change much in each period, but the coefficients between the types have large differences. The total amount of EC in the Yangtze River Delta ecological barrier (YRDEB) is RMB 38,098.11 billion, and Shitai County is the area with the highest priority for compensation. We believe that this decision-making framework has the potential to be applied to the implementation of EC in other regions of China. At the same time, it can also be used to enrich the international views on EC research.

Problem setting. The impact of IT technologies, innovative handy programs, accumulation and the ability to use a variety of information databases significantly expand a person's ability to respond quickly and effectively to the challenges and needs of the social environment, and most importantly – to be the focus of modern public administration relations. Having largely expanded its own resource potential, man today is a key communicator of public administration processes and, accordingly, becomes an increasingly demanding object and subject in the development of public services, including social, which must fully fill the interests of everyday life. existence, especially in regions with vulnerable social infrastructure. Therefore, the issue of finding optimal and pragmatic communication motives with the use of digital technologies that will contribute to the consolidation of territorial communities and their sustainable development in the current content of decentralization in Ukraine is relevant.Recent research and publications analysis. The concept of "public services" is quite relevant in national scientific approaches. I. Venediktova, K. Nikolaenko, V. Mykhalska, and O. Feoktistova wrote about this. An interesting opinion was expressed, in particular, by L. Andersson and L. Van der Heiden in the analytical report "Directing Digitization: Guidelines for Boards and Executives", which substantiated the study and provided practical advice on taking into account digital technologies in updating the style and content of organizations.Investigating this problem, we also analyzed V. Litvinov's arguments on the use of the Polish experience of digitalization of public services. Also useful for this study are the approaches of the Scottish scientist E. Williamson to the "digital" involvement of citizens and public authorities, which can improve public-state relations and strengthen partnerships between stakeholders. A significant layer of relevant information can be obtained from the material of O. Yevsyukova on the digital capacity of Ukrainian territorial communities at the present stage.Highlighting previously unsettled parts of the general problem. The aim of the article is to outline new challenges in the development of communicative approaches and digital transformation in the content of the tasks of spatial self-organization of territorial communities. After all, it is considered as one of the key mechanisms of socially effective implementation of the state policy of decentralization. Digitalization, with the appropriate interaction of the public (including with the help of public organizations) and self-government bodies, can become the basis of community self-organization processes. The intensity of interaction and the quality of managerial informativeness are also important, which depends on the innovative basis of communication and the organizational culture of communication of actors.Paper main body. In order to speak confidently about the government's ability to promote sustainable community development, it is necessary to point out two important advantages of the digital transformation process and state the need for intermediaries (NGOs) to be unpredictable and constantly changing environmental conditions and its representatives – service customers.The first is the expansion of opportunities for the social functionality of NGOs. Although the use of managerial innovations with the use of digital technologies transforms the perception of all market participants - citizens as customers and NGOs as a performer, the latter still takes the initiative in fulfilling the tasks of social mediation, increasing the effect of competitiveness and skillfully organizes the service delivery process. those who need them.Secondly, it is a feeling of comfort and convenience for all participants in the process of digitalization of services. Qualitative and responsible technological and social approaches to each step of this procedure have a chance to ensure the dynamic establishment of pragmatic public communication of stakeholders. A well-established system of providing social services for all segments of the population and regardless of their geographical location (fragments of the community) is a modern technological novelty around the world. Of course, an important condition for the implementation of long-term plans should be proper technological and innovative network coverage, but this only stimulates the development of public services and a comprehensive approach to its continuous improvement. The process of democratization in Ukraine, its course to decentralize the system of public administration, promoting the involvement of citizens in public discussion and socially significant decisions forces various institutions to adequately respond to the demands of society and technological progress. After all, more and more innovations are reflected in the field of citizen service. This indicates the spread of technological progress and the best innovations of its market to society, to which public policy must respond in a timely manner.In addition, the process of digitalization of services can be an excellent example of the synergetic action of state institutions and civil society in the direction of state formation with a view to the socially just nature of public administration relations. It is impossible to ignore the possibility of significantly simplifying the mechanism of communication between citizens and government agencies, heads of various government agencies, civil servants, clerks, social workers, and others. Conclusions of the research and prospects for further studies. We believe that the successful implementation of modern challenges of communication approaches and digital transformation in the focus of spatial self-organization of territorial communities in Ukraine is important for the prospects of their sustainable development and, ultimately, is a key mechanism of socially effective state decentralization policy. The general success is ensured by the conditions of universal interest in progressive processes, due to the awareness of each member of society of the synergistic effect of the interaction of all actors of communication.

Abstract Objectives The scale of overweight and obesity amongst women of childbearing age or mothers to be, living in Wales, places a considerable burden on the NHS and public health. High BMI (over 30) during pregnancy increases the health risks for mother and baby. Policy advice recommends weight management services are available to help women lose weight before and whilst planning pregnancy. In parts of Wales, NHS partnerships with commercial companies provide weight management services for women considering or planning pregnancy. This study evaluates whether an established referral Weight Watchers (WW) programme, known to be effective in adults in England, can help mothers-to-be living in North Wales lose weight. Methods Analysis used routine data from 82 referrals to WW between June 2013 and January 2015. Participants received a referral letter inviting them to attend face-to-face group workshops combined with a digital experience. The programme encompassed healthy eating, physical activity and positive mind-set. Trained WW staff measured bodyweight before, during and at 12 weeks. On entry to the course, participants had a median age of 31.4 years (interquartile range (IQR) 28–34) with a median BMI of 36.8 kg/m2 (IQR 33.3–43.7). Results Women completing the course (n = 34) had a median weight loss of 5.65 kg (IQR 0.45–10.85), equating to 5.7% (SD 3.46) of initial body weight. Intention-to-treat analysis (last observation carried forward), which included lapsed courses n = 66, showed a median weight loss of 3.6 kg (IQR − 2.53 to 9.73), equating to 3.7% (SD 3.62) of initial body weight. Overall, there was significant weight loss during the WW programme (Wilcoxon signed rank test Z = − 6.16; p < 0.001). Weight loss was significantly correlated with the number of workshops attended (Spearman correlation coefficient 0.61 p < 0.001). The proportion of all 82 participants (intention to treat, baseline observation carried forward) that achieved a weight loss of ≥ 5% initial weight was 30.5%. Conclusions for Practice Referral of obese mothers-to-be into WW can successfully achieve short-term weight loss, at or above 5%, in approximately one third of participants. The dose–response effect supports a causal inference. Successful weight loss at this critical life stage may provide women with the necessary motivation to initiate weight loss for healthy pregnancy, however further research is required.

Abstract Background Patients and primary care providers (PCPs) can experience frustration about poor access to specialist care. The Champlain Building Access to Specialists through eConsultation (BASETM) is a secure online platform that allows PCPs to ask a clinical question to 142 different specialty groups. The specialist is expected to respond within 7 days. Methods This is a retrospective review of the Champlain BASETM respirology eConsults from January 2017 to December 2018. The eConsults were categorized by types of questions asked by the referring provider and by the clinical content of the referral. Specialists’ response time and time spent answering the clinical question were analyzed. Referring providers’ close-out surveys were reviewed to assess the impact of the respirology eConsult service on traditional referral rates and clinical course of action. Results Of the 26 679 cases submitted to the Champlain BASE TM eConsult service, 268 were respirology cases (1%). 91% were sent by family physicians and 9% by nurse practitioners. The median time to respond by specialists was 0.8 days, and the median time billed by specialists was 20 min. The most common topics were pulmonary nodules and masses (16.4%), cough (10.4%), infective problems (8.6%), chronic obstructive pulmonary disease (8.6%) and dyspnea Not Yet Diagnosed (NYD) (7.8%). The most common types of questions asked by PCP were related to investigations warranted (43.1% of cases), general management (17.5%), monitoring (12.6%), need for a respirology referral (12.3%) and drug of choice (6.3%). In 23% of cases, the PCP indicated they were planning to refer the patient for an in-person consultation but no longer needed to after receiving the eConsult advice (avoided referrals). On the other hand, in 13% of cases, the PCP was not going to refer but did after the eConsult (prompted referrals). The eConsult led to a new or additional clinical course of action by the PCP in 49% of cases. In 51% of cases, the PCP suggested the clinical topic would be well suited to a CME event. Conclusions Participation in eConsult services can improve timely access to respirologists while potentially avoiding clinic visits and significantly impacting referring PCPs clinical course of action. Using the most common clinical topics and types of questions for CME planning should be considered. Future research may include a cost analysis and provider perspectives on the role of eConsult in respirology care.

In mid-2001, in a cultural policy discussion at Arts Queensland, an Australian state government arts policy and funding apparatus, a senior arts bureaucrat seeking to draw a funding client’s gaze back to the bigger picture of what the state government was trying to achieve through its cultural policy settings excused his own abstracting comments with the phrase, “but then I might just be a policy ‘wank’”. There was some awkward laughter before one of his colleagues asked, “did you mean a policy ‘wonk’”? The incident was a misstatement of a term adopted in the 1990s to characterise the policy workers in the Clinton Whitehouse (Cunningham). This was not its exclusive use, but many saw Clinton as an exemplary wonk: less a pragmatic politician than one entertained by the elaboration of policy. The policy work of Clinton’s kitchen cabinet was, in part, driven by a pervasive rationalist belief in the usefulness of ordered policy processes as a method of producing social and economic outcomes, and, in part, by the seductions of policy-play: its ambivalences, its conundrums, and, in some sense, its aesthetics (Klein 193-94). There, far from being characterised as unproductive “self-abuse” of the body-politic, policy processes were alive as a pragmatic technology, an operationalisation of ideology, as an aestheticised field of play, but more than anything as a central rationalist tenant of government action. This final idea—the possibilities of policy for effecting change, promoting development, meeting government objectives—is at the centre of the bureaucratic imagination. Policy is effective. And a concomitant belief is that ordered or organised policy processes result in the best policy and the best outcomes. Starting with Harold Lasswell, policy theorists extended the general rationalist suppositions of Western representative democracies into executive government by arguing for the value of information/knowledge and the usefulness of ordered process in addressing thus identified policy problems. In the post-war period particularly, a case can be made for the usefulness of policy processes to government—although, in a paradox, these rationalist conceptions of the policy process were strangely irrational, even Utopian, in their view of transformational capacities possibilities of policy. The early policy scientists often moved beyond a view of policy science as a useful tool, to the advocacy of policy science and the policy scientist as panaceas for public ills (Parsons 18-19). The Utopian ambitions of policy science finds one of their extremes in the contemporary interest in whole-of-government approaches to policy making. Whole-of-governmentalism, concern with co-ordination of policy and delivery across all areas of the state, can seen as produced out of Western governments’ paradoxical concern with (on one hand) order, totality, and consistency, and (on the other) deconstructing existing mechanisms of public administration. Whole-of-governmentalism requires a horizontal purview of government goals, programs, outputs, processes, politics, and outcomes, alongside—and perhaps in tension with—the long-standing vertical purview that is fundamental to ministerial responsibility. This often presents a set of public management problems largely internal to government. Policy discussion and decision-making, while affecting community outcomes and stakeholder utility, are, in this circumstance, largely inter-agency in focus. Any eventual policy document may well have bureaucrats rather than citizens as its target readers—or at least as its closest readers. Internally, cohesion of objective, discourse, tool and delivery are pursued as a prime interests of policy making. Failing at Policy So what happens when whole-of-government policy processes, particularly cultural policy processes, break down or fail? Is there anything productive to be retrieved from a failed fantasy of policy cohesion? This paper examines the utility of a failure to cohere and order in cultural policy processes. I argue that the conditions of contemporary cultural policy-making, particularly the tension between the “boutique” scale of cultural policy-making bodies and the revised, near universal, remit of cultural policy, require policy work to be undertaken in an environment and in such a way that failure is almost inevitable. Coherence and cohesions are fundamental principles of whole-of-government policy but cultural policy ambitions are necessarily too comprehensive to be achievable. This is especially so for the small arts or cultural offices government that normally act as lead agencies for cultural policy development within government. Yet, that these failed processes can still give rise to positive outcomes or positive intermediate outputs that can be taken up in a productive way in the ongoing cycle of policy work that categorises contemporary cultural governance. Herein, I detail the development of Building the Future, a cultural policy planning paper (and the name of a policy planning process) undertaken within Arts Queensland in 1999 and 2000. (While this process is now ten years in the past, it is only with a decade past that as a consultant I am in apposition to write about the material.) The abandonment of this process before the production of a public policy program allows something to be said about the utility and role of failure in cultural policy-making. The working draft of Building the Future never became a public document, but the eight months of its development helped produce a series of shifts in the discourse of Queensland Government cultural policy: from “arts” to “creative industries”; and from arts bureaucracy-centred