The relationships among knowledge, self-efficacy, preparedness, decisional conflict, and decisions to participate in a cancer clinical trial

Evaluation of a Novel Hospice-Specific Patient Decision Aid

Background: We tested a novel hospice-specific patient decision aid to determine whether the decision aid could improve hospice knowledge, opinions of hospice, and decision self-efficacy in making decisions about hospice. Methods: Two patient-level randomized studies were conducted using two different cohorts. Recruitment was completed from March 2019 through May 2020. Cohort #1 was recruited from an academic hospital and a safety-net hospital and Cohort #2 was recruited from community members. Participants were randomized to review a hospice-specific patient decision aid. The primary outcomes were change in hospice knowledge, hospice beliefs and attitudes, and decision self-efficacy Wilcoxon signed rank tests were used to evaluate differences on the primary outcomes between baseline and 1-month. Participants: Participants were at least 65 years of age. A total of 266 participants enrolled (131 in Cohort #1 and 135 in Cohort #2). Participants were randomized to the intervention group (n = 156) or control group (n = 109). The sample was 74% (n = 197) female, 58% (n = 156) African American and mean age was 74.9. Results: Improvements in hospice knowledge between baseline and 1-month were observed in both the intervention and the control groups with no differences between groups (.43 vs .275 points, P = .823). There were no observed differences between groups on Hospice Beliefs and Attitudes scale (3.29 vs 3.08, P = .076). In contrast, Decision Self-Efficacy improved in both groups and the effect of the intervention was significant (8.04 vs 2.90, P = -.027). Conclusions: The intervention demonstrated significant improvements in decision self-efficacy but not in hospice knowledge or hospice beliefs and attitudes.

Pet owner perspectives, motivators and concerns about veterinary biobanking

Introduction

Veterinary biobanks store samples for future use and distribute samples to academic researchers and industry entities; however, informed consent provided by owners for pets contributing to biobanks can be complicated by limited understanding of goals, purpose, and logistics of biobanking.

Methods

This survey-based study aimed to gather feedback from pet owners on how they viewed allowing their pet to contribute to a veterinary biobank, with the goal of identifying opportunities to improve education, awareness of veterinary biobanking initiatives, and the consent processes. An electronic survey was distributed to a listserv of 2,119 pet owners and responses were received from 118 respondents (5.6%).

Results

Most respondents (67%) were not familiar with the concept of veterinary biobanking prior to having responded to the survey. Most (89%) were willing to allow their healthy pet to contribute samples to a veterinary biobanking program. Ninety-five percent would allow their sick pet to contribute. Most were neutral about financial incentives as a motivator to participate, although 40% indicated that if their pet's condition resulted in a decision to humanely euthanize, they would be more likely to contribute to the biobank if the veterinary biobanking program covered the cost of euthanasia. Common concerns included security/confidentiality (36%), that results would not be shared with them (33%) or that samples would be used for other purposes beyond those advertised (22%).

Discussion

These results suggest veterinary biobanking initiatives are well received by owners and most are willing to allow their pets to participate. Respondent concerns represent opportunities for veterinary biobanks to improve messaging and dissemination of results from work they support.

Development and Evaluation of the Clinical Trial HEalth Knowledge and Beliefs Scale (CHEKS)

Patient health literacy is vital to clinical trial engagement. Knowledge and beliefs about clinical trials may contribute to patient literacy of clinical trials, influencing engagement, enrollment and retention. We developed and assessed a survey that measures clinical trial health knowledge and beliefs, known as the Clinical trial HEalth Knowledge and belief Scale (CHEKS). The 31 survey items in CHEKS represent knowledge and beliefs about clinical trial research (n = 409) in 2017. We examined item-scale correlations for the 31 items, eliminated items with item-scale correlations less than 0.30, and then estimated internal consistency reliability for the remaining 25 items. We used the comparative fit index (CFI) and the root mean squared error of approximation (RMSEA) to evaluate model fit. The average age of the sample was 34 (SD = 15.7) and 48% female. We identified 6 of the 31 items that had item-scale correlations (corrected for overlap) lower than 0.30. Coefficient alpha for the remaining 25 items was 0.93 A one-factor categorical confirmatory factor analytic model with 16 correlated errors was not statistically significant (chi-square = 10011.994, df = 300, p < 0.001) but fit the data well (CFI = 0.95 and RMSEA = 0.07). CHEKS can assess clinical trial knowledge and beliefs.

