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The COVID-19 Delta variant of concern continues to pose significant challenges to health systems globally, with increased transmissibility and different patient populations affected. In Sydney, a virtual model of care was implemented in response to the COVID-19 pandemic and Special Health Accommodation (SHA) was made available for community patients with COVID-19 who could not isolate at home or needed health support.This retrospective observational cohort study of all patients with COVID-19 Delta variant in SHA during the initial phases of the Delta variant outbreak in Sydney describes the demographic and clinical characteristics of patients with Delta variant COVID-19 and determines predictors of need for in-patient hospital admission.Data from 794 patients were analysed. One hundred and fifty-seven patients (19.8%) were transferred to ED. Of those, 125 were admitted to an in-patient unit (admission rate from ED 79.6%), and of these 30 (24%) went to ICU and seven were intubated. Two patients died within the follow-up period. Age40 years, obesity, and presence of fever (temperature37.5°C), hypoxia (oxygen saturation 95%), tachycardia or gastrointestinal symptoms on initial assessment in SHA were independent predictors of in-patient admission with an AUROC of 0.78 (95% confidence interval 0.73, 0.82).Initial symptoms and vital signs were just as predictive for short-term deterioration as age and pre-existing comorbidities and should be included in future risk prediction models for COVID-19. Based on this, we derive a proposed risk prediction score that incorporates these predictors with further validation required.

The COVID-19 pandemic is an unfolding crisis which is continually testing the resilience of healthcare organisations. In this context, a key requirement for executives, managers and frontline staff is continually adapting, learning and coping with complexity under pressure to deliver high quality and safe care. Sydney Local Health District has responded to the COVID-19 crisis, in part, through the pivoting of rpavirtual, a newly established virtual health service, to deliver an innovative model of care in a clinically rigorous and safe manner. Through reviewing the rapid evolution of rpavirtual's purpose, implementation challenges and impact, we investigate how it has displayed resilience and derive key lessons for health organisations.

BACKGROUND As a response to the COVID-19 pandemic, the Royal Prince Alfred Hospital in NSW (Australia) launched the rpavirtual program, the first full-scale virtual hospital in Australia, to remotely monitor and follow-up stable COVID-19 patients. As part of the intervention, a pulse oximeter wearable device was delivered to patients to monitor their oxygen saturation levels, a critical indicator of COVID-19 patient deterioration. Understanding users’ perceptions towards the device is fundamental to assessing its usability and acceptability and contributing to the effectiveness of the intervention, but no research to date has explored the user experience of the pulse oximeter for remote monitoring. OBJECTIVE To explore the utilization, performance, and acceptability of the pulse oximeter by clinicians and patients in rpavirtual during COVID-19. METHODS Semi-structured interviews and usability testing were conducted. Adult patients (≥18 years old) who used the pulse oximeter and were monitored by rpavirtual and rpavirtual clinicians were interviewed. Usability testing was conducted with patients who had the pulse oximeter when they were contacted. Interviews were coded using the Theoretical Framework of Acceptability. RESULTS Twenty-one patients and 15 clinicians completed the interview. Eight patients completed the usability testing. All participants liked the device and thought it was easy to use. They also had a good understanding of how to use the device and the device's purpose. Patient age and device-use related characteristics (e.g., the warmth of hands, hand steadiness) were identified by users as factors negatively impacting the accurate use of the pulse oximeter. CONCLUSIONS Patients and clinicians had very positive perceptions of the pulse oximeter for COVID-19 remote monitoring, indicating high acceptability and usability of the device. However, factors that may impact the accuracy of the device should be considered when delivering interventions using the pulse oximeter for remote monitoring.