cultural policy to the whole-of-government policy frameworks. These concepts were then taken up and elaborated in the Creative Queensland policy statement published by Arts Queensland in October 2002, particularly the concern with creative industries; whole-of-government cultural policy; and the repositioning of Arts Queensland as a service agency to other potential cultural funding-bodies within government. Despite the failure of the Building the Future process, it had a role in the production of the policy document and policy processes that superseded it. This critique of cultural policy-making rather than cultural policy texts, announcements and settings is offered as part of a project to bring to cultural policy studies material and theoretical accounts of the particularities of making cultural policy. While directions in cultural policy have much to do with the overall directions of government—which might over the past decade be categorised as focus on de-regulation, out-sourcing of services—there are developments in cultural policy settings and in cultural policy processes that are particular to cultural policy and cultural policy-making. Central to the development of cultural policy studies and to cultural policy is a transformational broadening of the operant definition of culture within government (O'Regan). Following Raymond Williams, the domain of culture is broadened to include the high culture, popular culture, folk culture and the culture of everyday life. Accordingly, in some sense, every issue of governance is deemed to have a cultural dimension—be it policy questions around urban space, tourism, community building and so on. Contemporary governments are required to act with a concern for cultural questions both within and across a number of long-persisting and otherwise discrete policy silos. This has implications for cultural policy makers and for program delivery. The definition of culture as “everyday life”, while truistically defendable, becomes unwieldy as an imprimatur or a container for administrative activity. Transforming cultural policy into a domain incorporating most social policy and significant elements of economic policy makes the domain titanically large. Potentially, it compromises usual government efforts to order policy activity through the division or apportionment of responsibility (Glover and Cunningham 19). The problem has given rise to a new mode of policy-making which attends to the co-ordination of policy across and between levels of government, known as whole-of government policy-making (see O’Regan). Within the domain of cultural policy the task of whole-of-government cultural policy is complicated by the position of, and the limits upon, arts and cultural bureaux within state and federal governments. Dedicated cultural planning bureaux often operate as “boutique” agencies. They are usually discrete line agencies or line departments within government—only rarely are they part of the core policy function of departments of a Premier or a Prime Minister. Instead, like most line agencies, they lack the leverage within the bureaucracy or policy apparatus to deliver whole-of-government cultural policy change. In some sense, failure is the inevitable outcome of all policy processes, particularly when held up against the mechanistic representation of policy processes in policy typical of policy handbooks (see Bridgman and Davis 42). Against such models, which describe policy a series of discrete linear steps, all policy efforts fail. The rationalist assumptions of early policy models—and the rigid templates for policy process that arise from their assumptions—in retrospect condemn every policy process to failure or at least profound shortcoming. This is particularly so with whole-of-government cultural policy making To re-think this, it can be argued that the error then is not really in the failure of the process, which is invariably brought about by the difficulty for coherent policy process to survive exogenous complexity, but instead the error rests with the simplicity of policy models and assumptions about the possibility of cohesion. In some sense, mechanistic policy processes make failure endogenous. The contemporary experience of making policy has tended to erode any fantasies of order, clear process, or, even, clear-sightedness within government. Achieving a coherence to the policy message is nigh on impossible—likewise cohesion of the policy framework is unlikely. Yet, importantly, failed policy is not without value. The churn of policy work—the exercise of attempting cohrent policy-making—constitutes, in some sense, the deliberative function of government, and potentially operates as a force (and site) of change. Policy briefings, reports, and draft policies—the constitution of ideas in the policy process and the mechanism for their dissemination within the body of government and perhaps to other stakeholders—are discursive acts in the process of extending the discourse of government and forming its later actions. For arts and cultural policy agencies in particular, who act without the leverage or resources of central agencies, the expansive ambitions of whole-of-government cultural policy makes failure inevitable. In such a circumstance, retrieving some benefits at the margins of policy processes, through the churn of policy work towards cohesion, is an important consolation. Case study: Cultural Policy 2000 The policy process I wish to examine is now complete. It ran over the period 1999–2002, although I wish to concentrate on my involvement in the process in early 2000 during which, as a consultant to Arts Queensland, I generated a draft policy document, Building the Future: A policy framework for the next five years (working draft). The imperative to develop a new state cultural policy followed the election of the first Beattie Labor government in July 1998. By 1999, senior Arts Queensland staff began to argue (within government at least) for the development of a new state cultural policy. The bureaucrats perceived policy development as one way of establishing “traction” in the process of bidding for new funds for the portfolio. Arts Minister Matt Foley was initially reluctant to “green-light” the policy process, but eventually in early 1999 he acceded to it on the advice of Arts Queensland, the industry, his own policy advisors and the Department of Premier. As stated above, this case study is offered now because the passing of time makes the analysis of relatively sensitive material possible. From the outset, an abbreviated timeframe for consultation and drafting seem to guarantee a difficult birth for the policy document. This was compounded by a failure to clarity the aims and process of the project. In presenting the draft policy to the advisory group, it became clear that there was no agreed strategic purpose to the document: Was it to be an advertisement, a framework for policy ideas, an audit, or a report on achievements? Tied to this, were questions about the audience for the policy statement. Was it aimed at the public, the arts industry, bureaucrats inside Arts Queensland, or, in keeping with the whole-of-government inflection to the document and its putative use in bidding for funds inside government, bureaucrats outside of Arts Queensland? My own conception of the document was as a cultural policy framework for the whole-of-government for the coming five years. It would concentrate on cultural policy in three realms: Arts Queensland; the arts instrumentalities; and other departments (particularly the cultural initiatives undertaken by the Department of Premier and the Department of State Development). In order to do this I articulated (for myself) a series of goals for the document. It needed to provide the philosophical underpinnings for a new arts and cultural policy, discuss the cultural significance of “community” in the context of the arts, outline expansion plans for the arts infrastructure throughout Queensland, advance ideas for increased employment in the arts and cultural industries, explore the development of new audiences and markets, address contemporary issues of technology, globalisation and culture commodification, promote a whole-of-government approach to the arts and cultural industries, address social justice and equity concerns associated with cultural diversity, and present examples of current and new arts and cultural practices. Five key strategies were identified: i) building strong communities and supporting diversity; ii) building the creative industries and the cultural economy; iii) developing audiences and telling Queensland’s stories; iv) delivering to the world; and v) a new role for government. While the second aim of building the creative industries and the cultural economy was an addition to the existing Australian arts policy discourse, it is the articulation of a new role for government that is most radical here. The document went to the length of explicitly suggesting a series of actions to enable Arts Queensland to re-position itself inside government: develop an ongoing policy cycle; position Arts Queensland as a lead agency for cultural policy development; establish a mechanism for joint policy planning across the arts portfolio; adopt a whole-of-government approach to policy-making and program delivery; use arts and cultural strategies to deliver on social and economic policy agendas; centralise some cultural policy functions and project; maintain and develop mechanisms and peer assessment; establish long-term strategic relationships with the Commonwealth and local government; investigate new vehicles for arts and cultural investment; investigate partnerships between industry, community and government; and develop appropriate performance measures for the cultural industries. In short, the scope of the document was titanically large, and prohibitively expansive as a basis for policy change. A chief limitation of these aims is that they seem to place the cohesion and coherence of the policy discourse at the centre of the project—when it might have better privileged a concern with policy outputs and industry/community outcomes. The subsequent dismal fortunes of the document are instructive. The policy document went through several drafts over the first half of 2000. By August 2000, I had removed myself from the process and handed the drafting back to Arts Queensland which then produced shorter version less discursive than my initial draft. However, by November 2000, it is reasonable to say that the policy document was abandoned. Significantly, after May 2000 the working drafts began to be used as internal discussion documents with government. Thus, despite the abandonment of the policy process, largely due to the unworkable breadth of its ambition, the document had a continued policy utility. The subsequent discussions helped organise future policy statements and structural adjustments by government. After the re-election of the Beattie government in January 2001, a more substantial policy process was commenced with the earlier policy documents as a starting point. By early 2002 the document was in substantial draft. The eventual policy, Creative Queensland, was released in October 2002. Significantly, this document sought to advance two ideas that I believe the earlier process did much to mobilise: a whole-of-government approach to culture; and a broader operant definition of culture. It is important not to see these as ideas merely existing “textually” in the earlier policy draft of Building the Future, but instead to see them as ideas that had begun adhere themselves to the cultural policy mechanism of government, and begun to be deployed in internal policy discussions and in program design, before finding an eventual home in a published policy text. Analysis The productive effects of the aborted policy process in which I participated are difficult to quantify. They are difficult, in fact, to separate out from governments’ ongoing processes of producing and circulating policy ideas. What is clear is that the effects of Building the Future were not entirely negated by it never becoming public. Instead, despite only circulating to a readership of bureaucrats it represented the ideas of part of the bureaucracy at a point in time. In this instance, a “failed” policy process, and its intermediate outcomes, the draft policy, through the churn of policy work, assisted government towards an eventual policy statement and a new form of governmental organisation. This suggests that processes of cultural policy discussion, or policy churn, can be as productive as the public “enunciation” of formal policy in helping to organise ideas within government and determine programs and the allocation of resources. This is even so where the Utopian idealism of the policy process is abandoned for something more graspable or politic. For the small arts or cultural policy bureau this is an important incremental benefit. Two final implications should be noted. The first is for models of policy process. Bridgman and Davis’s model of the Australian policy cycle, despite its mechanistic qualities, is ambiguous about where the policy process begins and ends. In one instance they represent it as linear but strictly circular, always coming back to its own starting point (27). Elsewhere, however, they represent it as linear, but not necessarily circular, passing through eight stages with a defined beginning and end: identification of issues; policy analysis; choosing policy instruments; consultation; co-ordination; decision; implementation; and evaluation (28–29). What is clear from the 1999-2002 policy process—if we take the full period between when Arts Queensland began to organise the development of a new arts policy and its publication as Creative Queensland in October 2002—is that the policy process was not a linear one progressing in an orderly fashion towards policy outcomes. Instead, Building the Future, is a snapshot in time (namely early to mid-2000) of a fragmenting policy process; it reveals policy-making as involving a concurrency of policy activity rather than a progression through linear steps. Following Mark Considine’s conception of policy work as the state’s effort at “system-wide information exchange and policy transfer” (271), the document is concerned less in the ordering of resources than the organisation of policy discourse. The churn of policy is the mobilisation of information, or for Considine: policy-making, when considered as an innovation system among linked or interdependent actors, becomes a learning and regulating web based upon continuous exchanges of information and skill. Learning occurs through regulated exchange, rather than through heroic insight or special legislative feats of the kind regularly described in newspapers. (269) The acceptance of this underpins a turn in contemporary accounts of policy (Considine 252-72) where policy processes become contingent and incomplete Policy. The ordering of policy is something to be attempted rather than achieved. Policy becomes pragmatic and ad hoc. It is only coherent in as much as a policy statement represents a bringing together of elements of an agency or government’s objectives and program. The order, in some sense, arrives through the act of collection, narrativisation and representation. The second implication is more directly for cultural policy makers facing the prospect of whole-of-government cultural policy making. While it is reasonable for government to wish to make coherent totalising statements about its cultural interests, such ambitions bring the near certainty of failure for the small agency. Yet these failures of coherence and cohesion should be viewed as delivering incremental benefits through the effort and process of this policy “churn”. As was the case with the Building the Future policy process, while aborted it was not a totally wasted effort. Instead, Building the Future mobilised a set of ideas within Arts Queensland and within government. For the small arts or cultural bureaux approaching the enormous task of whole-of government cultural policy making such marginal benefits are important. References Arts Queensland. Creative Queensland: The Queensland Government Cultural Policy 2002. Brisbane: Arts Queensland, 2002. Bridgman, Peter, and Glyn Davis. Australian Policy Handbook. St Leonards: Allen & Unwin, 1998. Considine, Mark. Public Policy: A Critical Approach. South Melbourne: Palgrave Macmillan, 1996. Cunningham, Stuart. "Willing Wonkers at the Policy Factory." Media Information Australia 73 (1994): 4-7. Glover, Stuart, and Stuart Cunningham. "The New Brisbane." Artlink 23.2 (2003): 16-23. Glover, Stuart, and Gillian Gardiner. Building the Future: A Policy Framework for the Next Five Years (Working Draft). Brisbane: Arts Queensland, 2000. Klein, Joe. "Eight Years." New Yorker 16 & 23 Oct. 2000: 188-217. O'Regan, Tom. "Cultural Policy: Rejuvenate or Wither". 2001. rtf.file. (26 July): AKCCMP. 9 Aug. 2001. ‹http://www.gu.edu.au/centre/cmp>. Parsons, Wayne. Public Policy: An Introduction to the Theory and Practice of Policy Analysis. Aldershot: Edward Edgar, 1995.Williams, Raymond. Key Words: A Vocabulary of Culture and Society. London: Fontana, 1976.