Equitable Representation of Latinos in Clinical Research Is Needed to Achieve Health Equity in Cancer Care

PURPOSE

Identify key barriers that keep Latinos from participating in clinical trials (CTs) and interventions proven effective in increasing their representation in clinical research.

METHODS

Utilize our own extensive research experience and review the literature to: identify key barriers, summarize strategies that have been proven effective in increasing Latino representation in CTs, issue a call to action for programs/practices and practitioners to implement what is proven effective, and make recommendations for further research to address current gaps.

RESULTS

Participation barriers are complex, multifactorial, and exist at different levels, including study design (eg, protocol complexity, patient exclusion criteria, trial duration and frequency), healthcare system barriers (eg, lack of minority staff), patient-related factors (eg, lack of awareness, low health literacy, language, social determinants of health [SDoH]), and medical team issues (eg, lack of cultural competence, lack of referrals, implicit bias, provider/patient communication). Research has shown that the most effective strategies to increase participation of underrepresented minorities in CTs include culturally sensitive educational tools aimed at community members, patients, and physicians, and strategies to address the multiple SDoH and other barriers to participation facing cancer patients and the factors that influence patient decision-making.

CONCLUSION

Raising awareness or offering clinical trials to everyone will not alone increase Latino participation. Other key barriers at different levels must also be addressed, especially SDoH and patients' contextual factors. To achieve equitable participation of Latinos and other underrepresented groups in clinical research, comprehensive approaches that address interrelated multilevel and multifactorial barriers to participation can produce a substantial, sustained impact-ensuring everyone equitably benefits from scientific advances in cancer treatment, improved cancer outcomes and quality of life, and reduced health care costs.

Feasibility, acceptability, and effectiveness of a decision aid versus an informational website to promote clinical trial decision-making among cancer patients: A pilot randomized controlled trial

OBJECTIVE

To assess intervention feasibility and acceptability, and compare the effectiveness of the CHOICES Decision Aid (DA) versus the National Cancer Institute (NCI) Cancer Clinical Trials (CCT) website to improve knowledge about CCTs and preparedness to make an informed decision.

METHODS

Oncology patients (n = 101) with a scheduled clinic visit were enrolled and randomized. Decision-making variables were collected at two timepoints. Post-intervention scores were examined via paired t-tests and multivariate regression analyses. Predictors of the magnitudes of the change in scores were examined in multivariable regression analyses.

RESULTS

The interventions were feasible to implement and acceptable to participants. Both interventions increased objective and subjective knowledge, improved clarity of opinions, and reduced decisional conflict (p-values < 0.01). Improvements in the belief that one could find out about CCTs were observed in the CHOICES DA arm (p < 0.001). Multivariable analyses controlling for educational attainment showed no significant differences in the magnitude of change in outcome variables between intervention arms, but did find that improvements in some variables in the NCI arm - but not CHOICES DA arm - were associated with previous educational attainment.

CONCLUSIONS

Interventions were feasible to implement and acceptable. Improvements in knowledge and decision-making outcomes were observed in both arms, supporting the view that interventions to improve CCT decision making are effective and feasible. Our results suggest that the CHOICES DA may be more effective than an informational website in improving decision-making outcomes regardless of participants' educational attainment.

PRACTICE IMPLICATIONS

CCT resources should support informed decision-making among all cancer survivors, regardless of educational attainment.

Tailored Messages About Research Participation: Using an Interactive Information Aid to Improve Study Recruitment

After a diagnosis of cancer (or other serious disease), patients may be asked to consider joining a clinical trial. Because most people are unfamiliar with the scientific concepts that are necessary to the provision of meaningful informed consent, patient education is necessary. Increasing knowledge alone is not sufficient; understanding how clinical trial participation aligns with personal circumstances and knowledge is central to the decision-making process. In this study, 302 cancer patients and survivors evaluated an interactive information aid (IA) designed to inform their decision to join a research study or clinical trial by providing tailored information to patients' responses to questions pertaining to seven key barriers or facilitators of clinical trial participation. The development of the IA was done with input from the authors' Clinical Translational Science Institute; linked components of the IA were vetted by members and leaders of the institution's NCI-designated comprehensive cancer center. Results of the study indicated that the information aid was successful in significantly reducing fears and increasing knowledge, attitudes, perceived behavioral control, and behavioral intentions about research participation relative to a control condition. Thus, an interactive information aid that provides information that is responsive to patients' values, knowledge, and personal circumstances can help patients to be better prepared to consider a decision about research participation.