Background The first COVID-19 cases were diagnosed in Australia on 25 January 2020. Initial epidiemiology showed that the majority of cases were in returned travellers from overseas. One aspect of Public Health response was to introduce compulsory 14 day quarantine for all travellers returning to New South Wales (NSW) by air or sea in Special Health Accommodation (SHA). We aim to outline the establishment of a specialised health quarantine accommodation service in the context of the COVID-19 pandemic, and describe the first month of COVID-19 screening. Methods The SHA was established with a comprehensive governance structure, remote clinical management through Royal Prince Alfred Virtual Hospital (rpavirtual) and site management with health care workers, NSW Police and accommodation staff. Results From 29 March to 29 April 2020, 373 returning travellers were admitted to the SHA from Sydney Airport. 88 (26.1%) of those swabbed were positive for SARS-CoV 2. The day of diagnosis of COVID-19 varied from Day 1 to Day 13, with 63.6% (n = 56) of these in the first week of quarantine. 50% of the people in the SHA were referred to rpavirtual for ongoing clinical management. Seven people required admission to hospital for ongoing clinical care. Conclusion The Public Health response to COVID-19 in Australia included early and increased case detection through testing, tracing of contacts of confirmed cases, social distancing and prohibition of gatherings. In addition to these measures, the introduction of mandated quarantine for travellers to Australia was integral to the successful containment of COVID-19 in NSW and Australia through the prevention of transmission locally and interstate from returning travellers.

The Vajrayana dance tradition of Nepal is a yogic practice and ritual art of the Vajracharyas, the Vajrayana priesthood of the Kathmandu Valley. Charya dance (caryā-nṛtya) serves primarily as a form of deity yoga (deva-yoga), a method of bodily transformation into deity. To the staple practices of mantra recitation and visualization common to all Tantric traditions, Charya dance adds the full-bodied, kinesthetic dimension of embodying the dynamic movement quality of the deity. After situating dance within Newar Vajrayana, this chapter considers how dance figures in the goal of embodying deity. The chapter presents three strands of explanation offered within the tradition, elicits the differing views of deity they entail, and identifies principles that support and unify the three explanatory modes. A dance of Avalokiteśvara, the bodhisattva of universal compassion, serves as a focus for the analyses.

The objectives of this review were to map and summarize the existing evidence from a global perspective about inequity in access and delivery of virtual care interventions and to identify strategies that may be adopted by virtual care services to address these inequities. We searched MEDLINE, EMBASE, and CINAHL using both medical subject headings (MeSH) and free-text keywords for empirical studies exploring inequity in ambulatory services offered virtually. Forty-one studies were included, most of them cross-sectional in design. Included studies were extracted using a customized extraction tool, and descriptive analysis was performed. The review identified widespread differences in accessing and using virtual care interventions among cultural and ethnic minorities, older people, socioeconomically disadvantaged groups, people with limited digital and/or health literacy, and those with limited access to digital devices and good connectivity. Potential solutions addressing these barriers identified in the review included having digitally literate caregivers present during virtual care appointments, conducting virtual care appointments in culturally sensitive manner, and having a focus on enhancing patients’ digital literacy. We identified evidence-based practices for virtual care interventions to ensure equity in access and delivery for their virtual care patients.

Virtual models of care are seen as a sustainable solution to the growing demand for health care. This paper analyses the experience of virtual care among patients diagnosed with COVID-19 in home isolation or health hotel quarantine using a patient-reported experience questionnaire. Results found that patients respond well to virtual models of care during a pandemic. Lessons learned can inform future developments of virtual care models.