IntroductionIn July 1997, the Mackay campus of Central Queensland University hosted a conference with the theme Regional Australia: Visions of Mackay. It was the first academic conference to be held at the young campus, and its aim was to provide an opportunity for academics, business people, government officials, and other interested parties to discuss their visions for the development of Mackay, a regional community of 75,000 people situated on the Central Queensland coast (Danaher). I delivered a presentation at that conference and authored a chapter in the book that emerged from its proceedings. The chapter entitled “Mackay Online” explored the potential impact that the Internet could have on the Mackay region, particularly in the areas of regional business, education, health, and entertainment (Pace). Two decades later, how does the reality compare with that vision?Broadband BluesAt the time of the Visions of Mackay conference, public commercial use of the Internet was in its infancy. Many Internet services and technologies that users take for granted today were uncommon or non-existent then. Examples include online video, video-conferencing, Voice over Internet Protocol (VoIP), blogs, social media, peer-to-peer file sharing, payment gateways, content management systems, wireless data communications, smartphones, mobile applications, and tablet computers. In 1997, most users connected to the Internet using slow dial-up modems with speeds ranging from 28.8 Kbps to 33.6 Kbps. 56 Kbps modems had just become available. Lamenting these slow data transmission speeds, I looked forward to a time when widespread availability of high-bandwidth networks would allow the Internet’s services to “expand to include electronic commerce, home entertainment and desktop video-conferencing” (Pace 103). Although that future eventually arrived, I incorrectly anticipated how it would arrive.In 1997, Optus and Telstra were engaged in the rollout of hybrid fibre coaxial (HFC) networks in Sydney, Melbourne, and Brisbane for the Optus Vision and Foxtel pay TV services (Meredith). These HFC networks had a large amount of unused bandwidth, which both Telstra and Optus planned to use to provide broadband Internet services. Telstra's Big Pond Cable broadband service was already available to approximately one million households in Sydney and Melbourne (Taylor), and Optus was considering extending its cable network into regional Australia through partnerships with smaller regional telecommunications companies (Lewis). These promising developments seemed to point the way forward to a future high-bandwidth network, but that was not the case. A short time after the Visions of Mackay conference, Telstra and Optus ceased the rollout of their HFC networks in response to the invention of Asynchronous Digital Subscriber Line (ADSL), a technology that increases the bandwidth of copper wire and enables Internet connections of up to 6 Mbps over the existing phone network. ADSL was significantly faster than a dial-up service, it was broadly available to homes and businesses across the country, and it did not require enormous investment in infrastructure. However, ADSL could not offer speeds anywhere near the 27 Mbps of the HFC networks. When it came to broadband provision, Australia seemed destined to continue playing catch-up with the rest of the world. According to data from the Organisation for Economic Cooperation and Development (OECD), in 2009 Australia ranked 18th in the world for broadband penetration, with 24.1 percent of Australians having a fixed-line broadband subscription. Statistics like these eventually prompted the federal government to commit to the deployment of a National Broadband Network (NBN). In 2009, the Kevin Rudd Government announced that the NBN would combine fibre-to-the-premises (FTTP), fixed wireless, and satellite technologies to deliver Internet speeds of up to 100 Mbps to 90 percent of Australian homes, schools, and workplaces (Rudd).The rollout of the NBN in Mackay commenced in 2013 and continued, suburb by suburb, until its completion in 2017 (Frost, “Mackay”; Garvey). The rollout was anything but smooth. After a change of government in 2013, the NBN was redesigned to reduce costs. A mixed copper/optical technology known as fibre-to-the-node (FTTN) replaced FTTP as the preferred approach for providing most NBN connections. The resulting connection speeds were significantly slower than the 100 Mbps that was originally proposed. Many Mackay premises could only achieve a maximum speed of 40 Mbps, which led to some overcharging by Internet service providers, and subsequent compensation for failing to deliver services they had promised (“Optus”). Some Mackay residents even complained that their new NBN connections were slower than their former ADSL connections. NBN Co representatives claimed that the problems were due to “service providers not buying enough space in the network to provide the service they had promised to customers” (“Telcos”). Unsurprisingly, the number of complaints about the NBN that were lodged with the Telecommunications Industry Ombudsman skyrocketed during the last six months of 2017. Queensland complaints increased by approximately 40 percent when compared with the same period during the previous year (“Qld”).Despite the challenges presented by infrastructure limitations, the rollout of the NBN was a boost for the Mackay region. For some rural residents, it meant having reliable Internet access for the first time. Frost, for example, reports on the experiences of a Mackay couple who could not get an ADSL service at their rural home because it was too far away from the nearest telephone exchange. Unreliable 3G mobile broadband was the only option for operating their air-conditioning business. All of that changed with the arrival of the NBN. “It’s so fast we can run a number of things at the same time”, the couple reported (“NBN”).Networking the NationOne factor that contributed to the uptake of Internet services in the Mackay region after the Visions of Mackay conference was the Australian Government’s Networking the Nation (NTN) program. When the national telecommunications carrier Telstra was partially privatised in 1997, and further sold in 1999, proceeds from the sale were used to fund an ambitious communications infrastructure program named Networking the Nation (Department of Communications, Information Technology and the Arts). The program funded projects that improved the availability, accessibility, affordability, and use of communications facilities and services throughout regional Australia. Eligibility for funding was limited to not-for-profit organisations, including local councils, regional development organisations, community groups, local government associations, and state and territory governments.In 1998, the Mackay region received $930,000 in Networking the Nation funding for Mackay Regionlink, a project that aimed to provide equitable community access to online services, skills development for local residents, an affordable online presence for local business and community organisations, and increased external awareness of the Mackay region (Jewell et al.). One element of the project was a training program that provided basic Internet skills to 2,168 people across the region over a period of two years. A second element of the project involved the establishment of 20 public Internet access centres in locations throughout the region, such as libraries, community centres, and tourist information centres. The centres provided free Internet access to users and encouraged local participation and skill development. More than 9,200 users were recorded in these centres during the first year of the project, and the facilities remained active until 2006. A third element of the project was a regional web portal that provided a free easily-updated online presence for community organisations. The project aimed to have every business and community group in the Mackay region represented on the website, with hosting fees for the business web pages funding its ongoing operation and development. More than 6,000 organisations were listed on the site, and the project remained financially viable until 2005.The availability, affordability and use of communications facilities and services in Mackay increased significantly during the period of the Regionlink project. Changes in technology, services, markets, competition, and many other factors contributed to this increase, so it is difficult to ascertain the extent to which Mackay Regionlink fostered those outcomes. However, the large number of people who participated in the Regionlink training program and made use of the public Internet access centres, suggests that the project had a positive influence on digital literacy in the Mackay region.The Impact on BusinessThe Internet has transformed regional business for both consumers and business owners alike since the Visions of Mackay conference. When Mackay residents made a purchase in 1997, their choice of suppliers was limited to a few local businesses. Today they can shop online in a global market. Security concerns were initially a major obstacle to the growth of electronic commerce. Consumers were slow to adopt the Internet as a place for doing business, fearing that their credit card details would be vulnerable to hackers once they were placed online. After observing the efforts that finance and software companies were making to eliminate those obstacles, I anticipated that it would only be a matter of time before online transactions became commonplace:Consumers seeking a particular product will be able to quickly find the names of suitable suppliers around the world, compare their prices, and place an order with the one that can deliver the product at the cheapest price. (Pace 106)This expectation was soon fulfilled by the arrival of online payment systems such as PayPal in 1998, and online shopping services such as eBay in 1997. eBay is a global online auction and shopping website where individuals and businesses buy and sell goods and services worldwide. The eBay service is free to use for buyers, but sellers are charged modest fees when they make a sale. It exemplifies the notion of “friction-free capitalism” articulated by Gates (157).In 1997, regional Australian business owners were largely sceptical about the potential benefits the Internet could bring to their businesses. Only 11 percent of Australian businesses had some form of web presence, and less than 35 percent of those early adopters felt that their website was significant to their business (Department of Industry, Science and Tourism). Anticipating the significant opportunities that the Internet offered Mackay businesses to compete in new markets, I recommended that they work “towards the goal of providing products and services that meet the needs of international consumers as well as local ones” (107). In the two decades that have passed since that time, many Mackay businesses have been doing just that. One prime example is Big on Shoes (bigonshoes.com.au), a retailer of ladies’ shoes from sizes five to fifteen (Plane). Big on Shoes has physical shopfronts in Mackay and Moranbah, an online store that has been operating since 2009, and more than 12,000 followers on Facebook. This speciality store caters for women who have traditionally been unable to find shoes in their size. As the store’s customer base has grown within Australia and internationally, an unexpected transgender market has also emerged. In 2018 Big on Shoes was one of 30 regional businesses featured in the first Facebook and Instagram Annual Gift Guide, and it continues to build on its strengths (Cureton).The Impact on HealthThe growth of the Internet has improved the availability of specialist health services for people in the Mackay region. Traditionally, access to surgical services in Mackay has been much more limited than in metropolitan areas because of the shortage of specialists willing to practise in regional areas (Green). In 2003, a senior informant from the Royal Australasian College of Surgeons bluntly described the Central Queensland region from Mackay to Gladstone as “a black hole in terms of surgery” (Birrell et al. 15). In 1997 I anticipated that, although the Internet would never completely replace a visit to a local doctor or hospital, it would provide tools that improve the availability of specialist medical services for people living in regional areas. Using these tools, doctors would be able to “analyse medical images captured from patients living in remote locations” and “diagnose patients at a distance” (Pace 108).These expectations have been realised in the form of Queensland Health’s Telehealth initiative, which permits medical specialists in Brisbane and Townsville to conduct consultations with patients at the Mackay Base Hospital using video-conference technology. Telehealth reduces the need for patients to travel for specialist advice, and it provides health professionals with access to peer support. Averill (7), for example, reports on the experience of a breast cancer patient at the Mackay Base Hospital who was able to participate in a drug trial with a Townsville oncologist through the Telehealth network. Mackay health professionals organised the patient’s scans, administered blood tests, and checked her lymph nodes, blood pressure and weight. Townsville health professionals then used this information to advise the Mackay team about her ongoing treatment. The patient expressed appreciation that the service allowed her to avoid the lengthy round-trip to Townsville. Prior to being offered the Telehealth option, she had refused to participate in the trial because “the trip was just too much of a stumbling block” (Averill 7).The Impact on Media and EntertainmentThe field of media and entertainment is another aspect of regional life that has been reshaped by the Internet since the Visions of Mackay conference. Most of these changes have been equally apparent in both regional and metropolitan areas. Over the past decade, the way individuals consume media has been transformed by new online services offering user-generated video, video-on-demand, and catch-up TV. These developments were among the changes I anticipated in 1997:The convergence of television and the Internet will stimulate the creation of new services such as video-on-demand. Today television is a synchronous media—programs are usually viewed while they are being broadcast. When high-quality video can be transmitted over the information superhighway, users will be able to watch what they want, when and where they like. […] Newly released movies will continue to be rented, but probably not from stores. Instead, consumers will shop on the information superhighway for movies that can be delivered on demand.In the mid-2000s, free online video-sharing services such as YouTube and Vimeo began to emerge. These websites allow users to freely upload, view, share, comment on, and curate online videos. Subscription-based streaming services such as Netflix and Amazon Prime have also become increasingly popular since that time. These services offer online streaming of a library of films and television programs for a fee of less than 20 dollars per month. Computers, smart TVs, Blu-ray players, game consoles, mobile phones, tablets, and other devices provide a multitude of ways of accessing streaming services. Some of these devices cost less than 100 dollars, while higher-end electronic devices include the capability as a bundled feature. Netflix became available in Mackay at the time of its Australian launch in 2015. The growth of streaming services greatly reduced the demand for video rental shops in the region, and all closed down as a result. The last remaining video rental store in Mackay closed its doors in 2018 after trading for 26 years (“Last”).Some of the most dramatic transformations that have occurred the field of media and entertainment were not anticipated in 1997. The rise of mobile technology, including wireless data communications, smartphones, mobile applications, and tablet