Objective: To determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care. Design: A systematic review of randomised controlled trials reported since 1980. Data sources: 10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites. Included studies: Randomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes. Results: 11 trials were included. In four trials of alternative provider ambulatory primary care roles , nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: −€6.41; 95% CI −€9.28 to −€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles , nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles , 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly. Conclusions: Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study.

University students are within the age group at highest risk for acquiring sexually transmitted infections and other negative health outcomes. Despite the availability of sexual health services at university health centres to promote sexual health, many students delay or avoid seeking care. This study aimed to identify the perceived barriers and enablers to sexual health service use among university undergraduate students. We used a qualitative descriptive design to conduct semi-structured focus groups and key informant interviews with university students, health care providers, and university administrators at two university health centres in Nova Scotia, Canada. The semi-structured focus group and interview guides were developed using the Theoretical Domains Framework and COM-B Model. Data were analyzed using a directed content analysis approach, followed by inductive thematic analysis. We conducted 6 focus groups with a total of 56 undergraduate students (aged 18–25) and 7 key informant interviews with clinicians and administrators. We identified 10 barriers and enablers to sexual health service use, under 7 TDF domains: knowledge; memory, attention and decision-making processes; social influences; environmental context and resources; beliefs about consequences; optimism; and emotion. Key linkages between students’ social opportunity and motivation were found to influence students’ access of sexual health services. We identified barriers and enablers related to students’ capability, opportunity and motivation that influence sexual health service use. We will use these findings to design an intervention that targets the identified barriers and enablers to improve students’ use of sexual health services, and ultimately, their overall health and well-being.

Objective: to examine advanced practice nursing (APN) roles internationally to inform role development in Latin America and the Caribbean to support universal health coverage and universal access to health. Method: we examined literature related to APN roles, their global deployment, and APN effectiveness in relation to universal health coverage and access to health. Results: given evidence of their effectiveness in many countries, APN roles are ideally suited as part of a primary health care workforce strategy in Latin America to enhance universal health coverage and access to health. Brazil, Chile, Colombia, and Mexico are well positioned to build this workforce. Role implementation barriers include lack of role clarity, legislation/regulation, education, funding, and physician resistance. Strong nursing leadership to align APN roles with policy priorities, and to work in partnership with primary care providers and policy makers is needed for successful role implementation. Conclusions: given the diversity of contexts across nations, it is important to systematically assess country and population health needs to introduce the most appropriate complement and mix of APN roles and inform implementation. Successful APN role introduction in Latin America and the Caribbean could provide a roadmap for similar roles in other low/middle income countries.

To provide an updated synthesis of the current state of the evidence for the effectiveness of breast-feeding and expressed breast milk feeding in reducing procedural pain in preterm and full-term born infants. A systematic search of key electronic databases (PubMed, CINAHL, EMBASE) was completed. Of the 1032 abstracts screened, 21 were found eligible for inclusion. Fifteen studies reported on the use of breast-feeding or expressed breast milk in full-term infants and 6 reported on preterm infants. Direct breast-feeding was more effective than maternal holding, maternal skin-to-skin contact, topical anesthetics, and music therapy, and was as or more effective than sweet tasting solutions in full-term infants. Expressed breast milk was not consistently found to reduce pain response in full-term or preterm infants. Studies generally had moderate to high risk of bias. There is sufficient evidence to recommend direct breast-feeding for procedural pain management in full-term infants. Based on current evidence, expressed breast milk alone should not be considered an adequate intervention.