An introduction Sydney Local Health District (SLHD) is a densely populated and socioeconomically and culturally diverse region in inner-Sydney experiencing significant population growth. 45% of the District’s residents were born overseas and 58% spoke a non-English language at home. With 15% of the population children aged 0-12 years. Annually 8,500 babies are born to mothers residing in the District. In the last year our child and family health services delivered care to 22,779 children on 77,783 occasions and managed 27,746 phone calls through our contact centre. The aim of this project was to challenge existing child and family health models of care and distribution of resources by redesigning services to be more patient centred, integrated, accessible, flexible and responsive. Description of practice change implemented A multi-layered, multi-level redesign strategy was implemented including: • Partnerships and integration: with the wider social care sector, research partners and internally within a local health district • Consumers: engagement and co-design • Workforce: maximising scope and roles, supporting innovation and celebrating success • Models of care: developing new and revising existing models and delivery modes • Policy: influencing and reshaping policy • Funding: positioning services for funding opportunities • Governance and leadership: across the health system and social care sector Aim To maximise workforce potential and create a service environment that met the needs of all families and enabled integration, flexibility, innovation and change. All initiatives were assessed for efficient resource allocation and utilisation. An iterative approach to implementation and redesign was taken with ongoing review and evaluation. Population and stakeholders Families with children antenatal to five years old in SLHD. Timeline The redesign strategy commenced in mid-2015 and is ongoing. Highlights • Partnerships and integration: united leadership across key government agencies and primary health • Consumers: informed a communications plan, strategic priorities, programs and resource allocation • Workforce: trust and permission to take risks and trial. Maximised capacity to deliver new models of care within existing resources, improved job satisfaction and autonomy to apply clinical judgement • Models of care: right care, rather than prescribed care, determined by family need • Policy: state policy influenced and other health districts following our lead • Additional funding • Governance and leadership: created an enabling environment for ongoing collaboration Sustainability and transferability The service redesign has secured significant funding and service models are being scaled. Conclusions This redesign has enabled changes in service delivery that have been evaluated. We have attracted increased investment and reallocated existing resources to sustain engagement with families requiring additional intervention, more accessible universal services for all families and stimulated statewide discussion regarding care models. This work is ongoing in order to remain responsive, flexible and innovative. We will continue to measure, evaluate and refine. By creating an enabling environment, continued opportunities will emerge. Lessons learned Be courageous and challenge state directives when there is misalignment with local need. Embrace the complexity of delivering universal and targeted health improving services across a diverse population. Value and maximise the potential of your workforce.

Objectives: To describe the implementation and early experience of virtual health care for community management of patients with COVID-19. Design: observational cohort study. Setting: large Australian metropolitan health service with established virtual health care program and remote patient monitoring capability. Participants: patients with COVID-19 living within the health service who can self-isolate safely, do not require immediate admission to an inpatient setting, have no major active comorbid illness and can be managed at home or other suitable accommodation. Main outcome measures: care escalation rates, including hospital admission. Results: between 11-29 March 2020, 162/173 (93.6%) locally diagnosed patients with COVID-19 were accepted to the virtual health care program, median age 38y (range 11-79). For the 62 patients discharged during this period the median length of stay was 8 days (range 1-17). The peak of 100 prevalent patients equated to approximately 25 patients per Registered Nurse per shift. Patients were contacted a median of 16 times (range 1-30) during this period, with video consultations used 66.3% of the time; 132/162 (81.5%) patients were monitored remotely. Care escalation rates were low: ambulance attendance, 5 (3%); ED attendance, 4 (2.5%); hospital admission, 3 (1.9%). There were no deaths. Conclusions: community-based virtual health care is feasible for managing most patients with COVID-19 and can be rapidly implemented in an urban Australian context for pandemic management. Health services implementing virtual health care should anticipate challenges with rapid technology deployments and provide adequate support to resolve them including strategies supporting consumer use of health information technologies.