computers, was largely unforeseen at that time. Some Internet luminaries such as Vinton Cerf expected that mobile access to the Internet via laptop computers would become commonplace (Lange), but this view did not encompass the evolution of smartphones, and it was not widely held. Similarly, the rise of social media services and the impact they have had on the way people share content and communicate was generally unexpected. In some respects, these phenomena resemble the Black Swan events described by Nassim Nicholas Taleb (xvii)—surprising events with a major effect that are often inappropriately rationalised after the fact. They remind us of how difficult it is to predict the future media landscape by extrapolating from things we know, while failing to take into consideration what we do not know.The Challenge for MackayIn 1997, when exploring the potential impact that the Internet could have on the Mackay region, I identified a special challenge that the community faced if it wanted to be competitive in this new environment:The region has traditionally prospered from industries that control physical resources such as coal, sugar and tourism, but over the last two decades there has been a global ‘shift away from physical assets and towards information as the principal driver of wealth creation’ (Petre and Harrington 1996). The risk for Mackay is that its residents may be inclined to believe that wealth can only be created by means of industries that control physical assets. The community must realise that its value-added information is at least as precious as its abundant natural resources. (110)The Mackay region has not responded well to this challenge, as evidenced by measures such as the Knowledge City Index (KCI), a collection of six indicators that assess how well a city is positioned to grow and advance in today’s technology-driven, knowledge-based economy. A 2017 study used the KCI to conduct a comparative analysis of 25 Australian cities (Pratchett, Hu, Walsh, and Tuli). Mackay rated reasonably well in the areas of Income and Digital Access. But the city’s ratings were “very limited across all the other measures of the KCI”: Knowledge Capacity, Knowledge Mobility, Knowledge Industries and Smart Work (44).The need to be competitive in a technology-driven, knowledge-based economy is likely to become even more pressing in the years ahead. The 2017 World Energy Outlook Report estimated that China’s coal use is likely to have peaked in 2013 amid a rapid shift toward renewable energy, which means that demand for Mackay’s coal will continue to decline (International Energy Agency). The sugar industry is in crisis, finding itself unable to diversify its revenue base or increase production enough to offset falling global sugar prices (Rynne). The region’s biggest tourism drawcard, the Great Barrier Reef, continues to be degraded by mass coral bleaching events and ongoing threats posed by climate change and poor water quality (Great Barrier Reef Marine Park Authority). All of these developments have disturbing implications for Mackay’s regional economy and its reliance on coal, sugar, and tourism. Diversifying the local economy through the introduction of new knowledge industries would be one way of preparing the Mackay region for the impact of new technologies and the economic challenges that lie ahead.ReferencesAverill, Zizi. “Webcam Consultations.” Daily Mercury 22 Nov. 2018: 7.Birrell, Bob, Lesleyanne Hawthorne, and Virginia Rapson. The Outlook for Surgical Services in Australasia. Melbourne: Monash University Centre for Population and Urban Research, 2003.Cureton, Aidan. “Big Shoes, Big Ideas.” Daily Mercury 8 Dec. 2018: 12.Danaher, Geoff. Ed. Visions of Mackay: Conference Papers. Rockhampton: Central Queensland UP, 1998.Department of Communications, Information Technology and the Arts. Networking the Nation: Evaluation of Outcomes and Impacts. Canberra: Australian Government, 2005.Department of Industry, Science and Tourism. Electronic Commerce in Australia. Canberra: Australian Government, 1998.Frost, Pamela. “Mackay Is Up with Switch to Speed to NBN.” Daily Mercury 15 Aug. 2013: 8.———. “NBN Boost to Business.” Daily Mercury 29 Oct. 2013: 3.Gates, Bill. The Road Ahead. New York: Viking Penguin, 1995.Garvey, Cas. “NBN Rollout Hit, Miss in Mackay.” Daily Mercury 11 Jul. 2017: 6.Great Barrier Reef Marine Park Authority. Reef Blueprint: Great Barrier Reef Blueprint for Resilience. Townsville: Great Barrier Reef Marine Park Authority, 2017.Green, Anthony. “Surgical Services and Referrals in Rural and Remote Australia.” Medical Journal of Australia 177.2 (2002): 110–11.International Energy Agency. World Energy Outlook 2017. France: IEA Publications, 2017.Jewell, Roderick, Mary O’Flynn, Fiorella De Cindio, and Margaret Cameron. “RCM and MRL—A Reflection on Two Approaches to Constructing Communication Memory.” Constructing and Sharing Memory: Community Informatics, Identity and Empowerment. Eds. Larry Stillman and Graeme Johanson. Newcastle: Cambridge Scholars Publishing, 2007. 73–86.Lange, Larry. “The Internet: Where’s It All Going?” Information Week 17 Jul. 1995: 30.“Last Man Standing Shuts Doors after 26 Years of Trade.” Daily Mercury 28 Aug. 2018: 7.Lewis, Steve. “Optus Plans to Share Cost Burden.” Australian Financial Review 22 May 1997: 26.Meredith, Helen. “Time Short for Cable Modem.” Australian Financial Review 10 Apr. 1997: 42Nassim Nicholas Taleb. The Black Swan: The Impact of the Highly Improbable. New York: Random House, 2007.“Optus Offers Comp for Slow NBN.” Daily Mercury 10 Nov. 2017: 15.Organisation for Economic Cooperation and Development. “Fixed Broadband Subscriptions.” OECD Data, n.d. <https://data.oecd.org/broadband/fixed-broadband-subscriptions.htm>.Pace, Steven. “Mackay Online.” Visions of Mackay: Conference Papers. Ed. Geoff Danaher. Rockhampton: Central Queensland University Press, 1998. 111–19.Petre, Daniel and David Harrington. The Clever Country? Australia’s Digital Future. Sydney: Lansdown Publishing, 1996.Plane, Melanie. “A Shoe-In for Big Success.” Daily Mercury 9 Sep. 2017: 6.Pratchett, Lawrence, Richard Hu, Michael Walsh, and Sajeda Tuli. The Knowledge City Index: A Tale of 25 Cities in Australia. Canberra: University of Canberra neXus Research Centre, 2017.“Qld Customers NB-uN Happy Complaints about NBN Service Double in 12 Months.” Daily Mercury 17 Apr. 2018: 1.Rudd, Kevin. “Media Release: New National Broadband Network.” Parliament of Australia Press Release, 7 Apr. 2009 <https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id:"media/pressrel/PS8T6">.Rynne, David. “Revitalising the Sugar Industry.” Sugar Policy Insights Feb. 2019: 2–3.Taylor, Emma. “A Dip in the Pond.” Sydney Morning Herald 16 Aug. 1997: 12.“Telcos and NBN Co in a Crisis.” Daily Mercury 27 Jul. 2017: 6.

The Australian Government has been actively evaluating how best to merge the functions of the Australian Communications Authority (ACA) and the Australian Broadcasting Authority (ABA) for around two years now. Broadly, the reason for this is an attempt to keep pace with the communications media transformations we reduce to the term “convergence.” Mounting pressure for restructuring is emerging as a site of turf contestation: the possibility of a regulatory “one-stop shop” for governments (and some industry players) is an end game of considerable force. But, from a public interest perspective, the case for a converged regulator needs to make sense to audiences using various media, as well as in terms of arguments about global, industrial, and technological change. This national debate about the institutional reshaping of media regulation is occurring within a wider global context of transformations in social, technological, and politico-economic frameworks of open capital and cultural markets, including the increasing prominence of international economic organisations, corporations, and Free Trade Agreements (FTAs). Although the recently concluded FTA with the US explicitly carves out a right for Australian Governments to make regulatory policy in relation to existing and new media, considerable uncertainty remains as to future regulatory arrangements. A key concern is how a right to intervene in cultural markets will be sustained in the face of cultural, politico-economic, and technological pressures that are reconfiguring creative industries on an international scale. While the right to intervene was retained for the audiovisual sector in the FTA, by contrast, it appears that comparable unilateral rights to intervene will not operate for telecommunications, e-commerce or intellectual property (DFAT). Blurring Boundaries A lack of certainty for audiences is a by-product of industry change, and further blurs regulatory boundaries: new digital media content and overlapping delivering technologies are already a reality for Australia’s media regulators. These hypothetical media usage scenarios indicate how confusion over the appropriate regulatory agency may arise: 1. playing electronic games that use racist language; 2. being subjected to deceptive or misleading pop-up advertising online 3. receiving messaged imagery on your mobile phone that offends, disturbs, or annoys; 4. watching a program like World Idol with SMS voting that subsequently raises charging or billing issues; or 5. watching a new “reality” TV program where products are being promoted with no explicit acknowledgement of the underlying commercial arrangements either during or at the end of the program. These are all instances where, theoretically, regulatory mechanisms are in place that allow individuals to complain and to seek some kind of redress as consumers and citizens. In the last scenario, in commercial television under the sector code, no clear-cut rules exist as to the precise form of the disclosure—as there is (from 2000) in commercial radio. It’s one of a number of issues the peak TV industry lobby Commercial TV Australia (CTVA) is considering in their review of the industry’s code of practice. CTVA have proposed an amendment to the code that will simply formalise the already existing practice . That is, commercial arrangements that assist in the making of a program should be acknowledged either during programs, or in their credits. In my view, this amendment doesn’t go far enough in post “cash for comment” mediascapes (Dwyer). Audiences have a right to expect that broadcasters, production companies and program celebrities are open and transparent with the Australian community about these kinds of arrangements. They need to be far more clearly signposted, and people better informed about their role. In the US, the “Commercial Alert” <http://www.commercialalert.org/> organisation has been lobbying the Federal Communications Commission and the Federal Trade Commission to achieve similar in-program “visual acknowledgements.” The ABA’s Commercial Radio Inquiry (“Cash-for-Comment”) found widespread systemic regulatory failure and introduced three new standards. On that basis, how could a “standstill” response by CTVA, constitute best practice for such a pervasive and influential medium as contemporary commercial television? The World Idol example may lead to confusion for some audiences, who are unsure whether the issues involved relate to broadcasting or telecommunications. In fact, it could be dealt with as a complaint to the Telecommunication Industry Ombudsman (TIO) under an ACA registered, but Australian Communications Industry Forum (ACIF) developed, code of practice. These kind of cross-platform issues may become more vexed in future years from an audience’s perspective, especially if reality formats using on-screen premium rate service numbers invite audiences to participate, by sending MMS (multimedia messaging services) images or short video grabs over wireless networks. The political and cultural implications of this kind of audience interaction, in terms of access, participation, and more generally the symbolic power of media, may perhaps even indicate a longer-term shift in relations with consumers and citizens. In the Internet example, the Australian Competition and Consumer Commission’s (ACCC) Internet advertising jurisdiction would apply—not the ABA’s “co-regulatory” Internet content regime as some may have thought. Although the ACCC deals with complaints relating to Internet advertising, there won’t be much traction for them in a more complex issue that also includes, say, racist or religious bigotry. The DVD example would probably fall between the remits of the Office of Film and Literature Classification’s (OFLC) new “convergent” Guidelines for the Classification of Film and Computer Games and race discrimination legislation administered by the Human Rights and Equal Opportunity Commission (HREOC). The OFLC’s National Classification Scheme is really geared to provide consumer advice on media products that contain sexual and violent imagery or coarse language, rather than issues of racist language. And it’s unlikely that a single person would have the locus standito even apply for a reclassification. It may fall within the jurisdiction of the HREOC depending on whether it was played in public or not. Even then it would probably be considered exempt on free speech grounds as an “artistic work.” Unsolicited, potentially illegal, content transmitted via mobile wireless devices, in particular 3G phones, provide another example of content that falls between the media regulation cracks. It illustrates a potential content policy “turf grab” too. Image-enabled mobile phones create a variety of novel issues for content producers, network operators, regulators, parents and viewers. There is no one government media authority or agency with a remit to deal with this issue. Although it has elements relating to the regulatory activities of the ACA, the ABA, the OFLC, the TIO, and TISSC, the combination of illegal or potentially prohibited content and its carriage over wireless networks positions it outside their current frameworks. The ACA may argue it should have responsibility for this kind of content since: it now enforces the recently enacted Commonwealth anti-Spam laws; has registered an industry code of practice for unsolicited content delivered over wireless networks; is seeking to include ‘adult’ content within premium rate service numbers, and, has been actively involved in consumer education for mobile telephony. It has also worked with TISSC and the ABA in relation to telephone sex information services over voice networks. On the other hand, the ABA would probably argue that it has the relevant expertise for regulating wirelessly transmitted image-content, arising from its experience of Internet and free and subscription TV industries, under co-regulatory codes of practice. The OFLC can also stake its claim for policy and compliance expertise, since the recently implemented Guidelines for Classification of Film and Computer Games were specifically developed to address issues of industry convergence. These Guidelines now underpin the regulation of content across the film, TV, video, subscription TV, computer games and Internet sectors. Reshaping Institutions Debates around the “merged regulator” concept have occurred on and off for at least a decade, with vested interests in agencies and the executive jockeying to stake claims over new turf. On several occasions the debate has been given renewed impetus in the context of ruling conservative parties’ mooted changes to the ownership and control regime. It’s tended to highlight demarcations of remit, informed as they are by historical and legal developments, and the gradual accretion of regulatory cultures. Now the key pressure points for regulatory change include the mere existence of already converged single regulatory structures in those countries with whom we tend to triangulate our policy comparisons—the US, the UK and Canada—increasingly in a context of debates concerning international trade agreements; and, overlaying this, new media formats and devices are complicating existing institutional arrangements and legal frameworks. The Department of Communications, Information