Professor Christine Paul

Background: Despite the impact of cognitive decline during brain cancer care, implementing routine cognitive assessment can be challenging. Effective implementation of cognitive assessment necessitates an understanding of implementation from the patient perspective. However, little is known about how people with glioma and their caregivers experience cognitive changes, assessment and support. Objective: To understand the lived experiences of changes in cognition for people with glioma and their caregivers including experiences of: i) perceived or objectively measured cognitive decline (or absence of decline); ii) cognitive assessment following diagnosis, and; iii) met and unmet cognition-related supportive care needs. Design: Semi-structured qualitative telephone interviews were conducted with people with gliomas and support persons and analysed using reflexive thematic analysis. Setting(s): Two Australian cancer services Participants: 18 people with glioma and caregivers Methods: Semi-structured qualitative telephone interviews were conducted with people with gliomas and caregivers and analysed using reflexive thematic analysis. Results: People with glioma (n = 5) and caregivers (n = 13) completed interviews. Four themes were identified: Cognition needs to be considered within the context of glioma diagnosis and treatment; concerns about cognition were initially subordinate to survival but become important; there are challenges identifying and communicating about people with gliomas¿ changes in cognition; cognition-related supportive care can be helpful but challenging for people with glioma and caregivers to identify and access. Conclusions: Changes to cognition can have considerable impacts of people with glioma and their caregivers which may be overshadowed by treatment and survival. A multi-disciplinary approach to timely cognitive screening, structured referral pathways, and communication with caregivers may provide opportunities for support. Registration: n/a Tweetable abstract: Identifying cognitive changes in people with glioma is important and challenging. A multidisciplinary approach and inclusion of care coordination and caregivers can help.

Introduction: Addiction plays a key role in continued tobacco use. The study assessed association of perceived personal addiction and the perceived addictiveness of different forms of tobacco with type of tobacco product used, demographic characteristics and socio-cultural factors. Methods: A cross-sectional survey of 607 adult tobacco users with age 18 years and above attending a general medicine out-patient department was conducted. Participants were asked questions on perceived personal addiction to tobacco use and perception of addiction on tobacco products. Logistic regression was applied to investigate the association between demographic characteristics, type of tobacco, socio-cultural factors and addiction perceptions. Results: The odds of perceived addiction (PA) were lower among smokeless tobacco (SLT) users [OR (95% CI): 0.57 (0.37, 0.89) P¿=¿0.01]. An increase in the odds of PA was seen as age increased [OR (95% CI):1.02 (1.00, 1.03) P¿=¿0.01] and participants with secondary education and above had higher odds of PA compared to participants with no formal education [OR (95% CI): 1.68 (1.09, 2.58) P¿=¿0.02]. The odds of perceiving SLT products to be addictive was lower among SLT users [OR (95% CI): 0.48 (0.30, 0.75) P¿=¿0.002)] compared to combustible tobacco users. The odds of perceiving SLT products to be addictive was lower [(OR (95% CI): 0.35 (0.18, 0.67) P¿=¿0.002)] among females. Participants with secondary education and above had higher odds of perceiving combustible [OR (95% CI): 1.80 (1.17, 2.77) P¿=¿0.008)] and SLT products [OR (95% CI): 1.98 (1.20, 3.30) P¿=¿0.008)] to be addictive compared to no schooling. Discussion and Conclusions: There is a need to raise awareness in India of the addictiveness of tobacco, particularly for users of SLT, younger people and those with less education.

Smoking cessation reduces the risk of death, improves recovery, and reduces the risk of hospital readmission. Evidence and policy support hospital admission as an ideal time to deliver smoking-cessation interventions. However, this is not well implemented in practice. In this systematic review, the authors summarize the literature on smoking-cessation implementation strategies and evaluate their success to guide the implementation of best-practice smoking interventions into hospital settings. The CINAHL Complete, Embase, MEDLINE Complete, and PsycInfo databases were searched using terms associated with the following topics: smoking cessation, hospitals, and implementation. In total, 14,287 original records were identified and screened, resulting in 63 eligible articles from 56 studies. Data were extracted on the study characteristics, implementation strategies, and implementation outcomes. Implementation outcomes were guided by Proctor and colleagues' framework and included acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. The findings demonstrate that studies predominantly focused on the training of staff to achieve implementation. Brief implementation approaches using a small number of implementation strategies were less successful and poorly sustained compared with well resourced and multicomponent approaches. Although brief implementation approaches may be viewed as advantageous because they are less resource-intensive, their capacity to change practice in a sustained way lacks evidence. Attempts to change clinician behavior or introduce new models of care are challenging in a short time frame, and implementation efforts should be designed for long-term success. There is a need to embrace strategic, well planned implementation approaches to embed smoking-cessation interventions into hospitals and to reap and sustain the benefits for people who smoke.

Background: Patient-centered cancer care includes emotional, informational, and practical support that is personalised to the needs of patients and inclusive of family and friends. However, when supportive care referrals are offered in hospital settings, distressed patients and carers do not consistently act on those referrals, which can prolong patient suffering. The degree to which sub-optimal referral uptake also occurs in Australian telephone support services is unknown. Aims: To report, among a sample of distressed patients and caregivers who called a cancer information and support service: 1) the types of services used; 2) proportion who received and actioned a referral (uptake); 3) associations between referral to a service and callers¿ characteristics); and, 4) associations between uptake of a referred service and callers¿ characteristics. Methods: This study used cross-sectional data collected at 3-month post-baseline from control participants (usual care group) enrolled in the Structured Triage and Referral by Telephone (START) trial. The START trial recruited distressed adult cancer patients and caregivers from the Cancer Council Information and Support Service (CIS). A research assistant conducted a 30¿45 min telephone interview with participants, which included recall of referrals provided by CIS staff and reported uptake of referral(s) to the offered service types. Results: Most patients (98%) and caregivers (97%) reported receiving a referral to a service. For patients and caregivers respectively, information materials (71%, 77%), CIS call-back (51%, 43%), practical services (52%, 45%), and group peer support (49%, 51%) were the services most frequently offered. For callers receiving a referral, uptake was highest for information materials (91%) and CIS call-backs (89%) and lowest for specialist psychological services (30%). Significant association was found between older age and reduced uptake of services (p = 0.03). Conclusion: The high uptake rate of CIS call-backs suggests it is a potentially more acceptable form of support compared to specialist psychological services. Efforts to reduce the barriers to telephone-based psychological services are required. Specifically, older age peoples¿ and caregivers¿ preferences for support and priorities who may benefit from a referral coordinator.

(1) Background: This systematic review was conducted to identify cancer patient experi-ences, and the impact of out-of-pocket costs and financial burden in Australia. (2) Methods: A systematic review, following the Preferring Reporting Items for Systematic Reviews and Meta-Anal-yses, was conducted. Cumulative Index of Nursing and Allied Health Literature and PubMed were searched. The primary outcome was financial burden among cancer patients and their families in Australia. The secondary outcome was out-of-pocket costs associated with cancer care and treatment within the population sample, and the impact of financial burden. (3) Results: Nineteen studies were included, covering more than 70,000 Australians affected by cancer. Out-of-pocket costs varied by cancer type and ranged from an average of AUD 977 for breast cancer and lymphoedema patients to AUD 11,077 for prostate cancer patients. Younger aged patients (=65 years), Aboriginal and Torres Strait Islander people, people in rural and/or remote areas, households with low income, those who were unemployed and people with private health insurance were at increased risk of experiencing out-of-pocket costs, financial burden or a combination of both. (4) Conclusions: Australians diagnosed with cancer frequently experience financial burden, and the health and financial consequences are significant. Focusing efforts on the costs of care and options about where to have care within the context of informed decisions about cancer care is necessary.

Objectives: To examine if baseline stigma predicts psychological distress at 3 and 6 months follow-up among patients newly diagnosed with lung cancer. Methods: This longitudinal study was nested within a larger randomised controlled trial. Eligible participants were recruited via respiratory and oncology out-patient clinics in Australia (n¿=¿194). Consenting participants were asked to complete surveys at baseline, 3 and 6 months post-recruitment. Measures included lung cancer stigma (Cataldo Lung Cancer Stigma Scale) and psychological distress (General Health Questionnaire-12 [GHQ-12]). Results: One-hundred and ninety-four participants were included for analysis. Most were male (57.7%) with a mean age of 68 years (SD¿=¿8.8). A significant relationship between baseline lung cancer stigma and psychological distress at 6 months was found, where a one unit increase in lung cancer stigma increases psychological distress by 0.044 when adjusting for age, gender, smoking status, baseline GHQ-12 scores and intervention allocation (as part of the larger trial; p¿=¿0.001; ß¿=¿0.044, 95% CI¿=¿0.010, 0.079). Conclusion: Temporal links between lung cancer stigma and psychological distress was found at 6 months, suggesting stigma-related experiences may have a delayed impact. Development of routine lung cancer stigma assessments is recommended to identify those at risk of psychological distress.

Uptake of online and telephone services targeting health behaviours is low among vocational education students and barriers and facilitators are unknown. This study aimed to explore barriers and facilitators to uptake of online and telephone services for smoking, nutrition, alcohol, and physical activity (SNAP) risk behaviours via semi-structured individual telephone interviews with fifteen vocational education students. Two authors independently completed thematic analysis, classified themes according to the COM-B (Capability, Opportunity, Motivation, Behaviour) frame-work, and discussed disagreements until consensus was reached. Facilitators to uptake of online (e.g., desire to learn something new, cost-free, accessible) and telephone services (e.g., prefer to talk to provider, complements online support) primarily related to capability and opportunity. For telephone services, difficulty understanding accent/language was a capability-related barrier. Opportunity-related barriers for online and telephone services were preference for face-to-face interaction and lack of time, while preference for apps/online programs was a barrier for telephone services. For online and telephone services, not wanting to change SNAP behaviours was a motivation-related barrier and being able to change SNAP risk behaviours themselves was a motivation-related barrier for online services. Barriers and facilitators to online and telephone services are relevant for designing interventions vocational education students are more likely to use.

Over the past 10 years, there has been limited progress for the treatment of brain cancer and outcomes for patients are not much improved. For brain cancer researchers, a major obstacle to biomarker driven research is limited access to brain cancer tissue for research purposes. The Mark Hughes Foundation Brain Biobank is one of the first post-mortem adult brain banks in Australia to operate with protocols specifically developed for brain cancer. Located within the Hunter New England Local Health District and operated by Hunter Cancer Biobank, the boundaries of service provided by the Brain Bank extend well into the surrounding regional and rural areas of the Local Health District and beyond. Brain cancer biobanking is challenging. There are conflicting international guidelines for best practice and unanswered questions relating to scientific, psychosocial and operational practices. To address this challenge, a best practice model was developed, informed by a consensus of existing data but with consideration of the difficulties associated with operating in regional or resource poor settings. The regional application of this model was challenged following the presentation of a donor located in a remote area, 380km away from the biobank. This required biobank staff to overcome numerous obstacles including long distance patient transport, lack of palliative care staff, death in the home and limited rural outreach services. Through the establishment of shared goals, contingency planning and the development of an informal infrastructure, the donation was facilitated within the required timeframe. This experience demonstrates the importance of collaboration and networking to overcome resource insufficiency and geographical challenges in rural cancer research programmes.

Background: A high proportion of vocational education students smoke tobacco, have inadequate nutrition (ie, low fruit and vegetable intake), drink alcohol at risky levels, or are physically inactive. The extent to which vocational education students will sign up for proactively offered online and telephone support services for multiple health risk behaviors is unknown. Objective: The aim of this study is to examine the uptake of proactively offered online and telephone support services for smoking, nutrition, alcohol consumption, and physical activity risk behaviors, individually and in combination, among vocational education students in the Technical and Further Education (TAFE) setting. The characteristics associated with the uptake of online or telephone services for smoking, nutrition, alcohol consumption, and physical activity risk behaviors were also examined. Methods: Vocational education students enrolled in a TAFE class in New South Wales, Australia, which ran for 6 months or more, were recruited to participate in a cluster randomized controlled trial from May 2018 to May 2019. In the intervention arm, participants who did not meet the Australian health guidelines for each of the smoking, nutrition, alcohol consumption, and physical activity risk behaviors were provided electronic feedback and proactively offered online and telephone support services. Uptake of support was measured by whether participants signed up for the online and telephone services they were offered. Results: Vocational education students (N=551; mean age 25.7 years, SD 11.1; 310/551, 56.3% male) were recruited into the intervention arm. Uptake of the proactive offer of either online or telephone services was 14.5% (59/406) for fruit and vegetables, 12.7% (29/228) for physical activity, 6.8% (13/191) for smoking, and 5.5% (18/327) for alcohol use. Uptake of any online or telephone service for at least two health behaviors was 5.8% (22/377). Participants who were employed (odds ratio [OR] 0.10, 95% CI 0.01-0.72) and reported not being anxious (OR 0.11, 95% CI 0.02-0.71) had smaller odds of signing up for online or telephone services for smoking, whereas participants who reported not being depressed had greater odds (OR 10.25, 95% CI 1.30-80.67). Participants who intended to change their physical activity in the next 30 days had greater odds (OR 4.01, 95% CI 1.33-12.07) of signing up for online or telephone services for physical activity. Employed participants had smaller odds (OR 0.18, 95% CI 0.06-0.56) of signing up for support services for at least two behaviors. Conclusions: Although the uptake of proactively offered online and telephone support services is low, these rates appear to be higher than the self-initiated use of some of these services in the general population. Scaling up the proactive offer of online and telephone services may produce beneficial health outcomes.