Introduction: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. The NSW Government’s Integrated Care Strategy funding enabled the establishment of an integrated care initiative called Healthy Homes and Neighbourhoods (HHAN). The Initiative was designed as a population-based, family-centered, care-coordination network that functioned across agencies to assist vulnerable families to navigate the health and social-care system, to keep themselves and their children safe, and in doing so, promote social cohesiveness. The evaluation framework is described. Methods: Since integrated care initiatives are an example of complex interventions in health and social care, we underpinned this programme of development, research and evaluation by the critical realist metatheory of science and the NSW Health Monitoring and Evaluation Framework, using the UK Medical Research Council (MRC) Framework for evaluating complex interventions.1 We adapted the iterative approach of development, feasibility/piloting, evaluation and implementation of the MRC framework to include critical realist, participatory, continuous and theory driven elements. Discussion: Both the 2008 UK Medical Research Council framework for evaluating complex interventions, and our previously reported critical realist methodology, provided the tools to enable an iterative approach to development, design, testing and continuous evaluation. The philosophical paradigms underpinning each approach are different. Both the NSW Health and MRC frameworks were developed from in the “logical positivist” inductive and deductive reasoning traditions with a strong focus on activities and outcomes but little emphasis on process. That weakness was been recognised and the MRC subsequently endorsed advice on process evaluation for complex interventions which accommodated the realist approach incorporated here. Conclusion: Integrated care initiatives are examples of complex interventions in health and social care. The interventions are multi-layered and operationalization is strongly influenced by both historical and current context. This aspect alone makes it imperative that the methodology used is post-positive and takes ontologically stratified context into account. The NSW Health Monitoring and Evaluation Framework did not make provision for assessment of context or mechanism of effect. We describe here a multilevel approach including a continuous improvement approach through constant comparison and triangulation of mixed method findings. Utilising the MRC framework for evaluating complex interventions within a critical realist methodology, enabled us to study both mechanisms of effect and context. Lessons learned: Evaluation of integrated care interventions will require a pluralist approach to methodology. It is possible to design evaluation approaches that allow study of context, mechanism, reach and efficacy in a complex layered design as used for integrated care initiatives. Limitations: The approach utilised was contrained by the requirements of the policy and funding organisation. We did not fully explore the application of Theory of Change and complexity science within the MRC framework. Suggestions for future research: We recommend that further theoretical and applied research be undertaken to advance the methods and tools available for evaluation of complex multi-layered integrated care initiatives. Reference: 1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655

Introduction : In July 2015 Sydney Local Health District (SLHD) implemented an integrated care initiative for vulnerable families in the inner West region of Sydney, Australia. That initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. We will describe the development of the integrated care design that drew on earlier realist causal and program theoretical work. Theory/Methods : Realist causal and program theory were used to inform the collaborative design of initiatives for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, consultation forums, interagency planning, and development of a service proposal. Results : The program theory mechanisms identified included: family-provider trust, willingness to share power, co-operation, Information, and building self-help skills. The Design Elements included: Wrap around services, place-based initiatives, care coordination, sustained nurse home visiting, primary care support, family group conferencing, targeted parenting, social media, outcome monitoring, workforce development and realist program evaluation. Discussion : The Design Elements included: identification of vulnerable families; care coordination; evidence-informed intervention(s); general Practice engagement and support; family health improvement; placed-based neighbourhood initiatives; interagency system change and planning; monitoring of individual and family outcomes; and evaluation. Conclusions : The design study described advances our earlier empirical and programme design studies toward the implementation of a full whole-of-government integrated health and social care initiative. That initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. In so doing we aim to break intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours, through strengthening family resiliency, improving access to services, and addressing the social determinants of health and well-being. Lessons learned : In undertaking this study we identified the importance of our earlier hierarchal program analysis for identifying the elements for the full design. The application of theory added rigour to the design of integrated care initiatives. The design benefited from the inclusion of elements of population health, primary care, consumer engagement, community engagement and social determinants of health. Limitations : The analysis and design process did not include a full critical realist analysis of pre-existing context. Consequently existing structural, cultural, relationship and agency barriers and enablers were not fully analysed as part of the design process. Suggestions for future research : Further methodological research to develop: 1) tools that can be rapidly applied during the design process to identify pre-existing contextual barriers and enablers; and 2) approaches to build the knowledge of context into the final design.

Introduction: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. In response, a family-centred, population-based, integrated care initiative for vulnerable families and their children in Sydney, Australia was developed. The initiative was called Healthy Homes and Neighbourhoods. A realist translational social epidemiology programme of research and collaborative design is at the foundation of its evaluation. Theory and Method: The UK Medical Research Council (MRC) Framework for evaluating complex health interventions was adapted. This has four components, namely 1) development, 2) feasibility/piloting, 3) evaluation and 4) implementation. We adapted the Framework to include: critical realist, theory driven, and continuous improvement approaches. The modified Framework underpins this research and evaluation protocol for Healthy Homes and Neighbourhoods. Discussion: The NSW Health Monitoring and Evaluation Framework did not make provisions for assessment of the programme layers of context, or the effect of programme mechanism at each level. We therefore developed a multilevel approach that uses mixed-method research to examine not only outcomes, but also what is working for whom and why. Published version