Technology & the Arts’s (DCITA) review brief was initially framed as “options for reform in spectrum management,” but was then widened to include “new institutional arrangements” for a converged regulator, to deal with visual content in the latest generation of mobile telephony, and other image-enabled wireless devices (DCITA). No other regulatory agencies appear, at this point, to be actively on the Government’s radar screen (although they previously have been). Were the review to look more inclusively, the ACCC, the OFLC and the specialist telecommunications bodies, the TIO and the TISSC may also be drawn in. Current regulatory arrangements see the ACA delegate responsibility for broadcasting services bands of the radio frequency spectrum to the ABA. In fact, spectrum management is the turf least contested by the regulatory players themselves, although the “convergent regulator” issue provokes considerable angst among powerful incumbent media players. The consensus that exists at a regulatory level can be linked to the scientific convention that holds the radio frequency spectrum is a continuum of electromagnetic bands. In this view, it becomes artificial to sever broadcasting, as “broadcasting services bands” from the other remaining highly diverse communications uses, as occurred from 1992 when the Broadcasting Services Act was introduced. The prospect of new forms of spectrum charging is highly alarming for commercial broadcasters. In a joint submission to the DCITA review, the peak TV and radio industry lobby groups have indicated they will fight tooth and nail to resist new regulatory arrangements that would see a move away from the existing licence fee arrangements. These are paid as a sliding scale percentage of gross earnings that, it has been argued by Julian Thomas and Marion McCutcheon, “do not reflect the amount of spectrum used by a broadcaster, do not reflect the opportunity cost of using the spectrum, and do not provide an incentive for broadcasters to pursue more efficient ways of delivering their services” (6). An economic rationalist logic underpins pressure to modify the spectrum management (and charging) regime, and undoubtedly contributes to the commercial broadcasting industry’s general paranoia about reform. Total revenues collected by the ABA and the ACA between 1997 and 2002 were, respectively, $1423 million and $3644.7 million. Of these sums, using auction mechanisms, the ABA collected $391 million, while the ACA collected some $3 billion. The sale of spectrum that will be returned to the Commonwealth by television broadcasters when analog spectrum is eventually switched off, around the end of the decade, is a salivating prospect for Treasury officials. The large sums that have been successfully raised by the ACA boosts their position in planning discussions for the convergent media regulatory agency. The way in which media outlets and regulators respond to publics is an enduring question for a democratic polity, irrespective of how the product itself has been mediated and accessed. Media regulation and civic responsibility, including frameworks for negotiating consumer and citizen rights, are fundamental democratic rights (Keane; Tambini). The ABA’s Commercial Radio Inquiry (‘cash for comment’) has also reminded us that regulatory frameworks are important at the level of corporate conduct, as well as how they negotiate relations with specific media audiences (Johnson; Turner; Gordon-Smith). Building publicly meaningful regulatory frameworks will be demanding: relationships with audiences are often complex as people are constructed as both consumers and citizens, through marketised media regulation, institutions and more recently, through hybridising program formats (Murdock and Golding; Lumby and Probyn). In TV, we’ve seen the growth of infotainment formats blending entertainment and informational aspects of media consumption. At a deeper level, changes in the regulatory landscape are symptomatic of broader tectonic shifts in the discourses of governance in advanced information economies from the late 1980s onwards, where deregulatory agendas created an increasing reliance on free market, business-oriented solutions to regulation. “Co-regulation” and “self-regulation’ became the preferred mechanisms to more direct state control. Yet, curiously contradicting these market transformations, we continue to witness recurring instances of direct intervention on the basis of censorship rationales (Dwyer and Stockbridge). That digital media content is “converging” between different technologies and modes of delivery is the norm in “new media” regulatory rhetoric. Others critique “visions of techno-glory,” arguing instead for a view that sees fundamental continuities in media technologies (Winston). But the socio-cultural impacts of new media developments surround us: the introduction of multichannel digital and interactive TV (in free-to-air and subscription variants); broadband access in the office and home; wirelessly delivered content and mobility, and, as Jock Given notes, around the corner, there’s the possibility of “an Amazon.Com of movies-on-demand, with the local video and DVD store replaced by online access to a distant server” (90). Taking a longer view of media history, these changes can be seen to be embedded in the global (and local) “innovation frontier” of converging digital media content industries and its transforming modes of delivery and access technologies (QUT/CIRAC/Cutler & Co). The activities of regulatory agencies will continue to be a source of policy rivalry and turf contestation until such time as a convergent regulator is established to the satisfaction of key players. However, there are risks that the benefits of institutional reshaping will not be readily available for either audiences or industry. In the past, the idea that media power and responsibility ought to coexist has been recognised in both the regulation of the media by the state, and the field of communications media analysis (Curran and Seaton; Couldry). But for now, as media industries transform, whatever the eventual institutional configuration, the evolution of media power in neo-liberal market mediascapes will challenge the ongoing capacity for interventions by national governments and their agencies. Works Cited Australian Broadcasting Authority. Commercial Radio Inquiry: Final Report of the Australian Broadcasting Authority. Sydney: ABA, 2000. Australian Communications Information Forum. Industry Code: Short Message Service (SMS) Issues. Dec. 2002. 8 Mar. 2004 <http://www.acif.org.au/__data/page/3235/C580_Dec_2002_ACA.pdf >. Commercial Television Australia. Draft Commercial Television Industry Code of Practice. Aug. 2003. 8 Mar. 2004 <http://www.ctva.com.au/control.cfm?page=codereview&pageID=171&menucat=1.2.110.171&Level=3>. Couldry, Nick. The Place of Media Power: Pilgrims and Witnesses of the Media Age. London: Routledge, 2000. Curran, James, and Jean Seaton. Power without Responsibility: The Press, Broadcasting and New Media in Britain. 6th ed. London: Routledge, 2003. Dept. of Communication, Information Technology and the Arts. Options for Structural Reform in Spectrum Management. Canberra: DCITA, Aug. 2002. ---. Proposal for New Institutional Arrangements for the ACA and the ABA. Aug. 2003. 8 Mar. 2004 <http://www.dcita.gov.au/Article/0,,0_1-2_1-4_116552,00.php>. Dept. of Foreign Affairs and Trade. Australia-United States Free Trade Agreement. Feb. 2004. 8 Mar. 2004 <http://www.dfat.gov.au/trade/negotiations/us_fta/outcomes/11_audio_visual.php>. Dwyer, Tim. Submission to Commercial Television Australia’s Review of the Commercial Television Industry’s Code of Practice. Sept. 2003. Dwyer, Tim, and Sally Stockbridge. “Putting Violence to Work in New Media Policies: Trends in Australian Internet, Computer Game and Video Regulation.” New Media and Society 1.2 (1999): 227-49. Given, Jock. America’s Pie: Trade and Culture After 9/11. Sydney: U of NSW P, 2003. Gordon-Smith, Michael. “Media Ethics After Cash-for-Comment.” The Media and Communications in Australia. Ed. Stuart Cunningham and Graeme Turner. Sydney: Allen and Unwin, 2002. Johnson, Rob. Cash-for-Comment: The Seduction of Journo Culture. Sydney: Pluto, 2000. Keane, John. The Media and Democracy. Cambridge: Polity, 1991. Lumby, Cathy, and Elspeth Probyn, eds. Remote Control: New Media, New Ethics. Melbourne: Cambridge UP, 2003. Murdock, Graham, and Peter Golding. “Information Poverty and Political Inequality: Citizenship in the Age of Privatized Communications.” Journal of Communication 39.3 (1991): 180-95. QUT, CIRAC, and Cutler & Co. Research and Innovation Systems in the Production of Digital Content and Applications: Report for the National Office for the Information Economy. Canberra: Commonwealth of Australia, Sept. 2003. Tambini, Damian. Universal Access: A Realistic View. IPPR/Citizens Online Research Publication 1. London: IPPR, 2000. Thomas, Julian and Marion McCutcheon. “Is Broadcasting Special? Charging for Spectrum.” Conference paper. ABA conference, Canberra. May 2003. Turner, Graeme. “Talkback, Advertising and Journalism: A cautionary tale of self-regulated radio”. International Journal of Cultural Studies 3.2 (2000): 247-255. ---. “Reshaping Australian Institutions: Popular Culture, the Market and the Public Sphere.” Culture in Australia: Policies, Publics and Programs. Ed. Tony Bennett and David Carter. Melbourne: Cambridge UP, 2001. Winston, Brian. Media, Technology and Society: A History from the Telegraph to the Internet. London: Routledge, 1998. Web Links http://www.aba.gov.au http://www.aca.gov.au http://www.accc.gov.au http://www.acif.org.au http://www.adma.com.au http://www.ctva.com.au http://www.crtc.gc.ca http://www.dcita.com.au http://www.dfat.gov.au http://www.fcc.gov http://www.ippr.org.uk http://www.ofcom.org.uk http://www.oflc.gov.au Links http://www.commercialalert.org/ Citation reference for this article MLA Style Dwyer, Tim. "Transformations" M/C: A Journal of Media and Culture <http://www.media-culture.org.au/0403/06-transformations.php>. APA Style Dwyer, T. (2004, Mar17). Transformations. M/C: A Journal of Media and Culture, 7, <http://www.media-culture.org.au/0403/06-transformations.php>

IntroductionIn a 2013 press release issued by Blind Citizens Australia, the advocacy group announced they were lodging a human rights complaint against the Australian government and the ABC over the lack of audio description available on the public broadcaster. Audio description is a track of narration included between the lines of dialogue which describes important visual elements of a television show, movie or performance. Audio description is broadly recognised as an essential feature to make television accessible to audiences who are blind or vision impaired (Utray et al.). Indeed, Blind Citizens Australia maintained that audio description was as important as captioning on Australian television:people who are blind have waited too long and are frustrated that audio description on television remains indefinitely beyond our reach. Our Deaf or hearing impaired peers have always seen great commitment from the ABC, but we continue to feel like second class citizens.While audio description as a technology was developed in the 1960s—around the same time as captions (Ellis, “Netflix Closed Captions”)—it is not as widely available on television and access is therefore often considered to be out of reach for this group. As a further comparison, in Australia, while the provision of captions was mandated in the Broadcasting Services Act (BSA) 1992 and television sets had clear Australian standards regarding their capability to display captions, there is no legislation for audio description and no consistency regarding the ability of television sets sold in Australia to display them (Ellis, “Television’s Transition”). While as a technology, audio description is as old as captioning it is not as widely available on television. This is despite the promise of technological advancements to facilitate its availability. For example, Cronin and King predicted that technological change such as the introduction of stereo sound on television would facilitate a more widespread availability of audio description; however, this has not eventuated. Similarly, in the lead up to the transition from analogue to digital broadcasting in Australia, government policy documents predicted a more widespread availability of audio description as a result of increased bandwidth available via digital television (Ellis, “Television’s Transition”). While these predictions paved way for an audio description trial, there has been no amendment to the BSA to mandate its provision.Audio description has been experienced on Australian broadcast television in 2012, but only for a 14-week trial on ABC1. The trial report, and feedback from disability groups, identified several technical impediments and limitations which effected the experience of audio described content during this trial, including: the timing of the trial during a period in which the transition from analogue to digital television was still occurring (creating hardware compatibility issues for some consumers); the limitations of the “ad hoc” approach undertaken by the ABC and manual implementation of audio description; and the need for upgraded digital receivers (ABC “Trial of Audio Description”, 2). While advocacy groups acknowledged the technical complexities involved, the expected stakeholder discussions that were due to be held post-trial, in part to attempt to resolve the issues experienced, were never undertaken. As a result of the lack of subsequent commitments to providing audio description, in 2013 advocacy group Blind Citizens Australia lodged their formal complaints of disability discrimination against the ABC and the Federal Government. Since the 2012 trial on ABC1, the ABC’s catch-up portal iView instigated another audio description trial in 2015. Through the iView trial it was further confirmed that audio description held considerable benefits for people with a vision impairment. They also demonstrated that audio description was technically feasible, with far less ‘technical difficulties’ than the experience of the 2012 broadcast-based trial. Over the 15 month trial on ABC iView 1,305 hours of audio described content was provided and played 158, 277 times across multiple platforms, including iOS, Android, the Freeview app and desktop computers (ABC, “ABC iView Audio Description Trial”).Yet despite repeated audio description trials and the lodgement of discrimination complaints, there remains no audio description on Australian broadcast television. Similarly, whereas 55 per cent of DVDs released in Australia have captions, only 25 per cent include an audio description track (Media Access Australia). At the time of writing, the only audio description available on Australian television is on Netflix Australia, a subscription video on demand provider.This article seeks to highlight the importance of television access for people with disability, with a specific focus on the provision of audio description for people with vision impairments. Research consistently shows that despite being a visual medium, people with vision impairments watch television at least once a day (Cronin and King; Ellis, “Netflix Closed Captions”). However, while television access has been a priority for advocates for people who are Deaf and hard of hearing (Downey), audiences advocating audio description are only recently making gains (Ellis, “Netflix Closed Captions”; Ellis and Kent). These gains are frequently attributed to technological change, particularly the digitisation of television and the introduction of subscription video on demand where users access television content online and are not constrained by broadcast schedules. This transformation of how we access television is also considered in the article, again with a focus on the provision–or lack thereof—of audio description.This article also reports findings of research conducted with Australians with disabilities accessing the emerging video on demand