Background: Real-time video counselling for smoking cessation uses readily accessible software (e.g. Skype). This study aimed to assess the short-term effectiveness of real-time video counselling compared to telephone counselling or written materials (minimal intervention control) on smoking cessation and quit attempts among rural and remote residents. Methods: An interim analysis of a three-arm, parallel group randomised trial with participants (n = 655) randomly allocated to; 1) real-time video counselling; 2) telephone counselling; or 3) written materials only (minimal intervention control). Participants were daily tobacco users aged 18 years or older residing in rural or remote areas of New South Wales, Australia. Video and telephone counselling conditions offered up to six counselling sessions while those in the minimal intervention control condition were mailed written materials. The study measured seven-day point prevalence abstinence, prolonged abstinence and quit attempts at 4-months post-baseline. Results: Video counselling participants were significantly more likely than the minimal intervention control group to achieve 7-day point prevalence abstinence at 4-months (18.9% vs 8.9%, OR = 2.39 (1.34¿4.26), p = 0.003), but the video (18.9%) and telephone (12.7%) counselling conditions did not differ significantly for 7-day point prevalence abstinence. The video counselling and minimal intervention control groups or video counselling and telephone counselling groups did not differ significantly for three-month prolonged abstinence or quit attempts. Conclusion: Given video counselling may increase cessation rates at 4 months post-baseline, quitlines and other smoking cessation services may consider integrating video counselling into their routine practices as a further mode of cessation care delivery. Trial registration: www.anzctr.org.au ACTRN12617000514303.

Purpose: Caring for a person diagnosed with cancer is associated with elevated distress that may impact on caregiver health and patient outcomes. However, caregivers¿ distress is relatively under-researched. This Australian study explored a range of caregivers¿ reported sources of distress. Methods: The grounded theory approach informed semi-structured interviews that were conducted with a purposive and broad range sample of distressed caregivers identified through the ¿Structured Triage And Referral by Telephone¿ (START) trial. A grounded theory framework was used to generate themes with data analysed by two independent coders using the NVivo software. Results: Caregivers (n = 14) were aged from 25 to 80 years, including two bereaved caregivers. The relationships of the caregivers to the patients were as follows: partner (n = 8), parent (n = 1), child (n = 3), sibling (n = 1), and friend (n = 1). Six major themes emerged in relation to sources of distress: (1) a lack of sufficient and timely information; (2) uncertainty; (3) the role and duties of caregiving; (4) lack of family-centred services; (5) practical challenges; and (6) impact of distress. Conclusion: Caregivers face a number of specific challenges beyond those experienced by patients. It is essential to ensure that caregivers are actively well-informed and well-supported alongside the person who is diagnosed with cancer.

Purpose: People affected by chronic diseases such as cancer report high levels of distress and a need for psychosocial support. It is unclear whether telephone-based services for people affected by chronic disease are a practical setting for implementing distress screening, referral protocols and rescreening to direct supportive care where it is needed. This systematic review aimed to describe the published literature regarding distress screening and supportive care referral practices in telephone-based services for people affected by chronic diseases such as cancer. Methods: A systematic literature search of MEDLINE, Embase, PsycInfo, CINAHL, Cochrane and Scopus was conducted in February 2018. Included quantitative studies involved: patients or caregivers affected by chronic diseases including cancer and describe a health service assessing psychosocial needs or distress via telephone. Extracted data included the type of cancer or other chronic disease, sample size, screening tool, referral or rescreening protocols, and type of health service. Results: The search identified 3989 potential articles with additional searches returning 30 studies (n = 4019); fourteen were eligible for full-text review. Of the 14 studies, 13 included cancer patients. Studies were across multiple settings and identified nine distress screening tools in use. Conclusion: The reviewed studies indicate that validated distress-screening tools are being used via telephone to identify distress, particularly in relation to cancer. Screening-driven supportive care referrals are also taking place in telephone-based services. However, not all services use an established referral protocol. Ongoing rescreening of callers¿ distress is also limited despite it being an important recommendation from psycho-oncology guidelines.

Background: It is unknown how many distressed patients receive the additional supportive care recommended by Australian evidence-based distress management guidelines. The study identifies the (1) distress screening practices of Australian cancer services; (2) barriers to improving practices; and (3) implementation strategies which are acceptable to service representatives interested in improving screening practices. Method: Clinic leads from 220 cancer services were asked to nominate an individual involved in daily patient care to complete a cross-sectional survey on behalf of the service. Questions related to service characteristics; screening and management processes; and implementation barriers. Respondents indicated which implementation strategies were suitable for their health service. Results: A total of 122 representatives participated from 83 services (51%). The majority of respondents were specialist nurses or unit managers (60%). Approximately 38% of representatives¿ services never or rarely screen; 52% who screen do so for all patients; 55% use clinical interviewing only; and 34% follow referral protocols. The most common perceived barriers were resources to action screening results (74%); lack of time (67%); and lack of staff training (66%). Approximately 65% of representatives were interested in improving practices. Of the 8 implementation strategies, workshops (85%) and educational materials (69%) were commonly selected. Over half (59%) indicated a multicomponent implementation program was preferable. Conclusions: Although critical gaps across all guideline components were reported, there is a broad support for screening and willingness to improve. Potential improvements include additional services to manage problems identified by screening, more staff time for screening, additional staff training, and use of patient-report measures.

Aim: Aims were to test the effectiveness of an organizational change intervention integrating smoking cessation treatment into usual alcohol and other drug (AOD) treatment, compared with usual care, on (1) 7-day point prevalence abstinence (PPA) at 8¿weeks follow-up; (2) prolonged abstinence; (3) cigarettes smoked per day; (4) number of quit attempts; and (5) offer and use of nicotine replacement therapy (NRT). All outcomes were assessed at 8¿weeks and 6.5¿months follow-up. Design: Cluster-randomized controlled trial, with AOD service as unit of randomization, conducted January 2015¿March 2016. Setting: Thirty-two eligible services (provided face-to-face client sessions to =¿50 clients/year) in Australia were randomized to control (usual care; n¿=¿15) or intervention (n¿=¿17) groups by an independent blinded biostatistician. Participants: Eligible participants (= 16¿years, current smoker) completed surveys at the service at baseline (n¿=¿896) and telephone follow-up surveys (conducted by blinded assessors) at 8¿weeks (n¿=¿471; 53%) and 6.5¿months (n¿=¿427; 48%). Intervention: Intervention services received an intervention to establish routine screening, assessment and delivery of smoking cessation care. Measurements: Primary outcome was biochemically verified 7-day PPA at 8-week follow-up. Secondary outcomes included verified and self-reported prolonged abstinence, self-reported 7-day PPA, cigarettes/day, quit attempts and offer and use of NRT. Intention-to-treat analyses were performed, assuming missing participants were not abstinent. Findings: At 8¿weeks, the findings in verified 7-day PPA between groups [2.6 versus 1.8%, odds ratio (OR)¿=¿1.72, 95% confidence interval (CI)¿=¿0.5¿5.7, P¿=¿0.373] were inconclusive as to whether a difference was present. Significantly lower mean cigarettes/day were reported in the intervention group compared to the usual care group at 8¿weeks [incidence rate ratio (IRR)¿=¿0.88, 95% CI¿=¿0.8¿0.95, P¿=¿0.001] but were similar at 6.5 months (IRR¿=¿0.96, 95% CI¿=¿0.9¿1.02, P¿=¿0.240) follow-up. At both follow-ups the intervention group reported higher rates of NRT use. Conclusions: Integrating smoking cessation treatment into addiction services did not significantly improve short-term abstinence from smoking.

Aims and objectives: To explore patient and healthcare provider (HCP) perspectives about patients¿ barriers to the performance of diabetic self-care behaviours in Ghana. Background: Sub-Saharan African urban populations are increasingly affected by type 2 diabetes due to nutrition transition, sedentary lifestyles and ageing. Diabetic self-care is critical to improving clinical outcomes. However, little is known about barriers to diabetic self-care (diet, exercise, medication taking, self-monitoring of blood glucose and foot care) in sub-Saharan Africa. Design: Qualitative study that followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Methods: Semi-structured interviews were conducted among 23 people living with type 2 diabetes and 14 HCPs recruited from the diabetes clinics of three hospitals in Tamale, Ghana. Interviews were audiotaped and transcribed verbatim. The constant comparative method of data analysis was used and identified themes classified according to constructs of the theory of planned behaviour (TPB): attitudes/behavioural beliefs, subjective norms and perceived behavioural control. Results: Barriers relating to attitudes included misconceptions that diabetes was caused by spiritual forces or curses, use of herbal medicines, intentional nonadherence, difficulty changing old habits, and feeling or lacking motivation to exercise. Barriers relating to subjective norms were inadequate family support, social stigma (usually by spouses and other members of the community) and cultural beliefs. Perceived behavioural control barriers were poor income levels, lack of glucometers, busy work schedules, long distance to the hospital and inadequate access to variety of foods due to erratic supply of foods or seasonality. Conclusions: Both patients and HCPs discussed similar barriers and those relating to attitude and behavioural control were commonly discussed. Relevance to Clinical Practice: Interventions to improve adherence to diabetic self-care should focus on helping persons with diabetes develop favourable attitudes and how to overcome behavioural control barriers. Such interventions should have both individualised and community-wide approaches.

Background: General practitioners¿ (GPs) views about deprescribing prescription opioid analgesics (POAs) may influence the care provided for patients experiencing chronic noncancer pain (CNCP). There are limited data addressing GPs¿ beliefs about deprescribing, including their decisions to deprescribe different types of POAs. Aim: To determine the proportion of GPs who hold attitudes congruent with local pain stewardship, describe their deprescribing decisions, and determine whether type of POA influences deprescribing. Design and setting: In 2016, a cross-sectional survey of all GPs (n=1,570) in one mixed urban and regional primary health network (PHN) in Australia was undertaken. Methods: A mailed self-report questionnaire assessed agreement with local guidelines for treating CNCP; influences on deprescribing POAs and likelihood of deprescribing in a hypothetical case involving either oral codeine or oxycodone. Results: A response rate of 46% was achieved. Approximately half (54%) of GPs agreed POAs should be reserved for people with acute, cancer pain or palliative care and a third (32%) did not agree that a medication focus has limited benefits for peoples¿ long-term quality of life and function. Most (77%) GPs were less likely to deprescribe when effective alternate treatments were lacking, while various patient factors (eg, fear of weaning) were reported to decrease the likelihood of deprescribing for 25% of GPs. A significantly higher proportion of GPs reported being very likely to deprescribe codeine compared to the equivalent opioid dose of oxycodone for a hypothetical patient. Conclusions: Many GPs in the PHN hold attitudes at odds with local guidance that opioids are a nonsuperior treatment for CNCP. Attitudinal barriers to deprescribing include: a lack of consistent approach to deprescribing opioids as a class of drugs, perceived lack of effective treatment alternatives and patient fear of deprescribing. Therefore, the next step in this target population is to appropriately train and support GPs in how to apply the evidence in practice and how to support patients appropriately.

Aims: To determine diabetes patient's adherence to five self-care behaviours (diet, exercise; medication, self-monitoring of blood glucose [SMBG] and foot care) in low- and middle-income countries. Design: Systematic review. Data sources: We searched MEDLINE, CINAHL, PUBMED, SCOPUS, PsycINFO, EMBASE, Cochrane library and EMCARE for the period January 1990 ¿ June 2017. Review Methods: Title, abstract and full text screening were done according to eligibility criteria. A narrative synthesis of the literature was conducted. Results: A total of 7,109 studies were identified of which 27 met the review eligibility criteria and were included. All the studies used self-report of adherence to diabetes self-care. Studies reported adherence rates in two major forms: (a) mean number of days participants performed a recommended dietary behaviour/activity during the past week; and (b) proportions of participants adhering to a recommended self-care behaviour. Mean number of days per week participants adhered to a self-care behaviour ranged from 2.34.6¿days per week for diet, 5.5¿6.8¿days per week for medication, 1.8¿5.7¿days per week for exercise, 0.2¿2.2¿days per week for SMBG and 2.2¿4.3¿days per week for foot care. Adherence rates ranged from 29.9%¿91.7% for diet, 26.0%¿97.0% for medication taking, 26.7%¿69.0% for exercise, 13.0%¿79.9% for self-monitoring of blood glucose and 17.0%¿77.4% for foot care. Conclusion: Although most diabetes patients do not adhere to recommended self-care behaviours, adherence rates vary widely and were found to be high in some instances. Impact: Health services in low- and middle-income countries should monitor adherence to diabetes self-care behaviours rather than assume adherence and resources should be invested in improving adherence to the self-care behaviours. Large-scale accurate monitoring of adherence to diabetes self-care behaviour is needed and consideration should be given to choice of measurement tool for such exercise.

Aims: We evaluated the content validity, factorial structure, internal consistency, construct validity, and floor and ceiling effects of the SDSCA among Ghanaian persons with type 2 diabetes. Methods: The summary of diabetes self-care activities measure (SDSCA) was administered to 187 adults living with type 2 diabetes from three diabetes clinics. Results: A confirmatory factor analysis maintained the four factor structure of the SDSCA. However, two items, 3 (fruit and vegetable servings) and 4 (red meat or full-fat dairy products) had factor loadings of 0.26 and 0.16 respectively. The model also had a statistical power of 0.72 (below acceptable criteria). Modification of the model by removing item 4 resulted in an improved revised model with a power of 0.82. Construct validity was found for the exercise and diet subscales of the SDSCA but not for the self-monitoring of blood glucose and foot care subscales. The internal consistency of the SDSCA measure was 0.68, below acceptable criteria for internal consistency. No floor effects were present but the exercise subscale had ceiling effects. Conclusion: The SDSCA measure had content validity, maintained its multidimensionality and met the criteria for floor effects but not for construct validity, internal consistency and ceiling effects. The SDSCA measure may require improvements to evaluate self-care behaviours of adult type 2 diabetes patients in Ghana and probably in other sub-Saharan countries.