Development and preliminary evaluation of tablet computer-based decision aid for patients participating in cancer clinical trials

Objectives

Patients often consent to participate in cancer clinical trials despite misunderstanding the trial content. We developed a tablet-based clinical trial decision aid and tested its use with the usual discussion at the time of clinical trial registration.

Methods

Participants were individuals considering participating in a breast cancer clinical trial. The control participated in usual discussions; the intervention group participated in discussion using the decision aid. Pre- and post-discussion, we investigated knowledge, decision-making conflict, and discussion length.

Results

We enrolled 54 patients, 27 in the control group and 27 in the intervention group. Post-discussion clinical trial knowledge was significantly higher in the intervention group than in the control group (p = 0.003). No significant difference was found in decisional conflict, but the intervention group tended to have lower post-discussion conflict than the control group. There was no between-group difference in the length of discussions with physicians and clinical research coordinators.

Conclusion

For women considering participation in cancer clinical trials, a tablet-based decision aid may promote clinical trial understanding without increasing discussion length or patient burden. This pre-learning decision aid incorporating a quiz and bidirectional question prompt lists may improve participants’ understanding of clinical trials.

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The tablet's interactivity helps participants make decisions efficiently.

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The quiz format may help patients better understand clinical trials.

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Interactive question prompt lists likely enhance physician–patient communication.

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Pre-learning decision aids may help to reduce consultation time.

Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: A randomized controlled trial

OBJECTIVE

To evaluate the efficacy of shared decision-making (SDM) intervention among patients with lumbar degenerative diseases (LDDs) in terms of decision self-efficacy, control preferences, SDM process, decision satisfaction, and conflict.

METHODS

A total of 130 outpatients with LDDs recruited from orthopedic or rehabilitation clinics were randomly assigned to the SDM intervention (n = 67) or comparison (n = 63) groups. Patients in the intervention group received decision aids (DAs) with decision coaching and those in controlled group received standard educational materials from a health educator. The primary outcome was decision self-efficacy, and secondary outcomes were control preference, SDM process, conflict, and satisfaction.

RESULTS

The SDM intervention significantly improved decision self-efficacy (mean difference [MD] = 7.1, 95% confidence interval [CI]: 1.7-12.5, partial η² = 0.05) and reduced conflict (MD = -7.0, 95% CI: -12.2 to -1.9, partial η² = 0.06), especially in patients without family involvement, compared with the health education group. However, no significant between-group differences were observed in other outcomes.

CONCLUSION

SDM intervention improved SDM self-efficacy and reduced conflict in patients with LDDs.

PRACTICE IMPLICATIONS

Clinicians can integrate DAs and decision coaching in SDM conversations. SDM intervention seems to engage patients in decision-making, especially those without family involvement.

A psychometric evaluation of the Family Decision-Making Self-Efficacy Scale among surrogate decision-makers of the critically ill

OBJECTIVES

The purpose of this study was to report the psychometric properties, in terms of validity and reliability, of the Unconscious Version of the Family Decision-Making Self-Efficacy Scale (FDMSE).

METHODS

A convenience sample of 215 surrogate decision-makers for critically ill patients undergoing mechanical ventilation was recruited from four intensive care units at a tertiary hospital. Cross-sectional data were collected from participants between days 3 and 7 of a decisionally impaired patient's exposure to acute mechanical ventilation. Participants completed a self-report demographic form and subjective measures of family decision-making self-efficacy, preparation for decision-making, and decisional fatigue. Exploratory factor analyses, correlation coefficients, and internal consistency reliability estimates were computed to evaluate the FDMSE's validity and reliability in surrogate decision-makers of critically ill patients.

RESULTS

The exploratory factor analyses revealed a two-factor, 11-item version of the FDMSE was the most parsimonious in this sample. Furthermore, modified 11-item FDMSE demonstrated discriminant validity with the measures of fatigue and preparation for decision-making and demonstrated acceptable internal consistency reliability estimates.

SIGNIFICANCE OF RESULTS

This is the first known study to provide evidence for a two-factor structure for a modified, 11-item FDMSE. These dimensions represent treatment and palliation-related domains of family decision-making self-efficacy. The modified FDMSE is a valid and reliable instrument that can be used to measure family decision-making self-efficacy among surrogate decision-makers of the critically ill.