Background/Aim : The establishment of effective and sustainable programs to promote healthy weight gain in the first years of life is a public health priority given the elevated rates of childhood overweight and obesity worldwide. Healthy Beginnings (HB) was a world-first randomised control trial to demonstrate the effectiveness of an intensive (eight sessions), home-based early obesity prevention intervention delivered by nurses from the third trimester until two years of age. The HB intervention targeting first-time mothers was effective in improving infant feeding practices, reducing TV viewing time and child body mass index (BMI) at two years. However, the program was not cost effective or sustainable without integrating with existing services. The aim of this study is to explore how the HB program has been integrated into existing on-going home-visiting services within New South Wales. Method/Results : In 2016, a steering committee was established by the Chief Executive of the Sydney Local Health District (SLHD) to instigate the integration of the HB program in existing home-visiting services in SLHD. The Healthy Families Healthy Children program, a sustained health home-visiting program targeting vulnerable families in SLHD and the HB team contributed to the development of an addendum. The addendum provided an overview of the service including eligibility criteria to engage families, the modules covered in the program (including behaviours targeted in the HB program), the program schedule (including the integration of the eight HB sessions over two years) and data collection (including expected HB outcomes). The nurses delivering the home visits were provided with a visit checklist containing standard minimum information as well as resources to support key messages developed from the HB Trial. For the purpose of this study a mixed methods approach will be used to explore the barriers, facilitators and effectiveness of integrating the HB program into the sustained health home-visiting program targeting vulnerable families in SLHD. Qualitative interviews will be conducted with higher, middle and program managers aimed at exploring their thoughts and experiences with integrating HB. Focus groups will be conducted with nurses delivering the HB sessions in order to explore their experiences with implementation. The researcher will observe the HB sessions delivered during home-visits and explore clients’ experiences and satisfaction with the sessions. Further, to measure the effectiveness of the integration, the data collected from the electronic medical record on infant feeding behaviours of the clients involved in the home-visits will be analysed. Conclusions/implications : The findings of this study will inform the integration of HB across other Local Health Districts in NSW. More broadly, this study will provide insight into the translation of an evidence-based health promotion program into a real-world setting.

Objectives: To describe sexual risk in Vietnamese men who have sex with female sex workers by describing the prevalence of sexual risk behaviours among Vietnamese men living in inner Sydney and comparing this prevalence with national data. Method: Telephone interviews were completed with a random sample of 499 Vietnamese men, selected from the electronic phone book using a list of common Vietnamese surnames. Results: Of the 761 eligible men contacted, data were obtained from 499 men giving a response rate of 66%. Twenty percent reported having had sex with a sex worker, including 12% of Vietnamese men who had sex with a sex worker outside Australia, predominantly in Vietnam. Of the men who had had sex with a sex worker in the last year, 28% had unprotected vaginal or anal sex at their most recent commercial sexual encounter. Ever having paid for sex was significantly associated with more lifetime number of sexual partners (p

Since 2002, biennial production of sexually transmissible infection testing guidelines for men who have sex with men has supported sexually transmitted infection control efforts in inner Sydney, Australia.

Objective: To describe hepatitis B and C knowledge and self-reported infection and risk behaviour in a group of Vietnamese men living in inner-urban Sydney, in order to assist with future program planning. Methods: Data were collected through telephone interviews conducted in Vietnamese using a structured questionnaire from 499 of 761 eligible men contacted, giving a response rate of 66%. The data were weighted to be consistent with the age distribution of Vietnamese men in the area. The findings were compared with a published national telephone study. Results: Low knowledge levels of hepatitis B and C were found when compared with data from a published national telephone study. The factors associated with higher mean knowledge scores for hepatitis B were being highly acculturated (P