Background: Many biobanks rely upon patients¿ willingness to donate biospecimens and healthcare professionals to initiate opt-in consent processes. This study explored if: (1) patients accept opt-in or opt-out consent models with varying levels of professional involvement; (2) professionals discuss participation with specific patient groups; and (3) this discussion is associated with patient knowledge of biobanking processes. Methods: Outpatients completed surveys at a tertiary cancer center in New South Wales, Australia. Eligible participants were English-speaking adults who recently had cancer-related surgery. Participants completed 27 questions exploring acceptable consent models, biobanking experiences, knowledge, and willingness. Logistic regression and chi-square tests examined differences in the characteristics and knowledge of participants who were offered the opportunity to participate versus those who were not. Results: A total of 113 outpatients participated (97% response). Most participants (92%) found opt-out, patient-initiated consent acceptable; however, high acceptability was reported for all models except for opt-in, patient-initiated consent (58%). University or technical qualifications (P = 0.001) was associated with increased odds (OR¿=¿4.5) of being offered biobanking. The majority did not know what occurred to samples after surgery (59.3%) or pathology review (81.4%) and ability to answer these questions was associated with discussion of participation (P¿<¿0.001). Of the few outpatients who discussed biobanking with their doctor (29%), all consented. Conclusion: Professional-initiated, opt-in consent resulted in a few educated patients being approached; greater professional initiation of consent would be fruitful as most patients were willing to participate if asked. However, other consent approaches minimizing professional involvement were as acceptable to participants warranting further consideration.

Background: Tobacco smoking is highest among population groups which are the most socially disadvantaged. Internet-based smoking cessation programs have been found to be effective, though rates of internet access are not well known in these groups. This study describes the rates of internet use and types of technology used to access the internet by a population of socially disadvantaged smokers. The study also examined relationships between sociodemographic and smoking behaviours with amount of internet use and type of device used. Methods: A cross-sectional survey of 369 clients (response rate 77%) from two non-government community service organisations in metropolitan New South Wales, Australia was conducted using touchscreen computers. Descriptive statistics and logistic regressions were used to examine results. Results: Eligible participants ranged from 19 to 88 years old current tobacco users. Over half (58%) of the participants reported weekly or more frequent use of the internet with less than a third (28%) not having any access. The odds of using the internet at least weekly decreased with age and as heaviness of smoking increased (OR = 0.94, p < 0.001; OR = 0.81, p = 0.022, respectively). Odds of internet use were higher as income increased (OR = 2.74, p < 0.001 for individuals earning $201-$400 per week; OR = 2.83, p = 0.006 for individuals earning > $400 per week). Device use differed for age and income. Conclusions: Internet-based interventions appear to reach the majority of socially disadvantaged populations. It is expected that this reach will continue to grow, making internet-based interventions a potential platform for providing care to low socioeconomic individuals who smoke, however inequalities may be exacerbated for those individual without internet access. Implications: Internet use among socially disadvantaged tobacco users is moderate (58%). An internet-based smoking cessation intervention for socially disadvantaged tobacco users may be an effective intervention however, older, heavier tobacco users may not benefit as easily due to limited internet access and therefore acknowledging these limitations when developing an intervention can help to acknowledge limitation of intervention reach.

Rationale & Objective: The number of people with diabetes and end-stage kidney disease (ESKD) is increasing worldwide, but it is unknown whether this indicates an increasing risk for ESKD in people with diabetes. We examined temporal trends in the incidence of ESKD within the Australian population with diabetes from 2002 to 2013. Study Design: Follow-up study using a national health care services registry. Setting & Participants: Registrants with type 1 or type 2 diabetes in Australia's National Diabetes Services Scheme (NDSS). Predictors: Age, sex, indigenous status, diabetes type, and calendar year. Outcome: Incidence of ESKD (dialysis or kidney transplantation) or death ascertained using the Australian and New Zealand Dialysis and Transplant Registry and the Australian national death index. Analytical Approach: NDSS registrants were followed up from 2002 or date of registration until onset of ESKD, death, or December 31, 2013. The incidence of ESKD in type 1 diabetes was calculated only in those younger than 55 years. Results: Among 1,375,877 registrants between 2002 and 2013, a total of 9,977 experienced incident ESKD, representing an overall incidence of ESKD in people with diabetes of 10.0 (95% CI, 9.8-10.2) per 10,000 person-years. Among those with type 1 diabetes, the age-standardized annual incidence was stable during the study period. Among those with type 2 diabetes, the incidence increased in nonindigenous people (annual percentage change, 2.2%; 95% CI, 0.4%-4.1%) with the greatest increases in those younger than 50 and those older than 80 years. No significant change over time was observed in indigenous people, although the adjusted incident rate ratio for indigenous versus nonindigenous was 4.03 (95% CI, 3.68-4.41). Limitations: Lack of covariates such as comorbid conditions, medication use, measures of quality of care, and baseline kidney function. Conclusions: The age-standardized annual incidence of ESKD increased in Australia from 2002 to 2013 for nonindigenous people with type 2 diabetes but was stable for people with type 1 diabetes. Efforts to prevent the development of ESKD, especially among indigenous Australians and those with early-onset type 2 diabetes, are warranted.

Background: This cross-sectional study aimed to explore, among a sample of patients attending one of four Aboriginal Health Services (ACCHSs), the degree of concordance between self-report and medical records for whether screening for key healthcare items had ever been undertaken, or had been undertaken within the recommended timeframe. Methods: Across the four ACCHSs, a convenience sample of 109 patients was recruited. Patients completed a self-report computer survey assessing when they last had preventive care items undertaken at the service. ACCHS staff completed a medical record audit for matching items. The degree of concordance (i.e. the percentage of cases in which self-reports matched responses from the medical record) was calculated. Results: Concordance was relatively high for items including assessment of Body Mass Index and blood pressure, but was substantially lower for items including assessment of waist circumference, alcohol intake, physical activity, and diet. Conclusions: Reliance on either patient self-report or medical record data for assessing the level of preventive care service delivery by ACCHSs requires caution. Efforts to improve documentation of some preventive care delivery in medical records are needed. These findings are likely to also apply to patients in other general practice settings.

Statement of the problem: Self-care support provided by healthcare providers (HCPs) is critical to diabetes self-care. However, a number of barriers prevent HCPs from providing self-care support to people with diabetes. We explored attitudes towards, barriers and facilitators of the provision of diabetes self-care support among Ghanaian HCPs. Methods: Fourteen semi-structured interviews were conducted among HCPs recruited from three diabetes clinics in Tamale, Ghana. All interviews were digitally recorded and transcribed verbatim. Transcripts were coded and analysed thematically. Results: HCPs reported a sense of responsibility and urgency to provide self-care education to diabetes patients; while believing it was the patients¿ responsibility to self-care for their diabetes condition. Accordingly, HCPs perceived their role to be limited to information sharing rather than behaviour change interventions. Facilitators to the provision of self-care support included patients¿ motivation, and team work among healthcare professionals. Barriers that hindered self-care support included language barriers and poor inter-professional collaboration. Furthermore, HCPs discussed that they felt inadequately trained to provide self-care support. Healthcare-system-related barriers were inadequate office space, lack of professional development programmes, high patient numbers, inadequate staff numbers, inadequate health insurance and a lack of sufficient supplies and equipment in the hospital. Conclusion: HCPs attitudes were generally favourable towards supporting self-care, albeit with a focus on information provision rather than behaviour change. Training in effective strategies for providing self-care support are needed, and better use of the resources that are available.

Introduction and Aims: This study aimed to compare current and ex-smokers' sociodemographic and psychosocial characteristics, use of cessation aids and abrupt versus gradual quitting approaches. Design and Methods: A cross-sectional survey of financially disadvantaged adults attending a community service organisation was conducted in New South Wales, Australia, between February 2012 and December 2013. Sociodemographic and psychosocial factors, use of cessation aids and gradual versus abrupt quit approach were assessed. ¿2 tests and logistic regression compared characteristics of current and ex-smokers. Results: Of 905 individuals who completed the survey, 639 (71%) were current smokers and 107 (12%) were ex-smokers. Ex-smokers were older [odds ratio (OR)¿=¿1.03, 95% confidence interval (CI)¿=¿1.01, 1.05], had higher odds of being female (OR¿=¿1.67, 95% CI¿=¿1.06, 2.65), lower odds of being financially stressed (OR¿=¿0.87, 95% CI¿=¿0.76, 0.99), lower odds of anxiety and depression symptoms (OR¿=¿0.91, 95% CI¿=¿0.84, 0.98) and lower odds of having friends and family who were smokers (ORs ranged from 0.30¿0.43). Ex-smokers had lower odds of using cessation aids and higher odds of reporting abrupt quitting during their last quit attempt (OR¿=¿4.48, 95% CI¿=¿2.66, 7.54). Conclusions: Lower levels of disadvantage, less smoking in social networks, less use of cessation aids and abrupt (vs. gradual) quitting approaches were associated with being an ex-smoker. Lower use of evidence based methods to quit by disadvantaged ex-smokers requires further exploration. [Twyman L, Bonevski B, Paul C, Bryant J, West R, Siahpush M, D'este C, Oldmeadow C, Palazzi K. What factors are associated with abstinence amongst socioeconomically disadvantaged smokers? A cross-sectional survey of use of cessation aids and quitting approach. Drug Alcohol Rev 2017;00:000-000].

Due to fewer cancer services in rural locations, rural survivors may have unique unmet needs compared to urban survivors. This study compared among rural and urban haematological cancer survivors the most common ¿high/very high¿ unmet supportive care needs and the unmet need scores for five domains (information, financial concerns, access and continuity of care, relationships and emotional health). Survivors¿ socio-demographics, rurality, cancer history and psychological factors associated with each unmet need domain were also explored. A total of 1511 haematological cancer survivors were recruited from five Australian state cancer registries and 1417 (1145 urban, 272 rural) allowed extraction of their residential postcode from registry records. A questionnaire that contained the Survivor Unmet Needs Survey was mailed to survivors. Dealing with feeling tired was the most common ¿high/very high¿ unmet need for rural (15.2%) and urban (15.5%) survivors. The emotional health domain had the highest mean unmet need score for rural and urban survivors. Rurality was associated with a decreased unmet emotional health domain score whereas travelling for more than 1¿h to treatment was associated with increased unmet financial concerns and unmet access and continuity of care. Depression, anxiety and stress were associated with increased unmet need scores for all five domains. Unmet need domain scores generally did not differ by rurality. Travelling for more than 1¿h to treatment was associated with increased unmet need scores on two domains. Telemedicine and increased financial assistance with travel and accommodation may help those travelling long distances for treatment.

Objective: To describe the prevalence and change in prevalence of electronic nicotine delivery systems (ENDS) use in youth by country and combustible smoking status. Methods: Databases and the grey literature were systematically searched to December 2015. Studies describing the prevalence of ENDS use in the general population aged =20 years in a defined geographical region were included. Where multiple estimates were available within countries, prevalence estimates of ENDS use were pooled for each country separately. Results: Data from 27 publications (36 surveys) from 13 countries were included. The prevalence of ENDS ever use in 2013¿2015 among youth were highest in Poland (62.1%; 95%CI: 59.9-64.2%), and lowest in Italy (5.9%; 95%CI: 3.3-9.2%). Among non-smoking youth, the prevalence of ENDS ever use in 2013¿2015 varied, ranging from 4.2% (95%CI: 3.8-4.6%) in the US to 14.0% in New Zealand (95%CI: 12.7-15.4%). The prevalence of ENDS ever use among current tobacco smoking youth was the highest in Canada (71.9%, 95%CI: 70.9-72.8%) and lowest in Italy (29.9%, 95%CI: 18.5-42.5%). Between 2008 and 2015, ENDS ever use among youth increased in Poland, Korea, New Zealand and the US; decreased in Italy and Canada; and remained stable in the UK. Conclusions: There is considerable heterogeneity in ENDS use among youth globally across countries and also between current smokers and non-smokers. Implications for public health: Population-level survey data on ENDS use is needed to inform public health policy and messaging globally.

Objective: This study explored help-seeking behaviours, group identification, and perceived legitimacy of discrimination, and its potential relationship with perceived lung cancer stigma. Methods: Consecutive consenting adults (n¿=¿274) with a primary diagnosis of lung cancer within the previous 4¿months were recruited at 31 outpatient clinics in Australia. A self-report survey assessed help-seeking, group identification, perceived legitimacy of discrimination, and perceived lung cancer stigma. Results: Services providing assistance from health professionals (69.5%) and informational support (68.5%) were more frequently used than emotional-based support. Only a small proportion (2.6%) of participants were unlikely to seek help from anyone, with the most popular sources of help being the general practitioner (91.0%), and oncologist/treating clinician (81.3%). One-fifth (21.1%) indicated they identified with being a lung cancer patient, and most did not perceive discrimination against lung cancer patients. Higher perceived lung cancer stigma was significantly associated with greater perceived legitimacy of discrimination (P¿<¿0.001), but not help-seeking behaviours or group identification. Conclusions: The relationship between lung cancer stigma and perceived legitimacy of discrimination may guide initiatives to reduce stigma for patients. It is encouraging that perceived stigma did not appear to inhibit help-seeking behaviours. However, further research in this emerging field is needed to investigate patterns of perceived stigma and help-seeking over time to identify how and when to offer support services most appropriate to the needs of lung cancer patients.