Decisional control preference among Chinese patients with advanced kidney disease: the role of mastery, perceived social support and self-efficacy

Although previous studies have shown a correlation between mastery, self-efficacy, and perceived social support among Chinese patients with advanced kidney disease, few studies have examined their relationship pathways. This study aimed to examine decisional control preference and the relationship between mastery, perceived social support, and self-efficacy among patients with advanced chronic kidney disease. A cross-sectional survey was conducted, and 350 participants were investigated using Control Preference Scale, Personal Mastery Scale, Perceived Social Support Scale, and Self-efficacy Scale. The mediating relationships were determined via structural equation modeling. Results showed that education and economic status were demographic factors influencing patients' decisional control preference. The model showed that mastery and self-efficacy had a direct effect on decisional control preference while perceived social support had an indirect effect mediated via mastery and self-efficacy. Therefore, improving self-efficacy can increase patient willingness to involve in medical decision-making. This study provides new interventions and future directions for promoting decisional control preference.

Randomized trial of a web-based nurse education intervention to increase discussion of clinical trials

Background

Clinical trials are a critical source of evidence for oncology care, yet very few patients participate. Among healthcare providers, nurses spend the most time with cancer patients and are the most highly trusted professionals. We developed and evaluated an educational program for oncology nurses targeting knowledge, attitudes, self-efficacy and perceived norms to facilitate discussion about clinical trials and support patient decision making.

Methods

A nationwide sample of oncology nurses were randomly assigned to receive general clinical trials education delivered as text (attention control) vs. tailored video vignettes (intervention) in a web-based continuing education program. Participants completed a baseline assessment and follow up assessments immediately after the educational program and three months later. The primary outcome was intention to discuss clinical trials with patients. Secondary outcomes were knowledge and attitudes about clinical trials, self-efficacy, and perceived norms.

Results

1393 nurses enrolled and completed the educational program and post-intervention assessment (720 control, 673 video). Both text education and tailored video education increased intention to discuss clinical trials with patients, with a greater effect in the video group (p < .0001). Likewise, knowledge, attitudes, perceived behavioral control, and perceived norms were all improved with education in both groups, and the magnitude of benefit was greater (p < .001) for the video group in all outcomes except knowledge.

Conclusion

A one-time online educational program for oncology nurses improves knowledge, attitudes, self-efficacy and intention to engage patients in discussions about clinical trials. A tailored video format was associated with a greater effect than standard text only material.

Untangling interactivity's effects: The role of cognitive absorption, perceived visual informativeness, and cancer information overload

OBJECTIVE

Learning about clinical trials is as stressful and challenging for cancer patients as it is for the clinical staff who provide education to patients. Information aids (IAs) can support both discussions and patients' decision-making, especially when IAs offer interactive features that provide information based on individuals' needs and experiences. However, it is not clear which factors contribute to interactive IAs' effectiveness.

METHODS

An experiment with cancer patients and survivors (n = 313) compared the effects of two IAs about clinical trial participation: one with modality (i.e. website/technological) interactivity only and one with both modality and message interactivity (i.e. provides information contingent on individual users' information needs).

RESULTS

The IA with both modality and message interactivity features elicited the higher perceived visual informativeness (PVI) and cognitive absorption (CA) scores. The model supports the moderating role of PVI and cancer information overload (CIO), and the mediating role of CA.

CONCLUSION

The IA with both modality and message interactivity better supported individuals' decision-making and improved attitudes and knowledge scores. CIO was experienced more by participants using the modality interactivity-only IA.

PRACTICE IMPLICATIONS

Message interactivity may simplify individuals' cognitive processes. IAs about clinical trial participation should include both message and modality interactivity.

Clinical trials: Predictors of knowledge and attitudes towards participation

AIMS

Clinical trials (CTs) are critical to advancing of patient care. Understanding the public's knowledge and the attitudes towards participating in CTs is important for their successful implication. In Jordan this data are currently not available. The present study aimed to explore the knowledge, attitude and perception of Jordanians towards CTs participation.

METHODS

A cross-sectional study was conducted on 1216 Jordanians recruited from public hospitals and pharmaceutical research centres.