environment in 2016. The survey was run online from January to February 2016. Survey respondents included people with disability, their families, and carers, and were sourced through disability organisations and community groups as well as via disability-focused social media. A total of 145 people completed the survey and 12 people participated in follow-up interviews. Insights were gained into both how people with disability are currently using video on demand and their anticipated usage of services. Of note is that most subscription video on demand services (Netflix Australia, Stan, and Presto) had only been introduced in Australia in the year before the survey being carried out, with only Foxtel Play and Quickflix having been in operation for some time prior to that.Finally, the article ends by looking at past and current advocacy in this area, including a discussion on existing—albeit, to date, limited—political will.Access to Television for People with DisabilitiesTelevision can be disabling in different ways for people with impairments, yet several accessibility features exist to translate information. For example, people who are D/deaf or hard of hearing may require captions, while people with vision impairments prefer to make use of audio description (Alper et al.). Similarly, people with mobility and dexterity impairments found the transition to digital broadcasting difficult, particularly with relation to set top box set up (Carmichael et al.). As Joshua Robare has highlighted, even legislation has generally favoured the inclusion of audiences with hearing impairments, while disregarding those with vision impairments. Similarly, much of the literature in this area focuses on the provision of captions—a vital accessibility feature for people who are D/deaf or hard of hearing. Consequently, research into accessibility to television for a diversity of impairments, going beyond hearing impairments, remains deficient.In a study of Australian audiences with disability conducted between September and November 2013—during the final months of the analogue to digital simulcast period of Australian broadcast television—closed captions, clean audio, and large/colour-coded remote control keys emerged as the most desired access features (see Ellis, “Digital Television Flexibility”). Audio description barely registered in the top five. In a different study conducted two years ago/later, when disabled Australian audiences of video on demand were asked the same question, captions continued to dominate at 63.4 per cent; however, audio description was also seen to be a necessary feature for almost one third of respondents (see Ellis et al., Accessing Subcription Video).Robert Kingett, founder of the Accessible Netflix Project, participated in our research and told us in an interview that video on demand providers treat accessibility as an “afterthought”, particularly for blind people whom most don’t think of as watching television. Yet research dating back to the 1990s shows almost 100 per cent of people with vision impairments watch television at least once a day (Cronin & King). Statistically, the number of Australians who identify as blind or vision impaired is not insignificant. Vision Australia estimates that over 357,000 Australians have a vision impairment, while one in five Australians have a disability of some form. With an ageing population, this number is expected to grow exponentially in the next ten years (Australian Network on Disability). Kingett therefore describes this lack of accessibility as evidence video on demand is “stuck in the dark ages”, and advocates that people with vision impairments do use video on demand and therefore continue to have unmet access needs.Video on Demand—Transforming TelevisionSubscription video on demand services have caused a major shift in the way television is used and consumed in Australia. Prior to 2015, there was a small subscription video on demand industry in this country. However, in 2015, following the launch of Netflix Australia, Stan, and Presto, Australia was described as having entered the “streaming wars” (Tucker) where consumers would benefit from the increased competition. As Netflix gained dominance in the video on demand market internationally, people with disability began to recognise the potential this service could have in transforming their access to television.For example, the growing availability of video on demand services continues to provide disruptive change to the way in which consumers enjoy information and entertainment. While traditional broadcast television has provided great opportunities for participation in news, events, and popular culture, both socially and in the workplace, the move towards video on demand services has seen a notable decline in traditional television viewing habits, with online continuing to increase at the expense of Australian free-to-air programming (C-Scott).For the general population, this always-on, always-available, and always-shareable nature of video on demand means that the experience is both convenient and instant. If a television show is of interest to friends and family, it can be quickly shared through popular social media with others, allowing everyone to join in the experience. For people with disability, the ability to both share and personalise the experience of television is critical to the popularity of video on demand services for this group. This gives them not only the same benefits as others but also ensures that people with disability are not unintentionally excluded from participation—it allows people with disability the choice as to whether or not to join in. However, exclusion from video on demand is a significant concern for people with disability due to the lack of accessibility features in popular subscription services. The lack of captions, audio description, and interfaces that do not comply with international Web accessibility standards are resulting in many people with disability being unable to fully participate in the preferred viewing platforms of family and friends.The impact of this expands beyond the consumption patterns of audiences, shifting the way the audience is defined and conceptualised. With an increasing distribution of audience attention to multiple channels, products, and services, the ability to, and strategies for, acquiring a large audience has changed (Napoli). As audience attention is distributed, it is broken up, into smaller, fragmented groups. The success, therefore, of a new provider may be to amass a large audience through the aggregation of smaller, niche audiences. This theory has significance for consumers who require audio description because they represent a viable target group. In this context, accessibility is reframed as a commercial opportunity rather than a cost (Ellis, “Netflix Closed Captions”).However, what this means for future provision of audio description in Australia is still unclear. Chris Mikul from Media Access Australia, author of Access on Demand, was interviewed as part of this research. He told us that the complete lack of audio description on local video on demand services can be attributed to the lack of Australian legislation requiring it. In an interview as part of this research he explained the central issue with audio description in this country as “the lack of audio description on broadcast TV, which is shocking in a world context”.International providers fare only slightly better. Robert Kingett established the Accessible Netflix Project in 2013 with the stated aim of advocating for the provision of audio description on Netflix. Netflix, despite a lack of a clear accessibility policy, are seen as being in front in terms of overall accessibility—captions are available for most content. However, the provision of audio description was initially not considered to be of such importance, and Netflix were initially against the idea, citing technical difficulties. Nevertheless, in 2015—shortly after their Australian launch—they did eventually introduce audio description on original programming, describing the access feature as an option customers could choose, “just like choosing the soundtrack in a different language” (Wright). However, despite such successful trials, the issue in the Australian market remains the absence of legislation mandating the provision of audio description in Australia and the other video on demand providers have not introduced audio description to compete with Netflix. As the Netflix example illustrates, both legislation and recognition of people with disability as a key audience demographic will result in a more accessible television environment for this group.Currently, it is debatable as to whether this increasingly competitive market, the shifting perception of audience attraction and retention, and the entry of multiple international video on demand providers, has influenced how accessibility is viewed, both for broadcast television and video on demand. Although there is some evidence for an increasing consideration of people with disability as “valid” consumers—take, for example, the iView audio description trial, or the inclusion of audio description by Netflix—our research indicates accessibility is still inconsistently considered, designed for, and applied by current providers.Survey Response: Key Issues Regarding AccessibilityRespondents were asked to provide an overall impression of video on demand services, and to tell us about their positive and negative experiences. Analysis of 68 extended responses, and the responses provided by the interview participants, identified a lack of availability of accessibility features such as audio description as a key problem. What our results indicate is that while customers with a disability are largely accommodating of the inaccessibility of providers—they use their own assistive technology to access content—they are keenly aware of the provisions that could be made. As one respondent put it:they could do a lot better: talking menus, spoken sub titles, and also spoken messages on screen.However, many expressed low expectations due to the continued absence of audio description on broadcast television:so, the other thing is, my expectations are quite low because of years of not having audio descriptions. I have slightly different expectations to other people.This reflection is important in considering both the shifting expectations regarding video on demand providers but also the need for a clear communication of what features are available so that providers can cater to—and therefore capture—niche markets.The survey identified captioning as the main accessibility problem of video on demand services. However, this may not accurately reflect the need for other accessibility features such as audio description. Rather, it may be indicative that this feature is often the only choice given to consumers. As, Chris Mikul identified, “the only disability being catered for to any great extent is deafness/hearing impairment”. Kingett agreed, noting:people who are deaf and hard of hearing are placed way before the rest because captions are beyond easy and cheap to create now. Please, there’s even companies that people use to crowd source captions so companies don’t have to do it anymore. This all came about because the deaf community has [banded] together … to achieve a cause. I know audio description isn’t as cheap to make as captions but, by these companies’ budgets that’s like dropping a penny.Advocacy and Political WillAs noted above, it has been argued by some that accessibility features that address vision impairments have been neglected. The reason behind this is twofold—the perception that this disability is experienced by a minority of the population and that, because blind people “don’t watch television”, it is not an important accessibility feature. This points towards a need for both disability advocacy and political will by politicians to introduce legislation. As one survey respondent identified, the reality is that, in Australia, neither politicians nor people with vision impairments have yet to address the issue on audio description in an organised or sustained way:we have very little audio described content available in Australia. We don’t have the population of blind people nor the political will by politicians to force providers to provide for us.However, Blind Citizens Australia—the coalition of television audiences with vision impairments who lodged the human rights complaint against the government and the ABC—suggest the tide is turning. Whereas advocates for people with vision impairments have traditionally focused on access to the workforce, the issue of television accessibility is increasingly gaining attention, particularly as a result of international activist efforts and the move towards video on demand (see Ellis and Kent).For example, Kingett’s Accessible Netflix Project in the US is considered one of the most successful accessibility movements towards the introduction of audio description. While its members are predominantly US-based, it does include several Australian members and continues to cover Netflix Australia’s stance on audio description, and be covered by Australian media and organisations (including Media Access Australia and Life Hacker). When Netflix launched in Australia, Kingett encouraged Australians to become more involved in the project (Ellis and Kent).However, despite the progress towards mandating of audio description in parliament and the resolution of efforts made by advocacy groups (including Vision Australia and Blind Citizens Australia), the status of audio description remains uncertain. Whilst some support has been gained—specifically through motions made by Senator Siewert and the ABC iView audio description trials—significant change has been slow. For example, conciliation discussions are still ongoing regarding the now four-year-old complaint brought against the ABC and the Federal Government by Blind Citizens Australia. Meanwhile, although the Senate supported Senator Siewert’s motion to change the Broadcasting Services Act to include audio description, the Act has yet to be amended.The results of multiple ABC trials of audio description remain in discussion. Whilst the recently released report on the findings of the April 2015—July 2016 iView trial states that the “trial has identified that those who utilised the audio description service found it a valuable enhancement to their media engagement and their social interactions” (ABC, “ABC iView Audio Description Trial” 18), it also cautioned that “any move to introduce AD services in Australia would have budgetary implications for the broadcasters in a constrained financial environment” and “broader legislative implications” (ABC, “ABC iView Audio Description Trial” 18). Indeed, although the trial was considered “successful”—in that experiences by users were generally positive and the benefits considerable (Media Access Australia, “New Report”)—the continuation of audio description on iView alone was clarified as representing “a systemic failure to provide people who are blind or have low vision with basic access to television now, given that iView is out of reach for many people in the blindness and low vision community” (Media Access Australia, “New Report”). Indeed, the relatively low numbers of plays of audio described content during the trial (158, 277 plays, representing 0.58% of total program plays on iView) were likely a result of a lack of access to smartphones or Internet technology, prohibitive data speeds and/or general Internet costs, all factors which affect the accessibility of video on demand significantly more for people with disability (Ellis et al., “Access for Everyone?”).On a more positive note, the culmination of advocacy pressure, the ABC iView trial, political attention, and increasing academic literature on the accessibility of Australian media has resulted in the establishment of an Audio Description Working Group by the government. This group consists of industry representatives, advocacy group representatives, academics, and “consumer representatives”. The aims of the group are to: identify options to sustainably increase access to audio description services; identify any impediments to the implementation of audio description; provide expert advice on audio description implementation options; and develop a report on the findings due at the end of 2017.ConclusionIn the absence of audio description, people who are blind or vision impaired report a less satisfying television experience (Cronin and King; Kingett). However, with each technological advancement in the delivery of television, from stereo sound to digital television, this group has held hopes for a more accessible experience. The reality, however, has been a continued lack of audio description, particularly in broadcast television.Several commentators have compared the provision of audio description with closed captioning. They find that audio description is not as widely available, and reflect this is likely a result of lack of legislation (Robare; Ellis, “Digital Television Flexibility”)—for example, in the Australian context, whereas the provision of captions is mandated in the Broadcasting Services Act 1992, audio description is not. As a result, there have been limited trials of audio description in this country and inconsistent standards in how to display it. As discussed throughout this paper, people with vision impairments and their allies therefore often draw on the example of the widespread “acceptance” of captions to make the case that audio description should also be more widely available.However, following the introduction of subscription video on demand in Australia, and particularly Netflix, the issue of audio description is receiving greater attention. It has been argued that video on demand has transformed television, particularly the ways in which television is accessed. Video on demand could also potentially transform the way we think about accessibility for audiences with disability. While captions are a well-established accessibility feature facilitating television access for people with a range of disabilities, video on demand is raising the profile of the importance of audio description for audiences with vision impairments.ReferencesABC. “Audio Description Trial on ABC Television: Report to the Minister for Broadband, Communications and the Digital Economy”. Dec. 2012. 