Background: Australia has a widely dispersed network of public sexual health services that test large numbers of people from high prevalence populations for genital Chlamydia trachomatis infection. These populations include young sexually active heterosexuals, men who have sex with men, sex workers and Aboriginal and Torres Strait Islander people. The Australian Collaboration for Chlamydia Enhanced Sentinel Surveillance (ACCESS) Project was established to monitor chlamydia testing rates and positivity rates at a national level, which in turn will help interpret trends in chlamydia diagnoses reported through passive surveillance. The ACCESS Project is the first time that chlamydia-related data including priority population and testing denominators has been collated at a national level. The present paper reports on chlamydia testing and positivity rates in a sexual health service in the inner west of Sydney between 2004 and 2008 and compares these to published national data from the ACCESS Project in sexual health services. Methods: Chlamydia positivity and testing rates at an inner western Sydney sexual health service were compared with aggregate data from the ACCESS Project obtained from 14 sexual health services across Australia. Using a standardised extraction program, retrospective de-identified line-listed demographic and chlamydia testing data on all patients were extracted from patient management systems. Results: Over the 5-year period, 5145 new patients attended the inner-west sexual health service. Almost 66% had a chlamydia test at first visit and there was no significant difference in this testing rate when compared with the ACCESS Project national rate for sexual health services (67.0%; odds ratio [OR] 0.94, 95% confidence intervals 0.88–1.00). The testing rate increased over time from 61% in 2004 to 70% in 2008. There were 281 chlamydia diagnoses at this service, giving an overall chlamydia positivity rate of 9.3%, significantly higher than the ACCESS Project national rate of 8.2% (OR 1.16, 95% confidence intervals 1.02–1.32). Discussion: Testing rates were similar and positivity rates for Chlamydia trachomatis were higher in this sexual health service in Sydney than national trends.

Background With an increasing prevalence of obesity in young children globally, there is an urgent need for the development of effective early interventions. A previous Healthy Beginnings Trial using a nurse-led home visiting program has demonstrated that providing mothers with evidence-based advice can improve maternal practice regarding obesity prevention, and can reduce Body Mass Index (BMI) in the first few years of life. However, the costs for scale-up of home visiting limit its population reach. This trial aims to determine the efficacy of Communicating Healthy Beginnings Advice by Telephone (CHAT) to mothers with infants in improving infant feeding practices and preventing the early onset of childhood overweight and obesity. Methods/Design We propose a 3-arm randomised controlled trial (RCT) with a consecutive sample of 1056 mothers with their newborn children in New South Wales (NSW) Australia. Pregnant women who are between weeks 28 and 34 of their pregnancy will be invited to participate in the CHAT trial. Informed consent will be obtained, and after baseline data collection, participants will be randomly allocated to the telephone intervention, text messaging intervention, or the control group. The intervention comprises telephone consultations or text messages, together with 6 intervention packages being mailed at specific times from the third trimester of pregnancy until 12 months post birth. The main trial outcome measures include a) duration of breastfeeding, b) timing of introduction of solids, c) nutrition behaviours, physical activity and television viewing, and d) weight and BMI z-score at 12 and 24 months, e) cost-effectiveness, as well as f) feasibility and acceptability of the interventions. Discussion The results will ascertain whether early intervention using telephone consultation or text messaging together with staged mailed intervention resources can be feasible and effective in improving infant feeding practices, physical activity and reducing children’s BMI in the early years of life. If proven to be feasible, effective as well as cost-effective, the trial results will inform a series of recommendations for policy and practice related to promoting healthy infant feeding and physical activity in young children in the first years of life. Trial registration The CHAT Trial is registered with the Australian Clinical Trial Registry ( ACTRN12616001470482p ). It was registered on October 21, 2016.

On dit generalement que les chefs-d'oeuvre de la peinture Song sont le resultat de l'apport fertilisant du bouddhisme et du taoisme. Cependant peu d'attention a ete portee a l'etude des developpements de cet art. Histoire de la peinture de paysage depuis les Six Dynasties. L'A. essaie ensuite d'isoler les themes predominants dans le modele culturel complexe qui conduira a la peinture de paysage classique : evolution des attitudes taoistes envers la nature | descriptions visuelles du paysage | aspects specifiques des enseignements et leur contribution au developpement de la peinture de paysage