Purpose: This study aimed to compare support persons of haematological cancer survivors living in rural and urban areas in regard to the type, prevalence and factors associated with reporting unmet needs. Methods: One thousand and four (792 urban and 193 rural) support persons of adults diagnosed with haematological cancer were recruited from five Australian state population-based cancer registries. Participants completed the Support Person Unmet Needs Survey (SPUNS) that assessed the level of unmet needs experienced over the past month across six domains. Results: Overall, 66% of support persons had at least one ¿moderate, high or very high¿ unmet need and 24% (n = 182) reported having multiple (i.e. 6 or more) ¿high/very high¿ unmet needs in the past month. There were no significant differences between rural and urban support persons in the prevalence of multiple unmet needs or mean total unmet needs scores. There were however significant differences in the types of ¿high/very high¿ unmet needs with support persons living in rural areas more likely to report finance-related unmet needs. Support persons who indicated they had difficulty paying bills had significantly higher odds of reporting multiple ¿high/very high¿ unmet needs. Conclusions: This is the first large, population-based study to compare the unmet needs of support persons of haematological cancer survivors living in rural and urban areas. Findings confirm previous evidence that supporting a person diagnosed with haematological cancer correlates with a high level of unmet needs and highlight the importance of developing systemic strategies for assisting support persons, especially in regard to making financial assistance and travel subsidies known and readily accessible to those living in rural areas.

Objectives: There remains a need to identify effective smoking cessation interventions in severely disadvantaged populations. This trial aimed to examine the effectiveness of an intervention (Call it Quits) developed to promote smoking cessation and delivered by community social service case-workers. Methods: Call it Quits was a pragmatic, parallel randomised trial of a case-worker delivered smoking cessation intervention conducted in a non-government community social service organisation in New South Wales (NSW), Australia. Adult smokers requiring financial assistance were randomly assigned to the five-session Call it Quits intervention or usual care control group. Of the 618 eligible individuals, 300 were randomised to the intervention group, of whom 187 (62%) consented and 318 were randomised to the control group, of whom 244 (77%) consented, resulting in 431 participants. The primary outcome measure was self-reported continuous abstinence up to 6-month follow-up with biochemical verification. Primary analysis was performed using all the available data from participants under the assumption the data is missing completely at random, followed by sensitivity analyses. Results: No statistically significant differences in the primary outcome were found (1.4% in the control group versus 1.0% in the intervention group, OR = 0.77, p = 0.828). Conclusions: A multi-component smoking cessation intervention delivering motivational interviewing-based counselling and free NRT by a trained case-worker within a community social service setting was not effective at achieving abstinence in a highly disadvantaged sample of smokers but increased attempts to stop and led to a reduction in number of cigarettes smoked daily.

Purpose: The majority of research on psychological outcomes for cancer patients has focussed on the role of individual characteristics, and disease and treatment factors. There has been very little exploration of the potential contribution of the treatment clinic to these outcomes. This study explored whether there is variation among clinics in cancer patients¿ psychological outcomes. Methods: Cancer outpatients were recruited from 22 medical oncology and haematology clinics in Australia. Participants completed a pen and paper survey including the Hospital Anxiety and Depression Scale (HADS), as well as sociodemographic, disease and treatment characteristics. Results: Of those eligible to participate, 4233 (82%) consented and 2811 (81% of consenters) returned the completed survey. There was no statistically significant variation in HADS depression scores across clinics. Some difference in anxiety scores derived from the HADS questionnaire between clinics (p = 0.03) was found with the percentage of between-clinic variation estimated to be 1.11%. However, once all demographic, disease and treatment predictors were adjusted for there was no statistical differences between clinics (percent of between-clinic variation = 0.53%; p = 0.1415). Conclusions: Psychological outcomes were not found to vary between clinics. Other sources of variation including patient characteristics may over-ride between-clinic variability, if it exists.

OBJECTIVES: To investigate perceived stigma and its possible associations with treatment expectations and preferences in newly diagnosed patients with lung cancer. SAMPLE & SETTING: 274 patients with lung cancer diagnosed in the previous four months at oncology and respiratory outpatient clinics in Australia. METHODS & VARIABLES: Participants completed a self-report survey about perceived lung cancer stigma and treatment expectations and preferences. RESULTS: A mean perceived stigma score of 52 of a possible 124 was reported, which is lower than scores reported in other studies using the same measure; the current study determined that perceived lung cancer stigma was observed less frequently. Significantly higher scores were observed in participants who were younger or who had a history of smoking. Perceived lung cancer stigma was significantly related to treatment expectations. No relationship was found between perceived lung cancer stigma and treatment preferences. IMPLICATIONS FOR NURSING: Healthcare providers are in a key position to provide support and communicate empathetically with patients to minimize potential stigma experiences.

Biobanking consent processes should accord with patients' preferences and be offered in a consistent and systematic manner. However, these aims can be difficult to achieve under healthcare professionals' (HCPs) time-constrained workflows, resulting in low participation rates. This current perspective provides a brief overview of HCP involvement in consent and reports new data on participant attrition at each step of the biobanking consent process as experienced by 113 patients at an Australian tertiary cancer centre. To determine attrition in this HCP-driven consent process, we reviewed medical records for the following events: inclusion of biobanking consent forms; visible patient and HCP signatures; consent status selected (decline or accept) and specimen registration with local biobank. Accessible medical records revealed the following data: 75 of 85 records included viewable forms; 22 of 85 records included patient and 19 of 85 included HCP signatures; 15 of 85 records included signed and completed forms and 3 of 85 had samples banked with annotated clinical data. We compared these data with self-reported experiences of being approached to participate by HCPs. Of the 15 participants (17.6%) who successfully completed consent, only five could recall being asked and providing consent. The low enrolment rate is a considerable lost opportunity because most patients (59%) who were not asked to participate indicated they would have consented if asked. Furthermore, in comparing self-reported experiences with medical records, we believe cancer patients' preferences for participation are mismatched with actual biobanking enrolment, which has considerable attrition at each step in the consent process.

Aim: Continued smoking in patients diagnosed with cancer affects treatment outcomes and overall survival. With national surveys of Australian medical oncologists (MO) and radiation oncologists (RO) we sought to determine current clinical practices, preferences and barriers in providing patient smoking cessation support. Methods: Oncologist members of the Medical Oncology Group of Australia (n¿=¿452) and Trans-Tasman Radiation Oncology Group (n¿=¿230) were invited to participate in a multiple choice survey exploring smoking cessation practices and beliefs. Results: The survey response rate was 43%. At first consultations more than 90% of MO and RO regularly asked patients if they smoke or use tobacco products, closely followed by documentation of duration of smoking history and current level of consumption. Less common was asking the patient if they intended to quit (MO 63%, RO 53%) and advising cessation (MO 70%, RO 72%). Less than 50% of oncologists regularly asked about current smoking in follow-up consultations. Although a range of referral options for smoking cessation care were used by oncologists, only 2% of MO and 3% of RO actively managed the patients¿ smoking cessation themselves and this was the least preferred option. The majority believed they require more training in cessation interventions (67% MO, 57% RO) and cited multiple additional barriers to providing cessation care. Conclusions: Oncologists strongly prefer smoking cessation interventions to be managed by other health workers. A collaborative approach with other health professionals is needed to aid the provision of comprehensive smoking cessation care tailored to patients with cancer.

Background: In Australia, rural and remote communities have high rates of diabetes-related death and hospitalisation. General practitioners (GPs) play a major role in diabetes detection and management. Education of GPs could optimise diabetes management and improve patient outcomes at a population level. The study aimed to describe the uptake of a continuing medical education intervention for rural GPs and its impact on the viability of a cluster randomised controlled trial of the effects of continuing medical education on whole-town diabetes monitoring and control. Method: Trial design: the cluster randomised controlled trial involved towns as the unit of allocation and analysis with outcomes assessed by de-identified pathology data (not reported here). The intervention programme consisted of an online active learning module, direct electronic access to specialist advice and performance feedback. Multiple rounds of invitation were used to engage GPs with the online intervention content. Evidence-based strategies (e.g. pre-notification, rewards, incentives) were incorporated into the invitations to enrol in the programme. Recruitment to the programme was electronically monitored through the hosting software package during the study intervention period. Results: Eleven matched pairs of towns were included in the study. There were 146 GPs in the 11 intervention towns, of whom 34 (23.3%) enrolled in the programme, and 8 (5.5%) completed the online learning module. No town had more than 10% of the resident GPs complete the learning module. There were no contacts made by GPs regarding requests for specialist advice. Consequently, the trial was discontinued. Conclusion: There is an ongoing need to engage primary care physicians in improving diabetes monitoring and management in rural areas. Online training options, while notionally attractive and accessible, are not likely to have high levels of uptake, even when evidence-based recruitment strategies are implemented. Trial registration: Australian New Zealand Clinical Trials Registry, identifier: ACTRN12611000553976. Retrospectively registered on 31 May 2011.

The stigma of non-communicable respiratory diseases (NCRDs), whether perceived or otherwise, can be an important element of a patient's experience of his/her illness and a contributing factor to poor psychosocial, treatment and clinical outcomes. This systematic review examines the evidence regarding the associations between stigma-related experiences and patient outcomes, comparing findings across a range of common NCRDs. Electronic databases and manual searches were conducted to identify original quantitative research published to December 2015. Articles focussing on adult patient samples diagnosed with asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, lung cancer or mesothelioma, and included a measurement of stigma-related experience (i.e. perceived stigma, shame, blame or guilt), were eligible for inclusion. Included articles were described for study characteristics, outcome scores, correlates between stigma-related experiences and patient outcomes and methodological rigor. Twenty-five articles were eligible for this review, with most (n = 20) related to lung cancer. No articles for cystic fibrosis were identified. Twenty unique scales were used, with low to moderate stigma-related experiences reported overall. The stigma-related experiences significantly correlated with all six patient-related domains explored (psychosocial, quality of life, behavioral, physical, treatment and work), which were investigated more widely in COPD and lung cancer samples. No studies adequately met all criteria for methodological rigor. The inter-connectedness of stigma-related experiences to other aspects of patient experiences highlight that an integrated approach is needed to address this important issue. Future studies should adopt more rigorous methodology, including streamlining measures, to provide robust evidence.

Objectives: To determine the proportion of Aboriginal Controlled Community Health Service (ACCHS) patients tested according to three national diabetes testing guidelines; to investigate whether specific patient characteristics were associated with being tested. Design, setting and participants: Cross-sectional study of 20 978 adult Indigenous Australians not diagnosed with diabetes attending 18 ACCHSs across Australia. De-identified electronic whole service data for July 2010 e June 2013 were analysed. Main outcomes measures: Proportions of patients appropriately screened for diabetes according to three national guidelines for Indigenous Australians: National Health and Medical Research Council (at least once every 3 years for those aged 35 years or more); Royal Australian College of General Practitioners and Diabetes Australia (at least once every 3 years for those aged 18 years or more); National Aboriginal Community Controlled Health Organisation (annual testing of those aged 18 years or more at high risk of diabetes). Results: 74% (95% CI, 74¿75%) of Indigenous adults and 77% (95% CI, 76¿78%) of 10 760 patients aged 35 or more had been tested for diabetes at least once in the past 3 years. The proportions of patients tested varied between services (range: all adults, 16¿90%; people aged 35 years or more, 23¿92%). 18% (95% CI, 18¿19%) of patients aged 18 or more were tested for diabetes annually (range, 0.1¿43%). Patients were less likely to be tested if they were under 50 years of age, were transient rather than current patients of the ACCHS, or attended the service less frequently. Conclusions: Some services achieved high rates of 3-yearly testing of Indigenous Australians for diabetes, but recommended rates of annual testing were rarely attained. ACCHSs may need assistance to achieve desirable levels of testing.

Purpose: This study aimed to explore the dyadic relationships between unmet need, depression, and anxiety in people diagnosed with haematological cancer and their support persons. Methods: Adult survivors (18¿years+) who had been diagnosed with a haematological cancer were recruited to a cross-sectional mailed survey via five state cancer registries in Australia. Participating survivors invited a support person to also complete a survey. Structural equation modelling was used to explore the relationships among survivor and support person self-reported depression, anxiety, and unmet needs. Results: Of the 4299 eligible haematological cancer survivors contacted by the registries, 1511 (35%) returned a completed survey as did 1004 support persons. There were 787 dyads with complete data. After adjusting for age, gender, rurality, cancer type, and whether the support person was a relative, positive correlations were found between survivor and support person scores for depression (p¿=¿0.0029) and unmet needs (p¿<¿0.001), but not anxiety scores (p¿=¿0.075). Survivor unmet needs were significantly related to support person depression (p¿=¿0.0036). Support person unmet needs were significantly related to a higher depression score for survivors (p¿=¿0.0067). Greater support person unmet needs were significantly related to a higher anxiety score for survivors (p¿=¿0.0083). Survivor unmet needs did not have a significant relationship to support person anxiety (p¿=¿0.78). Conclusion: Unmet needs may mediate the interdependence of psychosocial experiences for survivors and support persons, although a longitudinal study is required to confirm causality. Addressing unmet needs may be a potential target for improving outcomes for both groups.