8 Apr. 2017 <https://www.communications.gov.au/sites/g/files/net301/f/ABC-Audio-Description-Trial-Report2.pdf>.ABC. “ABC iView Audio Description Trial: Final Report to The Department of Communications and the Arts.” Oct. 2016. 6 Apr. 2017 <https://www.communications.gov.au/documents/final-report-trial-audio-description-abc-iview>.Alper, Meryl, et al. “Reimagining the Good Life with Disability: Communication, New Technology, and Humane Connections.” Communication and the Good Life. Ed. H. Wang. New York: Peter Lang, 2015.Australian Network on Disability. “Disability Statistics.” Mar. 2017. 30 Apr. 2017 <https://www.and.org.au/pages/disability-statistics.html>.Blind Citizens Australia. Government and ABC Fail to Deliver on Accessible TV for Australia’s Blind. Submission. 10 July 2013. 1 May 2017 <http://bca.org.au/submissions/>.C-Scott, Marc. “The Battle for Audiences as Free-TV Viewing Continues Its Decline.” Mumbrella 22 Apr. 2016. 24 May 2016 <https://mumbrella.com.au/the-battle-for-audiences-as-free-tv-viewing-continues-its-decline-362010>.Carmichael, Alex, et al. “Digital Switchover or Digital Divide: A Prognosis for Useable and Accessible Interactive Digital Television in the UK.” Universal Access in the Information Society 4 (2006): 400–16.Cronin, Barry J., and Sharon Robertson King. “The Development of the Descriptive Video Services.” National Center to Improve Practice in Special Education through Technology, Media and Materials. Sep. 1998. 8 May 2014 <https://www2.edc.org/NCIP/library/v&c/Cronin.htm>.Downey, G. “Constructing Closed-Captioning in the Public Interest: From Minority Media Accessibility to Mainstream Educational Technology.” Info 9.2–3 (2007): 69–82.Ellis, Katie. “Digital Television Flexibility: A Survey of Australians with Disability.” Media International Australia 150 (2014): 96.———. “Netflix Closed Captions Offer an Accessible Model for the Streaming Video Industry, But What about Audio Description?” Communication, Politics & Culture 47.3 (2015).———. “Television’s Transition to the Internet: Disability Accessibility and Broadband-Based TV in Australia.” Media International Australia 153 (2014): 53–63.Ellis, Katie, and Mike Kent. “Accessible Television: The New Frontier in Disability Media Studies Brings Together Industry Innovation, Government Legislation and Online Activism.” First Monday 20 (2015). <http://firstmonday.org/ojs/index.php/fm/article/view/6170>.Ellis, Katie, et al. Accessing Subscription Video on Demand: A Study of Disability and Streaming Television in Australia. Australian Communications Consumer Action Network. Aug. 2016. <https://accan.org.au/grants/current-grants/1066-accessing-video-on-demand-a-study-of-disability-and-streaming-television>.Ellis, Katie, et al. “Access for Everyone? Australia’s ‘Streaming Wars’ and Consumers with Disabilities.” Continuum (2017, publication pending).Kingett, Robert. “The Accessible Netflix Project Advocates Taking Steps to Ensure Netflix Accessibility for Everyone.” 2014. 30 Jan. 2014 <https://netflixproject.wordpress.com>.Media Access Australia. “Statistics on DVD Accessibility in Australia.” 2012. 21 Nov. 2014 <https://mediaaccess.org.au/dvds/Statistics%20on%20DVD%20accessibility%20in%20Australia>.———. “New Report on the Trial of A.D. on ABC iView.” 7 Mar. 2017. 30 Apr. 2017 <https://mediaaccess.org.au/latest_news/television/new-report-on-the-trial-of-ad-on-abc-iview>.Napoli, Philip M., ed. Audience Evolution: New Technologies and the Transformation of Media Audiences. New York: Columbia UP, 2011.Robare, Joshua S. “Television for All: Increasing Television Accessibility for the Visually Impaired through the FCC’s Ability to Regulate Video Description Technology.” Federal Communications Law Journal 63.2 (2011): 553–78.Tucker, Harry. “Netflix Leads the Streaming Wars, Followed by Foxtel’s Presto.” News.com.au 24 June 2016. 18 May 2016 <http://www.news.com.au/technology/home-entertainment/tv/netflix-leads-the-streaming-wars-followed-by-foxtels-presto/news-story/7adf45dcd7d9486ff47ec5ea5951287f>.Utray, Francisco, et al. “Monitoring Accessibility Services in Digital Television.” International Journal of Digital Multimedia Broadcasting (2012): 9.

Photo by Kelley Sikkema on Unsplash INTRODUCTION Patients seeking abortion services in the United States face several problems, including factual inaccuracies about the procedure, the stigma surrounding the procedure, and barriers to quality care across the country. The problems surrounding abortion pose a threat to patient autonomy and beneficence—ethical principles that are usually upheld in medicine. Abortion doulas can enhance patient autonomy, improve the quality of medical care, help women talk through their emotions or the associated stigma, and provide other benefits that can address the problems surrounding abortion. Their role ranges from discussing emotional decisions and answering patient questions before the procedure, to simply holding their hand in the recovery room. In this paper, I propose that the use of abortion doulas may help address some of the problems surrounding abortion by mitigating factual inaccuracies, stigma, and barriers to quality care. I. Background Abortion doulas were started byThe Doula Project in New York City.[1]They initially worked with New York City public hospitals and eventually expanded to working with Planned Parenthood clinics, as well as other care providers.[2]Over recent years, abortion doulas have been offered in more states such as California, Arizona, and New Hampshire. Abortion doulas can work independently, in a collective, or in an abortion clinic.[3]More often, they work in a collective where they are trained and employed in clinics that are partnered with the organization. Many abortion doulas started working on a volunteer basis. Now, many are funded by donations, which allow their services to be free for patients.[4]When abortion doulas work independently, their rates are based on the specific services that they provide.[5]Patients can seek out abortion doulas through multiple avenues. They can seek out doulas that work independently, work in an abortion clinic, or through doula organizations, such as the Doula Project or The San Francisco Doula Group. II. Doulas The role of a doula has existed since ancient times. The word “doula” comes from the Greek language and translates to “a woman who serves”.[6]In 1969, Dr. Dana Raphael originated the use of the word “doula” in the US to describe a person who guides mothers through childbirth and assists them postpartum, specifically helping them breastfeed.[7]Dr. Raphael encouraged emotionally supporting new mothers through creating the new professional role of a doula.[8] Currently, doulas are trained in helping women emotionally and physically during pregnancy, childbirth, and postpartum. Doulas do not provide medical care, but they provide services such as birthing education, massage, assistance with breastfeeding, and educating mothers about the delivery process, such as knowing what to expect and what can go wrong. Research has demonstrated the effectiveness and benefits of doulas. For example, one meta-analysis compared women who received doula support during childbirth to women who did not. The study showed that doula-supported women had shorter labors, decreased complications with delivery, and rated childbirth as less painful than women without doula support.[9]Psychosocial benefits such as reduced anxiety, decreased symptoms of depression, and positive feelings associated with childbirth were significant for the doula-supported group.[10]In the last couple of decades, doulas have become increasingly popular. More recently, doulas have started a movement labeled “full spectrum doula,” in which the role of a doula in supporting women has expanded beyond birth to include abortion and adoption.[11] III. Ethical Considerations Factual Inaccuracies Complete and accurate medical information is fundamental to informed consent and autonomous decision making. Inaccurate medical information about abortion is very common and can come from multiple sources. Currently, there are 29 states that have policies restricting abortion that are not based on scientific evidence.[12]While both state policies and national media may convey false information to the public about abortion, perhaps what is most surprising is when these inaccuracies are presented to patients by physicians or medical facilities. In most states, policies mandate that any medical facility providing abortions develop and present written material to patients that is intended to educate the patient about the abortion procedure.[13]However, in some states, laws have been passed that mandate the inclusion of misinformation in these materials.[14]Healthcare providers try to mitigate the harm of this inaccurate information by prefacing it with qualifiers, disclaimers, and apologies.[15]However, they are still not able to completely avoid harm from the outdated and misleading information, which also often intends to dissuade patients from receiving an abortion.[16]The most common factual inaccuracies include stating that an abortion leads to an increased risk of breast cancer, that the fetus can feel pain as early as 12 weeks old, and that psychological effects of the procedure can lead to suicide and “post abortion traumatic stress syndrome.”[17]All these statements are false and not supported by scientific evidence; in fact, psychologists and the Diagnostic and Statistical Manual of Mental Disorders(DSM-V) do not recognize a post-traumatic stress syndrome associated with abortion.[18]Furthermore, another common inaccuracy in almost 20 states includes materials with contact information to “Crisis Pregnancy Centers” that provide false information with the intent to deter women from having an abortion.[19] Even once piece of inaccurate information can impede a patient’s ability to make an informed, autonomous decision. When these false facts are given to patients from the hands of trusted medical professionals, it has a more influential impact than when portrayed in media and advertisements. Trust is a core value in the medical profession that determines the patient-physician relationship, and a part of this trust is communicating accurate and up-to-date information; if this trust did not exist in medicine, how would any patient make an informed decision? Where would they turn to for guidance and advice?[20]Challenges to informed consent and autonomy exist throughout medicine, as consent forms are complicated and filled with medical vocabulary that is often hard to understand. Signatures are sometimes scribbled onto forms before a procedure with minimal discussions to assess the patient’s understanding of the many risks and benefits. However, abortions have an additional layer of complexity regarding informed consent due to the religious and moral implications of choosing an abortion, while other common medical procedures, such as an appendectomy, do not carry the same implications. For example, a patient consenting to general surgery would probably not wonder if their physician’s advice against the surgery is due to his or her own moral values, or what the moral weight of the surgery will have on their conscious afterwards. Informed consent, regardless of procedure, should prioritize informed decision-making with evidence-based medicine without moral overtones. When inaccurate, biased, and false information is given to patients from medical institutions, it not only threatens the trust between patients and medical staff, but also prevents women from making an informed decision about their reproductive health. If abortion doulas can be a source of correct, up-to-date medical information, then women can make informed decisions based on thorough and accurate facts that allow them to exercise autonomy. Abortion doulas are well situated to correct the factual inaccuracies patients face for several reasons. First, abortion doulas are trained through a curated program with partnered medical facilities.[21]In other words, abortion doulas are thoroughly trained in patient-centered care that facilitates continuous patient support, which ranges from emotional support to providing accurate medical information when addressing patient concerns. Second, they have the time before the procedure to meet with the patient and discuss pre-abortion care topics such as providing information, addressing concerns, and preparing the patient for potential stigmatization.[22]Simultaneously, the doula can evaluate for any risk factors that may indicate negative emotions after the abortion, such as lack of social support, self-esteem, psychological stability, or multiple abortions.[23]Third, abortion doulas can provide post-abortion care counseling. While the doulas also have limited time with patients after the procedure, they would have more time than other healthcare professionals, such as nurses, to make sure the patient understands the medication regime while also offering psychological counseling for the patient on grief, guilt, and forgiveness.[24]With doulas providing technical post-procedure information, this allows them to answer any more questions that the patient may have about misleading, biased, out-of-date, or false information. Therefore, doulas can enhance patient autonomy by giving more accurate information. IV. Stigma Another critical problem facing patients who seek abortions is the stigma surrounding the procedure itself. An abortion requires many decisions to be made: do you want to be sedated or awake for the procedure? If you are awake, do you want someone to hold your hand or someone to talk to? Do you want to have privacy after the procedure? In fact, the first decision to be made is whether to have the abortion at all. For some women, that decision is immediate, quick, and assured. For others, the decision can be morally conflicting, such as due to religious reasons, society’s stigma, or other reasons. The moral conflict a woman faces when deciding on an abortion is determined by how much moral weight they apply to a fetus or embryo.