Issue addressed Universities represent important settings for the implementation of public health initiatives such as smoke-free policies. The study aimed to assess staff and student attitudes towards policy enforcement and compliance as well as the acceptability of the provision of cessation support in this setting. Methods A cross-sectional study was conducted following the introduction of a designated-areas partial smoke-free policy at two campuses of one Australian university in 2014. Staff (n=533) and students (n=3060) completed separate online surveys assessing attitudes towards smoke-free policy enforcement and compliance, and acceptability of university-provided cessation support. Results Students held significantly stronger beliefs than staff that the smoke-free policy required staff enforcement (69% vs 60%) and violation penalties (67% vs 60%; both P's <0.01); however, most staff (66%) did not believe enforcement was part of their role. Only 55% of student smokers were aware that the university provided any cessation support. 'Free or cheap nicotine replacement therapy' (65%) and 'free stop smoking counselling service' (60%) were the most popular strategies student smokers thought the university should provide. Conclusions University staff and students hold conflicting views over the need for policy enforcement and who is responsible for enforcement roles. Students view the university as an acceptable setting for the provision of smoking cessation support. So what? Where staff are expected to enforce smoke-free policies, specific education and training should be provided. Ongoing monitoring of compliance and enforcement behaviour appears necessary to avoid the pervasive kind of non-compliance to smoke-free policies that have been seen in other settings.

Purpose: There are few recent longitudinal studies investigating the quality of life of colorectal cancer patients in the early years following diagnosis. This study aimed to (i) compare the health status of people with colorectal cancer less than 1¿year from diagnosis with health status 1¿year later and (ii) determine the characteristics associated with a change in overall health status. Methods: The study was conducted as part of a larger trial. Participants (n = 539) were identified via the Victorian Cancer Registry in Australia, completed a computer-assisted baseline telephone interview (including the EQ-5D-3L) within 6¿12¿months of diagnosis, and mailed a survey 12¿months later. Results: At baseline, the majority of participants (55¿%) reported some problems, including difficulties in usual activities (26¿%), pain or discomfort (25¿%), anxiety or depression (23¿%) and mobility issues (15¿%). Sixty-nine percent had either an unchanged or increased health utility score from baseline to follow-up. The largest proportion reporting an increase in problems between baseline and follow-up related to pain or discomfort (18¿%). While visual analogue scale scores indicated a significantly improved health state over time overall, 32¿% reported a decreased health utility score from baseline to follow-up. Those aged over 80¿years were more likely to report a decreased health utility score compared to 60¿80-year-olds. Conclusions: A sizeable minority of patients experience ongoing problems in their daily lives and should be offered assistance in overcoming disabilities and returning to best possible functioning, particularly older patients who appear to be vulnerable to poor outcomes.

Background: Networks of clinical experts are increasingly being implemented as a strategy to improve health care processes and outcomes and achieve change in the health system. Few are ever formally evaluated and, when this is done, not all networks are equally successful in their efforts. There is a need to formatively assess the strategic and operational management and leadership of networks to identify where functioning could be improved to maximise impact. This paper outlines the development and psychometric evaluation of an Internet survey to measure features of clinical networks and provides descriptive results from a sample of members of 19 diverse clinical networks responsible for evidence-based quality improvement across a large geographical region. Methods: Instrument development was based on: a review of published and grey literature; a qualitative study of clinical network members; a program logic framework; and consultation with stakeholders. The resulting domain structure was validated for a sample of 592 clinical network members using confirmatory factor analysis. Scale reliability was assessed using Cronbach's alpha. A summary score was calculated for each domain and aggregate level means and ranges are reported. Results: The instrument was shown to have good construct validity across seven domains as demonstrated by a high level of internal consistency, and all Cronbach's a coefficients were equal to or above 0.75. In the survey sample of network members there was strong reported commitment and belief in network-led quality improvement initiatives, which were perceived to have improved quality of care (72.8 %) and patient outcomes (63.2 %). Network managers were perceived to be effective leaders and clinical co-chairs were perceived as champions for change. Perceived external support had the lowest summary score across the seven domains. Conclusions: This survey, which has good construct validity and internal reliability, provides a valid instrument to use in future research related to clinical networks. The survey will be of use to health service managers to identify strengths and areas where networks can be improved to increase effectiveness and impact on quality of care and patient outcomes. Equally, the survey could be adapted for use in the assessment of other types of networks.

Background: Obstructive sleep apnoea (OSA) affects up to 28 % of the adult population in Western countries. The detection and management of OSA by general practitioners (GPs) can be poor. The study aimed to examine what influence enhanced invitations had on uptake of on-line learning modules for OSA by GPs, and whether recent referrals of patients to sleep specialists influenced uptake. Methods: Practicing GPs in regional Australia were identified and randomised to receive either an enhanced or standard invitation letter to a new on-line education module for OSA. The enhanced letter included indication that the module was eligible for professional accreditation and described the prevalence and burden of sleep disorders. Some included extra emphasis if the GP had recently referred a patient for diagnostic investigation of OSA. Two reminder letters were sent. Results: Of 796 eligible GPs who received the letters, sixteen (2 %) accessed the website and four completed the modules over the four-month study period. GPs who received an enhanced invitation letter were not significantly more likely to access the website compared to GPs who received the standard invitation letter. Recent referral of a patient for diagnostic investigation was also not a significant factor in influencing use of the module. Conclusion: GP interest in on-line education about OSA appears low, and emphasis of relevant recent past patient(s) and the opportunity for professional education points was not successful in increasing engagement. There is a need to identify effective approaches to improving the detection and management of OSA in general practice.

Objective: To indicate levels of monitoring of type 2 diabetes in rural and regional Australia by examining patterns of glycated haemoglobin (HbA1c) and blood lipid testing. Design and Setting: Retrospective analysis of pathology services data from twenty regional and rural towns in eastern Australia over 24 months. Participants: Of 13 105 individuals who had either a single HbA1c result =7.0% (53 mmol mol-1); or two or more HbA1c tests within the study period. Main outcome measures: Frequency of testing of HbA1c and blood lipids (cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglycerides) were compared with guideline recommendations. Results: About 58.3% of patients did not have the recommended 6-monthly HbA1c tests and 30.6% did not have annual lipid testing. For those who did not receive tests at the recommended interval, the mean between-test interval was 10.5 months (95% CI = 7.5¿13.5) rather than 6 months for HbA1c testing; and 15.7 (95% CI = 13.3¿18.1) months rather than annually for blood lipids. For those with at least one out-of-range test result, 77% of patients failed to receive a follow-up HbA1c test and 86.5% failed to receive a follow-up blood lipid test within the recommended 3 months. Patients less than 50 years of age, living in a more remote area and with poor diabetes control were less likely to have testing at the recommended intervals (P < 0.0001). Conclusions: Although poor diabetes testing is not limited to rural areas, more intensive diabetes monitoring is likely to be needed for patients living in non-metropolitan areas, particularly for some subgroups.

Purpose: The financial impact of cancer diagnosis and treatment can be considerable to individuals and their households, leading to changes in treatment decision making. This study aimed to quantify effects on income and employment; describe how cost-related factors influence treatment decision making and need for financial assistance; and to identify patient sociodemographic factors associated with treatment decision making, use of financial assistance and financial effects. Methods: A cross-sectional self-report questionnaire was administered to oncology outpatients from two hospitals in Australia: one regional and one metropolitan. Results: Of 255 participants, 67¿% indicated a change in employment and 63¿% of those reported reduced household income since their diagnosis. Travel (15¿%), loss of income (14¿%) and cost of treatments (11¿%) were commonly cited factors influencing treatment decision making. Seventy-four percent of participants reported that they did not access financial assistance, with more than a third (37¿%) of those being unaware that financial assistance was available. Being currently not employed and more recent diagnosis were associated with a reduced income since diagnosis. After adjusting for employment status and age, patients with private health insurance had higher odds of reporting that financial factors had influenced treatment decision making (OR¿=¿2.5). Conclusion: Unemployment is a major driver of the financial impact of cancer. The costs of treatment may be particularly challenging for those with private health insurance who are more likely to be treated in the private health system where out-of-pocket costs are greater. Improved access to financial assistance is required to better avoid potential inequities.

In Australia and New Zealand, population groups who experience social disadvantage smoke at much higher rates than the general population. As there are limited data specific to these groups regarding the success of nicotine replacement therapy for smoking cessation, this commentary will provide an overview of the relevant international literature supplemented with observational data relevant to the policy contexts in Australia and New Zealand. [Paul C, Wolfenden L, Tzelepis F, Yoong S, Bowman J, Wye P, Sherwood E, Rose S, Wiggers J. Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need? Drug Alcohol Rev 2016;35:785¿789].

Objectives: To identify specific actions for patient-centred quality improvement in chronic disease outpatient settings, this study identified patients' general and specific preferences among a comprehensive suite of initiatives for change.Design and setting: A cross-sectional survey was conducted in three hospital-based clinics specializing in oncology, neurology and cardiology care located in New South Wales, Australia.Participants and measures: Adult English-speaking outpatients completed the touch-screen Consumer Preferences Survey in waiting rooms or treatment areas. Participants selected up to 23 general initiatives that would improve their experience. Using adaptive branching, participants could select an additional 110 detailed initiatives and complete a relative prioritization exercise.Results: A total of 541 individuals completed the survey (71.1% consent, 73.1% completion). Commonly selected general initiatives, presented in order of decreasing priority (along with sample proportion), included: improved parking (60.3%), up-to-date information provision (15.0%), ease of clinic contact (12.9%), access to information at home (12.8%), convenient appointment scheduling (14.2%), reduced wait-times (19.8%) and information on medical emergencies (11.1%). To address these general initiatives, 40 detailed initiatives were selected by respondents.Conclusions: Initiatives targeting service accessibility and information provision, such as parking and up-to-date information on patient prognoses and progress, were commonly selected and perceived to be of relatively greater priority. Specific preferences included the need for clinics to provide patient-designated parking in close proximity to the clinic, information on treatment progress and test results (potentially in the form of designated brief appointments or via telehealth) and comprehensive and trustworthy lists of information sources to access at home.

Obstructive sleep apnea affects 20% of the adult population. Weight control is considered the best non-medical means of managing the condition, therefore improving nutritional knowledge in individuals may be an appropriate strategy. This study aimed to describe the relationship between nutritional knowledge and: (i) sleep disorder severity; (ii) body mass index; and (iii) demographic characteristics in persons suspected of obstructive sleep apnea. Nutrition knowledge scores were also compared with the general population. Consecutive newly-referred patients attending the sleep laboratory for diagnostic polysomnography were invited to participate. Those who consented (n = 97) were asked to complete a touchscreen survey. Apnea-hypopnea index to measure sleep disorder severity and anthropometric measurements were obtained from the clinic. A quarter of participants were diagnosed with severe obstructive sleep apnea; and a majority (88%) were classed as being overweight or obese. The overall mean nutrition knowledge score was 58.4 ± 11.6 (out of 93). Nutrition knowledge was not associated with sleep disorder severity, body mass index or gender. The only significant difference detected was in relation to age, with older (=35 years) participants demonstrating greater knowledge in the 'food choices' domain compared with their younger counterparts (18-34 years; P < 0.030). Knowledge scores were similar to the general population. The findings suggest that nutrition knowledge alone is not an important target for weight control interventions for people with obstructive sleep apnea. However, given the complexities of sleep disorders, it may complement other strategies.

Purpose: To explore outcomes of psychological distress, including anxiety, depression and stress, amongst adult haematological cancer survivors, with a specific focus on potential differences between rural and urban survivors. Methods: One thousand four hundred fourteen urban and rural survivors were recruited from five Australian population-based cancer registries and completed a self-report pen-and-paper survey on their well-being, including the Depression Anxiety and Stress Scale 21-item version. Results: A quarter of survivors were identified as reporting above normal levels of anxiety and depression, respectively, and almost one fifth (17¿%) reported above normal levels of stress. There were no statistically significant differences in the percentage of rural and urban survivors reporting above normal levels of anxiety, depression, or stress. Survivors who had experienced financial burden due to their cancer or were of middle age had higher odds of reporting multiple domains of psychological distress, compared to their counterparts. Conclusions: Haematological cancer survivors diagnosed during middle age or who experience increased financial burden as a result of their diagnosis may require additional support and care with regards to psychological distress.

Purpose This cross-sectional study assessed the association between oncology outpatients' quality improvement preferences and health-related quality of life (HRQoL). Implementation of specific initiatives preferred by patients with lower HRQoL may be a strategic approach to enhancing care for potentially vulnerable patients. Methods English-speaking adults were recruited from five outpatient chemotherapy clinics located in New South Wales, Australia. Using touch screen devices, participants selected up to 25 initiatives that would improve their experiences and completed the Functional Assessment of Cancer Therapy-General (FACT-G) survey. The logistic odds of selecting an initiative according to FACT-G scores were calculated to determine whether preferences were associated with HRQoL after controlling for potential confounders. Results Of the 411 eligible outpatients approached to participate, 263 (64%) completed surveys. Commonly selected initiatives were up-to-date information on treatment and condition progress (19.8%), access to or information on financial assistance (18.3%), and reduced clinic wait times (17.5%). For those with relatively lower FACT-G scores, the adjusted odds of selecting five initiatives illustrated an increasing trend: convenient appointment scheduling systems (+23% [P =.002]), reduced wait times (+15% [P =.01]), information on medical emergencies (+14% [P =.04]), access to or information on financial assistance (+15% [P =.009]), help to maintain daily living activities (+18% [P =.007]). Conclusion Two areas of improvement were commonly selected: easily accessible health services and information and support for self-management. Although the results suggest an association between a few quality improvement preferences and HRQoL, a wider spectrum of patient characteristics must be considered when targeting quality improvement to patient subgroups.

Background The cost of medicines may prove prohibitive for some cancer patients, potentially reducing the ability of a health system to fully deliver best practice care. Objective To identify nonuse or nonpurchase of cancer-related medicines due to cost, and to describe the perceived financial burden of such medicines and associated patient characteristics. Methods A cross-sectional pen- And-paper questionnaire was completed by oncology outpatients at 2 hospitals in Australia; 1 in regional New South Wales and 1 in metropolitan Victoria. Results Almost 1 in 10 study participants had used over- The-counter medicines rather than prescribed medicines for cancer and obtained some but not all of the medicines prescribed in relation to their cancer. 63% of the sample reported some level of financial burden associated with obtaining these medicines, with 34% reporting a moderate or heavy financial burden. 11.8% reported using alternatives to prescribed medicines. People reporting reduced income after being diagnosed with cancer had almost 4 times the odds (OR, 3.73; 95% CI, 1.1-12.1) of reporting a heavy or extreme financial burden associated with prescribed medicines for cancer. Limitations Study response rate, narrow survey population, self-reported survey used. Conclusion This study identifies that a number of cancer patients, especially those with a reduced income after their diagnosis, experience financial burden associated with the purchase of medicines and that some go as far as to not use or to not purchase medicines. It seems likely that limiting the cost of medicines for cancer may improve patient ability to fully participate in the intended treatment. Funding Cancer Council NSW, National Health and Medical Research Council, and Hunter Medical Research Institute, Australia.

Introduction: Electronic cigarette (e-cigarette) awareness, trial of e-cigarettes in the past 12 months, source and perceptions of safety and effectiveness was assessed within a disadvantaged sample of adult Australian smokers receiving welfare aid. Methods: A cross-sectional survey was administered to clients who smoke at two community service organizations in New South Wales, Australia from October 2013 to July 2014. E-cigarette awareness, trial in past 12 months, sources of e-cigarettes and perceptions of the safety and effectiveness of e-cigarettes to help people quit were assessed along with sociodemographic and smoking-related variables. Results: In total, 369 participants completed the survey (77% response rate). Awareness and trial of e-cigarettes were reported by 77% (n = 283) and 35% (n = 103) of the sample, respectively. E-cigarettes were most commonly obtained from friends/strangers followed by tobacco shops (tobacconists). Trying e-cigarettes in the past 12 months was significantly associated with positive perceptions of their safety (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1, 3.1) and effectiveness (OR = 1.9, 95% CI = 1.1, 3.2). Motivation to quit tobacco smoking was also significantly positively associated with positive perceptions of e-cigarette safety (OR = 1.2, 95% CI = 1.1, 1.4) and effectiveness (OR = 1.2, 95% CI = 1.0, 1.3). Conclusions: Rates of awareness and trial of e-cigarettes within a disadvantaged sample of Australian smokers are comparable to rates found within representative samples of the general Australian population. Previously trying e-cigarettes and higher levels of motivation to quit were associated with more positive perceptions of e-cigarette safety and effectiveness. Implications: This study demonstrates that socioeconomically disadvantaged smokers are aware of and accessing e-cigarettes in a country with relatively high restrictions covering e-cigarette sale and use.

Objective: To describe self-reported inability to access health care and factors associated with lack of access among a socioeconomically disadvantaged group. Method: A cross-sectional survey with 906 adult clients of a large community welfare agency in New South Wales. Clients attending the service for emergency assistance completed a touchscreen survey. Results: Inability to access health care in the prior year was reported by more than one-third of the sample (38%), compared to the 5% found for the general population. Dentists (47%), specialists (43%) or GPs (29%) were the least accessible types of health care. The main reason for inability to access health care was cost, accounting for 60% of responses. Almost half (47%) the sample reported delayed or non-use of medicines due to cost. Increasing financial stress was associated with increased inability to access GP or specialist care, medicines and imaging. Higher anxiety scores were associated with inability to access health care, and with cost-related inability to access medicines and imaging. Conclusion: For disadvantaged groups, cost-related barriers to accessing care are prominent and are disproportionately high - particularly regarding dentistry, specialist and GP care. Implications: Improvements in health outcomes for disadvantaged groups are likely to require strategies to reduce cost-related barriers to health care.

Background: Tobacco use and heavy alcohol consumption occur more frequently in socioeconomically disadvantaged groups. Little is known about the sociodemographic and psychosocial factors associated with use of alcohol and tobacco in disadvantaged groups in comparison to low-risk users. Objectives: This study aimed to compare the characteristics of low-risk users with: disadvantaged smokers only; disadvantaged heavy drinkers only; and disadvantaged concurrent smokers and heavy drinkers. Methods: A cross-sectional survey of socioeconomically disadvantaged adult clients attending a community welfare agency assessed tobacco use, alcohol use, demographic, and psychosocial variables. Multivariable analysis using multinomial logistic regression was carried out. Results: The sample consisted of 835 participants; 40% (n = 331) were concurrent users, 31% were smokers only (n = 252), 11% were heavy drinkers only (n = 93), and 18% were low-risk users (n = 149). Compared with those who neither smoked nor consumed alcohol heavily, concurrent users were more likely to be younger, have only some contact with family, have more friends and family who were smokers, have no fixed home address, live alone, and have higher levels of financial stress. Most of these factors were shared by individuals who were smokers only. Factors associated with heavy drinkers only were frequent contact with family and having more friends and family who were smokers. Conclusion: Among those Australians who suffer severe economic hardship, being a concurrent smoker and heavy drinker appears to be associated with more isolated living conditions and financial stress but some contact with family.

Television advertisements, packaging regulations and health warning labels (HWLs) are designed to communicate anti-smoking messages to large number of smokers. However, only a few studies have examined how high smoking prevalence groups respond to these warnings. This study explored how socioeconomically disadvantaged smokers engage with health risk and cessation benefit messages. Six focus groups were conducted over September 2012-April 2013 with adult clients of welfare organizations in regional New South Wales, Australia who were current smokers (n = 51). Participants discussed HWLs, plain packaging and anti-smoking television advertisements. Discussions were audio-taped, transcribed verbatim and analysed using thematic analysis. Highly emotive warnings delivering messages of negative health effects were most likely to capture the attention of the study participants; however, these warning messages did not prompt quit attempts and participants were sceptical about the effectiveness of cessation programmes such as telephone quitlines. Active avoidance of health warning messages was common, and many expressed false and self-exempting beliefs towards the harms of tobacco. Careful consideration of message content and medium is required to communicate the anti-smoking message to disadvantaged smokers who consider themselves desensitized to warnings. Health communication strategies should continue to address false beliefs about smoking and educate on cessation services that are currently underutilized.

© 2015 Grady et al. Background: Emergency department staff play a crucial role in the triage of stroke patients and therefore the capacity to deliver time-dependent treatments such as tissue Plasminogen Activator. This study aimed to identify among emergency physicians, (1) rates of agreement with evidence supporting tissue Plasminogen Activator use in acute stroke care; and (2) individual and hospital factors associated with high agreement with evidence supporting tissue Plasminogen Activator use. Methods: Australian fellows and trainees of the Australasian College for Emergency Medicine were invited to complete an online cross-sectional survey assessing perceptions of tissue Plasminogen Activator use in acute stroke. Demographic and hospital characteristics were also collected. Results: 429 Australasian College for Emergency Medicine members responded (13% response rate). Almost half (47.2%) did not agree with any statements regarding the benefits of tissue Plasminogen Activator use for acute stroke. Perceived routine administration of tissue Plasminogen Activator by the head of respondents' emergency department was significantly associated with high agreement with the evidence supporting tissue Plasminogen Activator use in acute stroke. Conclusions: Agreement with evidence supporting tissue Plasminogen Activator use in acute stroke is not high among responding Australian emergency physicians. In order for tissue Plasminogen Activator treatment to become widely accepted and adopted in emergency settings, beliefs and attitudes towards treatment need to be in accordance with clinical practice guidelines.

Health utilization and need assessment data suggest there is considerable variation in access to outpatient specialist care. However, it is unclear if the types of barriers experienced are specific to chronic disease groups or experienced universally. This systematic review provides a detailed summary of common and unique barriers experienced by chronic disease groups when accessing and receiving care, and a synthesized list of possible health service initiatives to improve equitable delivery of optimal care in high-income countries. Quantitative articles describing barriers to specialist outpatient services were retrieved from CINAHL, MEDLINE, Embase, and PyscINFO. To be eligible for review, studies: were published from 2002 to May 2014; included samples with cancer, diabetes mellitus, osteoporosis, arthritis, ischaemic heart disease, stroke, asthma, chronic pulmonary disorder (COPD) or depression; and, were conducted in high-income countries. Using a previously validated model of access (Penchansky and Thomas' model of fit), barriers were grouped according to five overarching domains and defined in more detail using 33 medical subject headings. Results from reviewed articles, including the scope and frequency of reported barriers, are conceptualized using thematic analysis and framed as possible health service initiatives. A total of 3181 unique records were screened for eligibility, of which 74 studies were included in final analysis. The largest proportion of studies reported acceptability barriers (75.7 %), of which demographic disparities (44.6 %) were reported across all diseases. Other frequently reported barriers included inadequate need assessment (25.7 %), information provision (32.4 %), or health communication (20 %). Unique barriers were identified for oncology, mental health, and COPD samples. Based on the scope, frequency and measurement of reported barriers, eight key themes with associated implications for health services are presented. Examples include: common accommodation and accessibility barriers caused on service organization or physical structure, such as parking and appointment scheduling; common barriers created by poor coordination of care within the healthcare team; and unique barriers resulting from inadequate need assessment and referral practices. Consideration of barriers, across and within chronic diseases, suggests a number of specific initiatives are likely to improve the delivery of patient-centered care and increase equity in access to high-quality health services.

Issues addressed The National Bowel Cancer Screening Program (NBCSP) was introduced in Australia in 2006, offering free immunochemical Faecal Occult Blood Test (FOBT) to persons aged 50, 55 or 65. The study aimed to examine the prevalence of self-reported screening for colorectal cancer (CRC) using the FOBT and factors associated with not having an FOBT. Methods A cross-sectional study of Australian general practice patients aged 50 and over with no personal history of CRC completed a health risk survey while waiting for scheduled appointments between November 2010 and November 2011. Results A total of 5671 patients from 12 practices were approached to participate. Of the 4707 eligible patients (adults attending for care who understood English and were capable of providing informed consent), 4062 (86%) consented to participate, with 2269 eligible to complete the FOBT items. Approximately half (52%) of participants reported ever having an FOBT. More than one-third (39.7%) of the sample reported having an FOBT in the prior three years. Those who recalled receiving a mailed kit as part of the NBCSP were five times more likely to report being screened. Those less likely to report screening were aged 50-59 years, were female and had been diagnosed with a form of cancer other than CRC. Conclusions There is justification for the extension of the NBCSP to ensure a majority of the age-appropriate population is screened for CRC. So what? Further work is needed to identify whether high rates of screening are achievable using the mailed-kit approach, and how to increase participation by females, those aged 50-69 years and those diagnosed with other cancers.

BACKGROUND The Institute of Medicine (IOM) recommended 6 objectives for achieving patient-centered care. However, most patient-reported outcome measures developed with cancer populations fail to address all 6 patient-centeredness dimensions. The Quality of Patient-Centered Cancer Care (QPCCC) measure was developed on the basis of IOM recommendations, and the measure's validity, reliability, and floor and ceiling effects were examined. METHODS The development of the QPCCC measure included interviews with hematological cancer survivors and feedback from hematologists and cancer patients. To evaluate the measure's psychometric properties, hematological cancer survivors were identified via 2 cancer registries and were mailed the QPCCC measure. To examine test-retest reliability, a second QPCCC measure was mailed to survivors 7 to 14 days after they had returned the first measure. RESULTS Overall, 545 hematological cancer survivors completed the 48-item QPCCC measure. Exploratory factor analysis revealed a 10-factor structure with factor loadings>0.40. The subscales were labeled Treatment Delivery, Treatment Decision Making, Coordinated and Integrated Care, Emotional Support, Timely Care, Follow-Up Care, Respectful Communication, Patient Preferences and Values, Cancer Information, and Equitable Care. The QPCCC measure demonstrated acceptable internal consistency for all subscales (Cronbach's a=.73-.94). When test-retest reliability was assessed, 4 items demonstrated substantial agreement (¿>0.60), whereas 40 items showed moderate agreement (¿=0.41-0.60). Ceiling effects were present for 8 subscales. CONCLUSIONS The QPCCC measure has acceptable face and content validity, construct validity, and internal consistency. However, the measure's discriminant validity and test-retest reliability could be improved. The QPCCC measure could be used to improve patient-centered cancer care. Cancer 2015;121:2383-2392.