[25]An abortion can make a woman feel as though they are a bad person or doing something morally wrong, especially if they place more weight on the moral status, or viability, of the fetus or embryo.[26]Regardless of why a woman feels conflicted, the bottom line is that these feelings exist, which can affect their decision-making abilities during the actual process. Our society stigmatizes women for having an abortion, it is our “modern-day Scarlet Letter.”[27]This stigma is under-researched but often theorized to be based on gender-biased roles of women in society.[28]Women who receive an abortion are labeled as “irresponsible” for having an unwanted pregnancy, or “selfish” and “unmotherly” for not wanting children. Therefore, women avoid judgement and prefer privacy during their abortion—but are these choices made because that is truly what a woman desires, or are they making these choices to avoid stigma? And, if they are making these choices to avoid stigma, how does it affect their autonomy as a decision-maker for their own healthcare choices? There is a difference between secrecy and privacy: women may want to keep their abortion decision private, like any other medical decision or health information.[29]However, some women make the decision in secret to avoid judgment and stigmatization. There is evidence that stigma plays a role in every decision of the abortion process. For example, one study explores the reasons why some women prefer to be awake versus asleep during the procedure. Women who choose to be asleep want to be less emotionally present for the fear of “seeing something” during the procedure. On the other hand, women who choose to be awake want to feel present, safe, and receive support during the process.[30]The study also found that most women rated an abortion procedure a “good experience” if care was provided in a discreet and private manner.[31]By preferring anesthesia and privacy, many women try to avoid dealing with the stigma and judgement from others. The stigma also prevents women from seeking or receiving social support.[32]While some women may make these choices because it is what they truly want, others might choose these options to avoid others witnessing their decision and from being stigmatized as a woman who “got an abortion.” Although abortion doulas cannot completely abolish the overarching societal stigma, they can help in several different ways on an individualistic level. Abortion doulas may fit the role of personalizing each experience to fit patients’ specific preferences. Doulas have the time and appropriate training to understand and discuss the emotional burdens that come along with the social stigma that surrounds abortions.[33]They have the training to explore the patient’s reasons for their decisions and can make sure they are comfortable with them. They do so in a non-judgmental way and strive to act as an advocate for the patient.[34]By listening to women and validating their decisions, women may not feel as many negative emotions surrounding the stigma or feel empowered that they made the right decision for themselves, regardless of social labels. This validation and empowerment gives women more agency in their own healthcare decisions while also providing emotional support in a situation that requires many difficult choices. Abortion doulas would become a support system for women, thereby promoting feminist ethics by normalizing emotions in a morally charged decision. They also promote the principal of beneficence by helping patients address any conflict between societal stigma and the woman’s own beliefs and morals. V. Barriers to Quality Care Access to abortion is limited: only 62 percent of American women live in counties with an abortion provider.[35]Many insurance companies do not cover abortions and clinics are often busy with limited availability, staff, and resources. Additionally, many women would need time off from work, childcare, transportation, and other resources to make it to any medical appointments—abortion care is not an exception. Currently, there are no professional programs for abortion providers to offer post-abortion counseling.[36]Additionally, in busy clinics, hospitals, or non-profit organizations such as Planned Parenthood, physicians attempt to provide as many abortions as possible to as many patients, leaving little time for post-abortion care. Provider burn-out is a major problem throughout healthcare, which has become more pronounced throughout the COVID-19 pandemic. Many providers, nurses, and other hospital staff are overworked and underpaid while hospitals themselves are overcrowded and underfunded. Moreover, abortion providers may be especially vulnerable to burn-outas they tend to both their patient’s medical and emotional needs during a procedure that has both physical pain and a plethora of emotion surrounding it.[37]With an increase in patient number due to decreased availability of services and a physician’s responsibility to tend to the patient’s emotional well-being and physical pain, this increases the risk of provider burn-out, which in turn, can affect the quality of medical care given to women receiving abortions.[38] Abortion doulas can fill the role of providing post-abortion care and help alleviate provider burn-out in many ways. First, as mentioned previously, they have the time before the procedure to meet with the patient and discuss pre-abortion care topics, provide information, and answer questions.[39]Secondly, abortion doulas can provide patients with the post-abortion care counseling that many physicians and nurses are not able to provide. This role has multiple effects. While post-abortion counseling can help address factual inaccuracies through answering questions, it can also allow doulas to make sure the patient understands the medication regime and how to deal with the pain that follows the procedure.[40]With doulas providing technical post-procedure information, this relieves understaffed nurses of some of their many tasks and responsibilities in the post-abortion recovery room; this will likely decrease the number of women who come back to the clinic or hospital with complications or additional questions. By discussing various emotions during post-procedure counseling, doulas support women by listening to their feelings. Some women may feel relief and joy after the procedure, while other may feel despair, regret, grief, or shame. When a doula listens to and supports a patient, they validate their emotions and indirectly validate their abortion decision, thereby improving the quality of the experience. Lastly, the integration of doulas into routine abortion care allows physicians and staff to concentrate on the procedure itself.[41]The doula can offer patient-centered, hands-on care to the patient while the rest of the healthcare team focuses on their own technical tasks.[42]Doula support can also decrease the need for more clinic staff in the procedure room by “decreasing the redirection of clinic staff resources,”thus creating a more efficient medical environment.[43]As the historical role of a doctor playing every role is becoming more obsolete, and the idea of a multi-faceted, integrative healthcare team is becoming the norm, it makes sense that an abortion doula can fill a niche on a healthcare team for emotionally laden procedures like abortions. The niche that the doula fills is to support, comfort, and be present with the patient throughout the entirety of the procedure in a nonjudgmental way. While nurses and doctors can be supportive, sympathetic, and caring, their jobs and roles include other responsibilities that do not allow them to be a continuous presence for the patient throughout their visit.[44]By having a person on the healthcare team whose job is to provide patient support, even if it is simply to hold their hand, the patient is more likely to be treated as a whole and provided better quality medical care. CONCLUSION Inaccurate information, stigma, and quality of care barriers are only a few of the many problems facing patients who want to receive an abortion. Each problem poses ethical challenges while also impeding quality medical care and adding to patients’ emotional burdens. Inaccurate facts and stigma hinder an informed decision, and thereby, threaten patient autonomy. The stigma of abortion can also lead to patients experiencing more negative emotions. Furthermore, healthcare barriers include a wide range of problems, from understaffed clinics to provider burn-out, all of which affect the quality and access to care for patients seeking an abortion. Abortion doulas are part of the solution to these problems. They are an extra resource, a set of hands for the patients to hold in the procedure room, and an expert in providing emotional and social support for the patient. They can enhance a patient’s decision-making skills, support the patient’s emotional well-being, answer factual questions, counter stigma, and help provide quality medical care. Therefore, abortion doulas enhance patient autonomy, promote beneficence, improve access to quality abortion care, and fill a necessary role during the abortion process. [1]Shakouri, Shireen Rose "The Doula Project." Ed. Lee, Shannon2019. Print. [2]Shakouri, Shireen Rose "The Doula Project." Ed. Lee, Shannon2019. Print. [3]Onyenacho, Tracey. "Abortion Doulas Help People Navigate the Process. They Say Their Work Was More Crucial Than Ever in the Pandemic." The Lily 2021. Web. 12/29/2021 2021 [4]Onyenacho, Tracey. "Abortion Doulas Help People Navigate the Process. They Say Their Work Was More Crucial Than Ever in the Pandemic." The Lily 2021. Web. 12/29/2021 2021 [5]Onyenacho, Tracey. "Abortion Doulas Help People Navigate the Process. They Say Their Work Was More Crucial Than Ever in the Pandemic." The Lily 2021. Web. 12/29/2021 2021 [6]Dukehart, Coburn. "Doulas: Exploring a Tradition of Support." The Baby Project. National Public Radio 2011. Web2021. [7]Roberts, Sam. "Dana Raphael, Proponent of Breast-Feeding and Use of Doulas, Dies at 90." New York Times 2016. Web2020. [8]Roberts, Sam. "Dana Raphael, Proponent of Breast-Feeding and Use of Doulas, Dies at 90." New York Times 2016. Web2020. [9]Scott, K. D., P. H. Klaus, and M. H. Klaus. "The Obstetrical and Postpartum Benefits of Continuous Support During Childbirth." J Womens Health Gend Based Med 8.10 (1999): 1257-64. Print. [10]Scott, K. D., P. H. Klaus, and M. H. Klaus. "The Obstetrical and Postpartum Benefits of Continuous Support During Childbirth." J Womens Health Gend Based Med 8.10 (1999): 1257-64. Print. [11]Chor, J., et al. "Doulas as Facilitators: The Expanded Role of Doulas into Abortion Care." J Fam Plann Reprod Health Care 38.2 (2012): 123-4. Print. [12]Nash, Elizabeth; Gold, Rachel Benson; Mohamed, Lizamarie; Ansari-Thomas, Zohra; Capello, Olivia "Policy Trends in the States, 2017." Guttmacher Instititue 2018. Web. [13]Richardson, Chinue Turner; Nash, Elizabeth. "Misinformed Consent: The Medical Accuracy of State-Developed Abortion Counseling Materials " Guttmacher Policy Review 9.4 (2006). Print. [14]Buchbinder, Mara, et al. "“Prefacing the Script” as an Ethical Response to State-Mandated Abortion Counseling." AJOB Empirical Bioethics 7.1 (2016): 48-55. Print. [15]Buchbinder, Mara, et al. "“Prefacing the Script” as an Ethical Response to State-Mandated Abortion Counseling." AJOB Empirical Bioethics 7.1 (2016): 48-55. Print. [16]Richardson, Chinue Turner; Nash, Elizabeth. "Misinformed Consent: The Medical Accuracy of State-Developed Abortion Counseling Materials " Guttmacher Policy Review 9.4 (2006). Print. [17]Richardson, Chinue Turner; Nash, Elizabeth. "Misinformed Consent: The Medical Accuracy of State-Developed Abortion Counseling Materials " Guttmacher Policy Review 9.4 (2006). Print. [18]Blevins, Christy A., et al. "The Posttraumatic Stress Disorder Checklist for Dsm-5 (Pcl-5): Development and Initial Psychometric Evaluation." Journal of Traumatic Stress 28.6 (2015): 489-98. Print. [19]Richardson, Chinue Turner; Nash, Elizabeth. "Misinformed Consent: The Medical Accuracy of State-Developed Abortion Counseling Materials " Guttmacher Policy Review 9.4 (2006). Print. [20]Pellegrini, C. A. "Trust: The Keystone of the Patient-Physician Relationship." J Am Coll Surg 224.2 (2017): 95-102. Print. [21]Shakouri, Shireen Rose "The Doula Project." Ed. Lee, Shannon2019. Print. [22]Chor, Julie, et al. "Factors Shaping Women’s Pre-Abortion Communication with Members of Their Social Network." Journal of Community Health 44.2 (2019): 265-71. Print. [23]Harris, Amy A. "Supportive Counseling before and after Elective Pregnancy Termination." Journal of Midwifery & Women’s Health 49.2 (2004): 105-12. Print. [24]Chor, Julie, et al. "Factors Shaping Women’s Pre-Abortion Communication with Members of Their Social Network." Journal of Community ` Health 44.2 (2019): 265-71. Print. [25]Watson, Katie. The Scarlet A Oxford University Press, 2018. Print. [26]Altshuler, A. L., et al. "A Good Abortion Experience: A Qualitative Exploration of Women's Needs and Preferences in Clinical Care." Soc Sci Med 191 (2017): 109-16. Print. [27]Watson, Katie. The Scarlet A Oxford University Press, 2018. Print. [28]Norris, A., et al. "Abortion Stigma: A Reconceptualization of Constituents, Causes, and Consequences." Womens Health Issues 21.3 Suppl (2011): S49-54. Print. [29]Watson, Katie. The Scarlet A Oxford University Press, 2018. Print [30]Altshuler, A. L., et al. "A Good Abortion Experience: A Qualitative Exploration of Women's Needs and Preferences in Clinical Care." Soc Sci Med 191 (2017): 109-16. Print. [31]Altshuler, A. L., et al. "A Good Abortion Experience: A Qualitative Exploration of Women's Needs and Preferences in Clinical Care." Soc Sci Med 191 (2017): 109-16. Print. [32]Norris, A., et al. "Abortion Stigma: A Reconceptualization of Constituents, Causes, and Consequences." Womens Health Issues 21.3 Suppl (2011): S49-54. Print. [33]Basmajian, Alyssa. "Abortion Doulas." Anthropology Now 6.2 (2014): 44-51. Print. [34]Amram, Natalie Lea, et al. "How Birth Doulas Help Clients Adapt to Changes in Circumstances, Clinical Care, and Client Preferences During Labor." J Perinat Educ.2: 96-103. Print. [35]Dennis, Amanda, Ruth Manski, and Kelly Blanchard. "A Qualitative Exploration of Low-Income Women's Experiences Accessing Abortion in Massachusetts." Women's Health Issues 25.5 (2015): 463-69. Print. [36]Harris, Amy A. "Supportive Counseling before and after Elective Pregnancy Termination." Journal of Midwifery & Women’s Health 49.2 (2004): 105-12. Print. [37]Chor, J., et al. "Integrating Doulas into First-Trimester Abortion Care: Physician, Clinic Staff, and Doula Experiences." J Midwifery Womens Health 63.1 (2018): 53-57. Print. [38]Jerman J, Jones RK and Onda T. "Characteristics of U.S. Abortion Patients in 2014 and Changes since 2008." Guttmacher Instititue 2016. Web. [39]Chor, Julie, et al. "Factors Shaping Women’s Pre-Abortion Communication with Members of Their Social Network." Journal of Community Health 44.2 (2019): 265-71. Print. [40]Chor, Julie, et al. "Factors Shaping Women’s Pre-Abortion Communication with Members of Their Social Network." Journal of Community Health 44.2 (2019): 265-71. Print. [41]Chor, J., et al. "Integrating Doulas into First-Trimester Abortion Care: Physician, Clinic Staff, and Doula Experiences." J Midwifery Womens Health 63.1 (2018): 53-57. Print. [42]Chor, J., et al. "Integrating Doulas into First-Trimester Abortion Care: Physician, Clinic Staff, and Doula Experiences." J Midwifery Womens Health 63.1 (2018): 53-57. Print. [43]Chor, J., et al. "Doula Support During First-Trimester Surgical Abortion: A Randomized Controlled Trial." Am J Obstet Gynecol 212.1 (2015): 45.e1-6. Print. [44]Basmajian, Alyssa. "Abortion Doulas." Anthropology Now 6.2 (2014): 44-51. Print.