Background: High rates of anxiety, depression and unmet needs are evident amongst haematological cancer patients undergoing treatment and their Support Persons. Psychosocial distress may be minimised by ensuring that patients are sufficiently involved in decision making, provided with tailored information and adequate preparation for potentially threatening procedures. To date, there are no published studies evaluating interventions designed to reduce psychosocial distress and unmet needs specifically in patients with haematological cancers and their Support Persons. This study will examine whether access to a web-based information tool and nurse-delivered telephone support reduces depression, anxiety and unmet information needs for haematological cancer patients and their Support Persons. Methods/Design: A non-blinded, parallel-group, multi-centre randomised controlled trial will be conducted to compare the effectiveness of a web-based information tool and nurse-delivered telephone support with usual care. Participants will be recruited from the haematology inpatient wards of five hospitals in New South Wales, Australia. Patients diagnosed with acute myeloid leukaemia, acute lymphoblastic leukaemia, Burkitt's lymphoma, Lymphoblastic lymphoma (B or T cell), or Diffuse Large B-Cell lymphoma and their Support Persons will be eligible to participate. Patients and their Support Persons will be randomised as dyads. Participants allocated to the intervention will receive access to a tailored web-based tool that provides accurate, up-to-date and personalised information about: cancer and its causes; treatment options including treatment procedures information; complementary and alternative medicine; and available support. Patients and Support Persons will complete self-report measures of anxiety, depression and unmet needs at 2, 4, 8 and 12 weeks post-recruitment. Patient and Support Person outcomes will be assessed independently. Discussion: This study will assess whether providing information and support using web-based and telephone support address the major psychosocial challenges faced by haematological patients and their Support Persons. The approach, if found to be effective, has potential to improve psychosocial outcomes for haematological and other cancer patients, reduce the complexity and burden of meeting patients' psychosocial needs for health care providers with high potential for translation into clinical practice.

Objective: There is a growing body of literature examining the clustering of health risk behaviours, but little consensus about which risk factors can be expected to cluster for which sub groups of people. This systematic review aimed to examine the international literature on the clustering of smoking, poor nutrition, excess alcohol and physical inactivity (SNAP) health behaviours among adults, including associated socio-demographic variables. Method: A literature search was conducted in May 2014. Studies examining at least two SNAP risk factors, and using a cluster or factor analysis technique, or comparing observed to expected prevalence of risk factor combinations, were included. Results: Fifty-six relevant studies were identified. A majority of studies (81%) reported a 'healthy' cluster characterised by the absence of any SNAP risk factors. More than half of the studies reported a clustering of alcohol with smoking, and half reported clustering of all four SNAP risk factors. The methodological quality of included studies was generally weak to moderate. Males and those with greater social disadvantage showed riskier patterns of behaviours; younger age was less clearly associated with riskier behaviours. Conclusion: Clustering patterns reported here reinforce the need for health promotion interventions to target multiple behaviours, and for such efforts to be specifically designed and accessible for males and those who are socially disadvantaged.

Background: Indigenous Australians are a socially disadvantaged group who experience significantly poorer health and a higher prevalence of modifiable health behaviours than other Australians. Little is known about the clustering of health risks among Indigenous Australians. The aims of this study were to describe the clustering of key health risk factors, such as smoking, physical inactivity and alcohol consumption, and socio-demographics associated with clusters, among a predominantly Aboriginal sample. Methods: Participants (n = 377) attending an Aboriginal Community Controlled Health Service (ACCHS) in regional/rural New South Wales, Australia, in 2012-2013 completed a self-report touch screen health risk survey. Clusters were identified using latent class analysis. Results: Cluster 1 ('low fruit/vegetable intake, lower risk'; 51 %) consisted of older men and women; Cluster 2 ('risk taking'; 22 %) included younger unemployed males with a high prevalence of smoking, risky alcohol, and illicit drug use. Cluster 3 ('inactive, overweight, depressed'; 28 %) was characterised by younger to mid aged women likely to have experienced emotional or physical violence. Conclusions: If future research identifies similar stable clusters of health behaviours for this population, intervention approaches targeting these clusters of risk factors should be developed and tested for Aboriginal and Torres Strait Islander Australians.

Objective Patient-reported outcome measures (PROMs) that assess the quality of patient-centred cancer care have failed to measure all six patient-centredness dimensions endorsed by the Institute of Medicine (IOM). This study is the first to use the Quality of Patient-Centered Cancer Care (QPCCC) measure that covers all six IOM patient-centredness dimensions to examine haematological cancer survivors' perceptions of care and characteristics associated with perceived quality of care. Methods Haematological cancer survivors diagnosed in the last 6 years and aged 18-80 years were recruited from two Australian state population-based cancer registries. Survivors were mailed the 48-item QPCCC measure. Results Overall, 545 haematological cancer survivors completed the measure. Areas of care most commonly identified as delivered were hospital staff showing respect to survivors (93%) and making sure the correct treatment was received (93%). Aspects of care most frequently nominated as not delivered were hospital staff helping family and friends (34%) or the survivor (32%) to find other people with similar experiences to talk to. Characteristics associated with survivors perceiving higher quality care was delivered included being employed, having private health insurance, being younger, a Non-Hodgkin lymphoma diagnosis and more recent diagnosis. Being depressed or stressed was associated with perceived lower quality of care. Conclusions Provision of peer support programs that allow haematological cancer survivors and families and friends to talk to others in similar situations could be improved. Using PROMs to identify areas where cancer survivors perceive improvements are needed is essential to quality improvement efforts.

Background: Alcohol disproportionately affects socially disadvantaged groups including Aboriginal and Torres Strait Islander Australians. Methods to assess alcohol intake for disadvantaged communities need to be able to capture variable or episodic drinking. The ability of a seven-day diary to capture typical consumption for a predominantly Aboriginal sample has not been assessed. Objective: One aim of this paper was to examine agreement between a seven-day retrospective diary and 'usual' drinking assessed by a modified version of the Alcohol Use Disorders Identification Test question 3 (AUDIT-3m; two questions). Other aims were to describe drinking patterns as reported in the seven-day diary. Method: In 2012, consecutive adults attending an Aboriginal Community Controlled Health Service completed a cross-sectional health risk survey on a touch screen laptop (n = 188). Alcohol consumption questions included the retrospective diary and AUDIT-3m. Agreement was assessed using weighted kappa analysis. Results: There was good agreement between the two measures of consumption; however, the AUDIT-3m questions identified more current drinkers. Respondents who were drinkers (54%) tended to consume large amounts per drinking occasion: almost half (46%) of diary completers reported nine or more standard drinks on at least one occasion in the last week. Conclusions: The seven-day diary did not adequately capture variability in alcohol consumption common among this sample. Although the AUDIT-3m appeared acceptable, alternative approaches to assess usual or risky alcohol consumption, such as asking about specific drinking occasions, or allowing participants to respond in non-standard drink sizes, also need to be considered for indigenous and other disadvantaged communities.

Background: Technical and Further Education (TAFE) colleges are the primary provider of vocational education in Australia. Most TAFE students are young adults, a period when health risk behaviours become established. Furthermore, high rates of smoking, risky alcohol consumption, inadequate fruit and vegetable intake and insufficient physical activity have been reported in TAFE students. There have been no intervention studies targeting multiple health risk behaviours simultaneously in this population. The proposed trial will examine the effectiveness of providing TAFE students with electronic feedback regarding health risk behaviours and referral to a suite of existing online and telephone services addressing smoking, risky alcohol consumption, fruit and vegetable intake, and physical activity levels. Methods/Design: A two arm, parallel, cluster randomised trial will be conducted within TAFE campuses in New South Wales (NSW), Australia. TAFE classes will be randomly allocated to an intervention or control condition (50 classes per condition). To be eligible, students must be: enrolled in a course that runs for more than 6 months; aged 16 years or older; and not meet Australian health guideline recommendations for at least one of the following: smoking, alcohol consumption, fruit and/or vegetable intake, or physical activity. Students attending intervention classes, will undertake via a computer tablet a risk assessment for health risk behaviours, and for behaviours not meeting Australian guidelines be provided with electronic feedback about these behaviours and referral to evidence-based online programs and telephone services. Students in control classes will not receive any intervention. Primary outcome measures that will be assessed via online surveys at baseline and 6 months post-recruitment are: 1) daily tobacco smoking; 2) standard drinks of alcohol consumed per week; 3) serves of fruit consumed daily; 4) serves of vegetables consumed daily; and 5) metabolic equivalent minutes of physical activity per week. Discussion: Proactive enrolment to existing online and telephone services has the potential to address modifiable determinants of disease. This trial will be the first to examine a potentially scalable intervention targeting multiple health risk behaviours among students in the vocational training setting.

Objectives: This study identified smokers' intended use of new quitline features aimed at improving smoking cessation such as having the same quitline advisor for each call, longer-term telephone counselling and provision of additional cessation treatments. Methods: Smokers who had previously used quitline counselling completed a computer-assisted telephone interview examining intended use of potential quitline enhancements. Results: The majority of smokers (61.1%) thought their chances of quitting would have increased a lot/moderately if they had the same quitline advisor for each call. Most smokers reported likely use of longer-term quitline telephone support after a failed (58.3%) or successful (60%) quit attempt. Smokers were likely to use quitline support long-term (mean = 9.9 months). Most smokers would be likely to use free or subsidised nicotine replacement therapy (NRT) (74.9%) if offered by quitlines. Younger smokers had greater odds of being likely to use text messages, whereas less educated smokers had greater odds of being likely to use free or subsidised NRT. Conclusions: Smokers appear interested in quitlines offering longer-term telephone support, increased continuity of care and additional effective quitting strategies. Practice implications: Quitlines could adopt a stepped care model that involves increasingly intensive treatments and extended telephone counselling delivered by the same quitline advisor.

Background: Tailored feedback has been shown to be effective for modifying health risk behaviours and may aid the provision of preventive care by general practitioners (GPs). However, provision of tailored patient feedback for vulnerable or socially disadvantaged groups is not well explored. The aims of this study were to examine the acceptability and effectiveness of providing generic compared to tailored feedback on self-reported health risk behaviours among a high need sample of people attending an Aboriginal Community Controlled Health Service (ACCHS). Methods: Participants attending two ACCHSs in regional New South Wales completed a touch screen health risk survey and received either generic or tailored health risk feedback. Participants were asked to complete an exit survey after their appointment. The exit survey asked about feedback acceptability and effectiveness. Self-reported ease of understanding, relevance and whether the generic versus tailored feedback helped patients talk to their GP was compared using Chi-square analysis; The mean number of survey health risks talked about or for which additional actions were undertaken (such as provision of lifestyle advice or referral) was compared using t-tests. Results: Eighty seven participants (36 % consent rate) completed the exit survey. Tailored feedback was rated as more relevant and was more likely to be shown to the participant's GP than generic feedback. There was no difference in the mean number of health risk topics discussed or number of additional actions taken by the GP by type of feedback. Conclusions: Tailored and generic feedback showed no difference in effectiveness, and little difference in acceptability, among this socially disadvantaged population. Completing a health risk survey and receiving any type of feedback may have overwhelmed more subtle differences in outcomes between the generic and the tailored feedback. Future work to rigorously evaluate the longer-term effectiveness of the provision of tailored health risk feedback for Aboriginal Australians, as well as other high need groups, is still needed. Trial Registration: Australian New Zealand Clinical Trials Registry ANZCTRN12614001205628. Registered 11 November 2014.

Background: Primary care providers are an important source of information regarding appropriate alcohol consumption. As early presentation to a provider for alcohol-related concerns is unlikely, it is important that providers are able to identify at-risk patients in order to provide appropriate advice. This study aimed to report the sensitivity, specificity, positive predictive value and negative predictive value of General Practitioner (GP) assessment of alcohol consumption compared to patient self-report, and explore characteristics associated with GP non-detection of at-risk status. Method. GP practices were selected from metropolitan and regional locations in Australia. Eligible patients were adults presenting for general practice care who were able to understand English and provide informed consent. Patients completed a modified AUDIT-C by touchscreen computer as part of an omnibus health survey while waiting for their appointment. GPs completed a checklist for each patient, including whether the patient met current Australian guidelines for at-risk alcohol consumption. Patient self-report and GP assessments were compared for each patient. Results: GPs completed the checklist for 1720 patients, yielding 1565 comparisons regarding alcohol consumption. The sensitivity of GPs' detection of at-risk alcohol consumption was 26.5%, with specificity of 96.1%. Higher patient education was associated with GP non-detection of at-risk status. Conclusions: GP awareness of which patients might benefit from advice regarding at-risk alcohol consumption appears low. Given the complexities associated with establishing whether alcohol consumption is 'at-risk', computer-based approaches to routine screening of patients are worthy of exploration as a method for prompting the provision of advice in primary care. © 2014 Paul et al.; licensee BioMed Central Ltd.

Background: Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke.Objectives: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months.Methods and design: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS =2), compared to international benchmarks.Discussion: TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not.Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12613000939796. © 2014 Paul et al.; licensee BioMed Central Ltd.

Objective: To assess emergency physicians' perceptions of individual and system enablers to the use of tissue Plasminogen Activator in acute stroke.

Objectives: To determine the: (1) proportion of studies that describe characteristics of helpline service delivery, compared to the proportion that report trials testing efficacy or effectiveness of helplines in changing user outcomes; (2) proportion of efficacy or effectiveness studies that meet EPOC criteria for methodological rigor; and (3) potential benefits of cancer helplines for people affected by cancer based on findings from rigorous efficacy or effectiveness trials. Methods: Electronic databases (Medline, PsycINFO, EMBASE and CINAHL) were searched to identify English-language studies describing original research published from 1991 to 2011. Results: Twenty-eight publications met the review inclusion criteria. From these studies, data on: the characteristics of cancer helpline users; call content; and user satisfaction, were extracted. The potential for helplines to improve the psychosocial outcomes of callers was examined for the three intervention trials. Conclusion: There is a lack of robust evidence regarding the level and types of benefits that cancer helplines may deliver to callers affected by cancer. Given increased emphasis on delivering best-practise supportive care, building the evidence base in this field may assist cancer helplines to increase their service uptake, reach, and benefit to callers. Practise implications: There is a need for more rigorous intervention-focussed studies in this field across a broader range of cancer populations. Future studies should focus on relevant patient-centred outcomes, such as improved knowledge and greater involvement in decision-making, while incorporating process measures to account for intervention fidelity and clinical performance.

Objective: Although research suggests that socioeconomic status (SES) will be related to housing type with regard to second-hand smoke (SHS) exposure, there has been no comprehensive examination of these relationships. This study aimed to explore associations between SHS exposure a) at home and b) at other places, and a number of SES, housing, and health factors. Method: Data were drawn from the 45 and Up Study, a large cohort study with 266,848 adults in New South Wales, Australia, of which 160,824 participants aged 45-65. years were included in this study. Associations between socio-demographic characteristics, smoking status, housing-type, SES, and exposure to SHS were explored initially using Chi-square tests. Ordinal logistic models were created with increasing exposure to SHS at home and at other places. Results: When measuring SHS exposure at home, being female (odds ratio (OR) = 1.2, 95% confidence interval (CI) = 1.2, 1.3); being of lower age (45-49. years vs 60-64. years, OR = 1.4, 95%CI = 1.3, 1.5), being a current smoker of over 20 cigarettes per day (vs never smoked, OR = 10.2, 95%CI = 9.4,11); living in other types of dwelling compared to living at home (OR = 1.3, 95%CI = 1.1, 1.4), living with a partner (vs being single OR = 2.3, 95%CI = 2.1, 2.5), and low SES measures were associated with increased exposure. Increasing SHS exposure at other places was also related to low SES measures, however unlike SHS exposure at home, SHS exposure at other places was associated with being male (OR = 1.5, 95%CI = 1.5, 1.6); and greater paid hours of work (OR = 1.3, 95%CI = 1.2, 1.3). Conclusion: Improved monitoring of SHS exposure in high risk environments is required. Tailoring SHS messages to environments may also be required, for example to women living in units, apartments and mobile homes and males in lower income workplaces. © 2014 Elsevier Inc.

Introduction and Aims.: Understanding how tobacco, alcohol and mental health are related is important for developing population-level policies and individual-level treatments that target comorbidities. The current study aimed to examine sociodemographic characteristics and mental health comorbidities associated with the odds of using tobacco and harmful levels of alcohol concurrently. Design and Methods.: Data were drawn from the 45 and Up Study, a large cohort study with 267153 adults aged 45 years and over in New South Wales, Australia. Participants completed a survey assessing alcohol, smoking, psychological distress, treatment for depression and anxiety, and a range of socioeconomic status indicators. Univariate analyses and three multiple-logistic regression models were used to determine associations with (i) tobacco but not alcohol use; (ii) alcohol but not tobacco use; and (iii) concurrent tobacco and risky levels of alcohol use. Results.: Being female, younger, lower individual and area-level socioeconomic status (SES) and depression and psychological distress were associated with tobacco use alone. Factors associated with alcohol use alone were older age, male gender, higher SES, and lower psychological distress and no recent depression treatment. Factors associated with concurrent risky alcohol consumption and tobacco use included being 45-64, being male, less education, earning <$30000, being employed, and living in lower-SES areas, treatment for depression, and high distress on the Kessler-10. Discussion and Conclusions.: Results suggest strong links between SES, treatment for depression, psychological distress, and concurrent tobacco and alcohol use. This has implications for public health policies and clinical treatment for tobacco and alcohol use, suggesting greater emphasis on addressing multiple health and social concerns. © 2013 Australasian Professional Society on Alcohol and other Drugs.

Background: Several factors need to be considered when selecting a screening tool for depression including accuracy, level of burden for patients and for staff to administer and follow-up. Objective: This study aimed to explore the utility of a single self-assessment item in identifying possible cases of depression in primary care by examining sensitivity and specificity with the nine-item Patient Health Questionnaire (PHQ-9) at different thresholds. Design: Cross-sectional survey presented on a touchscreen computer. Participants. Adult patients attending 12 urban general practices in Australia completed a health status questionnaire (n = 1004). Main measures. Depression was assessed by the PHQ-9 and a single self-assessment item. Sensitivity, specificity, and positive and negative predictive values were calculated for the single item using a PHQ-9 score of 10 or more as the criterion value. Key results. A total of 1004 participants (61% female, 48% aged 55 years or older) completed both the PHQ-9 and a single self-assessment item. When using a threshold of mild depression or greater, the single item had adequate specificity (76%, 95% CI: 71-80%), with 76 out of every 100 people defined as non-depressed by the PHQ-9 also identified as not depressed by the single item. Sensitivity was high (91%, 95% CI: 84-95%), with the single item identifying 91 out of every 100 true cases (as defined by the PHQ-9). Conclusions: The single self-assessment item has high sensitivity and moderate specificity to identify possible cases of depression when used at a threshold of mild depression or greater. © The Author 2014.

Background: The Institute of Medicine (IOM) has endorsed six dimensions of patient-centredness as crucial to providing quality healthcare. These dimensions outline that care must be: 1) respectful to patients' values, preferences, and expressed needs; 2) coordinated and integrated; 3) provide information, communication, and education; 4) ensure physical comfort; 5) provide emotional support-relieving fear and anxiety; and 6) involve family and friends. However, whether patient-reported outcome measures (PROMs) comprehensively cover these dimensions remains unexplored. This systematic review examined whether PROMs designed to assess the quality of patient-centred cancer care addressed all six IOM dimensions of patient-centred care and the psychometric properties of these measures.Methods: Medline, PsycINFO, Current Contents, Embase, CINAHL and Scopus were searched to retrieve published studies describing the development and psychometric properties of PROMs assessing the quality of patient-centred cancer care. Two authors determined if eligible PROMs included the six IOM dimensions of patient-centred care and evaluated the adequacy of psychometric properties based on recommended criteria for internal consistency, test-retest reliability, face/content validity, construct validity and cross-cultural adaptation.Results: Across all 21 PROMs, the most commonly included IOM dimension of patient-centred care was " information, communication and education" (19 measures). In contrast, only five measures assessed the " involvement of family and friends." Two measures included one IOM-endorsed patient-centred care dimension, two measures had two dimensions, seven measures had three dimensions, five measures had four dimensions, and four measures had five dimensions. One measure, the Indicators (Non-small Cell Lung Cancer), covered all six IOM dimensions of patient-centred care, but had adequate face/content validity only. Eighteen measures met the recommended adequacy criteria for construct validity, 15 for face/content validity, seven for internal consistency, three for cross-cultural adaptation and no measure for test-retest reliability.Conclusions: There are no psychometrically rigorous PROMs developed with cancer patients that capture all six IOM dimensions of patient-centred care. Using more than one measure or expanding existing measures to cover all six patient-centred care dimensions could improve assessment and delivery of patient-centred care. Construction of new comprehensive measures with acceptable psychometric properties that can be used with the general cancer population may also be warranted. © 2014 Tzelepis et al.; licensee BioMed Central Ltd.

Background: This study aims to review the literature regarding the barriers to sampling, recruitment, participation, and retention of members of socioeconomically disadvantaged groups in health research and strategies for increasing the amount of health research conducted with socially disadvantaged groups. Methods. A systematic review with narrative synthesis was conducted. Searches of electronic databases Medline, PsychInfo, EMBASE, Social Science Index via Web of Knowledge and CINHAL were conducted for English language articles published up to May 2013. Qualitative and quantitative studies as well as literature reviews were included. Articles were included if they reported attempts to increase disadvantaged group participation in research, or the barriers to research with disadvantaged groups. Groups of interest were those described as socially, culturally or financially disadvantaged compared to the majority of society. Eligible articles were categorised according to five phases of research: 1) sampling, 2) recruitment and gaining consent, 3) data collection and measurement, 4) intervention delivery and uptake, and 5) retention and attrition. Results: In total, 116 papers from 115 studies met inclusion criteria and 31 previous literature reviews were included. A comprehensive summation of the major barriers to working with various disadvantaged groups is provided, along with proposed strategies for addressing each of the identified types of barriers. Most studies of strategies to address the barriers were of a descriptive nature and only nine studies reported the results of randomised trials. Conclusions: To tackle the challenges of research with socially disadvantaged groups, and increase their representation in health and medical research, researchers and research institutions need to acknowledge extended timeframes, plan for higher resourcing costs and operate via community partnerships. © 2014 Bonevski et al.; licensee BioMed Central Ltd.

Objectives: To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth. Design: A systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups. Data sources: MEDLINE, EMBASE, CINAHL and PsycInfo were searched using keywords and MeSH terms from each database's inception published prior to March 2014. Study selection: Studies that provided either qualitative or quantitative (ie, longitudinal, crosssectional or cohort surveys) descriptions of selfreported perceived barriers to quitting smoking in one of the six aforementioned vulnerable groups were included. Data extraction: Two authors independently assessed studies for inclusion and extracted data. Results: 65 eligible papers were identified: 24 with low socioeconomic groups, 16 with Indigenous groups, 18 involving people with a mental illness, 3 with homeless groups, 2 involving prisoners and 1 involving at-risk youth. One study identified was carried out with participants who were homeless and addicted to alcohol and/or other drugs. Barriers common to all vulnerable groups included: smoking for stress management, lack of support from health and other service providers, and the high prevalence and acceptability of smoking in vulnerable communities. Unique barriers were identified for people with a mental illness (eg, maintenance of mental health), Indigenous groups (eg, cultural and historical norms), prisoners (eg, living conditions), people who are homeless (eg, competing priorities) and at-risk youth (eg, high accessibility of tobacco). Conclusions: Vulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social networklevel interventions are priority areas for future smoking cessation interventions within vulnerable groups

Background Adolescence and young adulthood is a time of risky health behaviour initiation and experimentation. Smoking, risky drinking, poor nutrition and physical activity, and a lack of sun protection behaviour, often become established in early adulthood. Levels of health risk behaviours occurring amongst tertiary education and training students and their preferences for types of on-campus health promotion programs were examined. Method A cross-sectional pen-and-paper classroom survey was conducted at one Sydney-based TAFE New South Wales Institute campus in May 2010. The survey assessed demographics, smoking, alcohol use, sun protection, nutrition, physical activity and health promotion program preferences. Results: Two hundred and twenty-four students participated (97% consent); the majority were aged 16-24 years (59%) and female (51%). Current smoking (35%), risky drinking (49%) and inadequate physical activity (88%) rates were high. Adequate vegetable intake (3.6%) and sun protection behaviours (5.4%) were low and 33% of students were overweight or obese. Popular health promotion programs included food and activity subsidies, practical skills classes and social outings. Conclusion Participation in health risk behaviours among this sample was high. The setting of tertiary education and workplace training represents an opportunity for early intervention into risky health behaviours among young people. So what? This study is the first to provide information on the prevalence of health risk behaviours and preferences for types of health promoting programs among students of an Australian community college. The results show that young adults regularly participate in multiple health risk behaviours, such as smoking, drinking, poor nutrition, physical activity and lack of sun protection. © 2013 Australian Health Promotion Association.

Objective A patient-centred approach to discussing life expectancy with cancer patients is recommended in Western countries. However, this approach to eliciting and meeting patient preferences can be challenging for clinicians. The aims of this study were the following: (i) to examine cancer patients' preferences for life expectancy disclosure; and (ii) to explore agreement between cancer patients' preferences for, and perceived experiences of, life expectancy disclosure. Methods Cancer patients undergoing radiotherapy treatment in metropolitan Australia completed a cross-sectional touchscreen computer survey including optional questions about their life expectancy disclosure preferences and experiences. Results Of the 208 respondents, 178 (86%) indicated that they would prefer their clinician to ask them before discussing life expectancy, and 30 (14%) indicated that they would prefer others (i.e. clinicians, family) to decide whether they were given life expectancy information. Of the 175 respondents who were classified as having a self- determined or other-determined disclosure experience, 105 (60%) reported an experience of life expectancy disclosure that was in accordance with their preferences. Cohen's ¿ was -0.04 (95% CI, -0.17, 0.08), indicating very poor agreement between patients' preferences for and perceived experiences of life expectancy disclosure (p = 0.74). Conclusions In light of patient-centred prognosis disclosure guidelines, our findings of a majority preference for, and experience of, a self-determined approach to life expectancy disclosure amongst radiation oncology patients are encouraging. However, poor agreement between preferences and experiences highlights that additional effort from clinicians is required in order to achieve a truly patient-centred approach to life expectancy disclosure. Copyright © 2013 John Wiley & Sons, Ltd.

Objective: To examine the prevalence and clustering of six health risk behaviours (smoking, alcohol, inadequate sun protection, physical inactivity, and inadequate fruit and vegetable consumption) among severely disadvantaged individuals. Methods: A cross-sectional touch screen computer survey was conducted with 383 clients attending a social and community welfare organisation in New South Wales. Participants were assessed on smoking status, alcohol consumption, fruit and vegetable consumption, physical activity, sun protection and socio-demographic characteristics. Descriptive statistics, factor analysis and logistic regression were used to assess the prevalence, clustering and socio-demographic predictors of health risk behaviours. Results: Ninety-eight per cent of the participants reported inadequate vegetable consumption, 62.7% reported inadequate fruit consumption, 82.5% reported inadequate sun protection, 61.7% smoked tobacco, 51.4% consumed alcohol at risky levels and 36.5% were insufficiently active. Most participants (87%) reported three or more risk behaviours. Male participants, younger participants and those with lower education were more likely to smoke tobacco and consume alcohol. Conclusions: The prevalence of health risk behaviours among a sample of typically hard-to-reach, severely disadvantaged individuals is extremely high. Implications: Future intervention development should take into account the likelihood of health risk clustering among severely disadvantaged groups. © 2013 The Authors.