RESULTS

About 20.5% of the respondents have previously participated in a CT. About 68.3% and 50.1% had good knowledge and positive attitude towards CTs, respectively. Good knowledge was associated with male gender (OR = 1.696, 95% CI = 1.284-0.240, P < .001), higher education (OR = 1.433, 95% CI = 1.107-1.856, P = .006) and healthy condition (OR = 1.822, 95% CI = 1.234-2.690, P = .003); while older age was associated with a poor knowledge (OR = 0.985, 95% CI = 0.972-0.998, P = .026). Female gender (OR = 1.817, 95% CI = 1.406-2.349, P < .001), higher education (OR = 1.294, 95% CI = 1.017-1.646, P = .036) and previous participation (OR = 1.919, 95% CI = 1.388-2.653, P < .001) were factors predicting the positive attitudes. A very weak positive correlation was found between knowledge and attitude (Spearman's r = 0.074, P = .01). Regarding perceptions, most of the respondents (85.3%) perceive that CTs are conducted in an ethical manner in Jordan, only 52.9% however feel comfortable towards participation. A moderate positive correlation was found between knowledge and perception (Spearman's r = 0.275, P < .001). Taking part in a CT significantly affect knowledge, attitudes and perceptions.

CONCLUSIONS

This study revealed important insights regarding knowledge, attitudes and perception of Jordanians towards CTs. Educational interventions can improve awareness of the ethical standards under which CTs are conducted affecting the perception to participate. Promotion of CTs among patients and healthy individuals is needed to increase participation.

Needs assessment for a decision support tool in oral cancer requiring major resection and reconstruction: a mixed-methods study protocol

INTRODUCTION

Advanced oral cancer and its ensuing treatment engenders significant morbidity and mortality. Patients are often elderly with significant comorbidities. Toxicities associated with surgical resection can be devastating and they are often highlighted by patients as impactful. Given the potential for suboptimal oncological and functional outcomes in this vulnerable patient population, promotion and performance of shared decision making (SDM) is crucial.Decision aids (DAs) are useful instruments for facilitating the SDM process by presenting patients with up-to-date evidence regarding risks, benefits and the possible postoperative course. Importantly, DAs also help elicit and clarify patient values and preferences. The use of DAs in cancer treatment has been shown to reduce decisional conflict and increase SDM. No DAs for oral cavity cancer have yet been developed.This study endeavours to answer the question: Is there a patient or surgeon driven need for development and implementation of a DA for adult patients considering major surgery for oral cancer?

METHODS AND ANALYSIS

This study is the first step in a multiphase investigation of SDM during major head and neck surgery. It is a multi-institutional convergent parallel mixed-methods needs assessment study. Patients and surgeon dyads will be recruited to complete questionnaires related to their perception of the SDM process (nine-item Shared Decision-Making Questionnaire, SDM-Q-9 and SDM-Q-Doc) and to take part in semistructured interviews. Patients will also complete questionnaires examining decisional self-efficacy (Ottawa Decision Self-Efficacy Scale) and decisional conflict (Decisional Conflict Scale). Questionnaires will be completed at time of recruitment and will be used to assess the current level of SDM, self-efficacy and conflict in this setting. Thematic analysis will be used to analyse transcripts of interviews. Quantitative and qualitative components of the study will be integrated through triangulation, with matrix developed to promote visualisation of the data.

ETHICS AND DISSEMINATION

This study has been approved by the research ethics boards of the Nova Scotia Health Authority (Halifax, Nova Scotia) and the University Health Network (Toronto, Ontario). Dissemination to clinicians will be through traditional approaches and creation of a head and neck cancer SDM website. Dissemination to patients will include a section within the website, patient advocacy groups and postings within clinical environments.

Efficacy of a decision support intervention for reducing decisional conflict in patients with elevated serum prostate-specific antigen: A randomized controlled trial

PURPOSE

The study purpose is to test the efficacy of a decision support intervention for reducing decisional conflict, increasing prostate biopsy knowledge, and enhancing decision self-efficacy in patients with elevated serum prostate-specific antigen.

METHOD

The study is based on a randomized pre-post test design. A convenience sample of men with elevated prostate-specific antigen was recruited and 1:1 randomized to the intervention and control groups. The intervention group received the decision support intervention and the control group received health education. Data were collected at the baseline and post-test by using self-reported questionnaires, including the Prostate Biopsy Knowledge Scale, the Decision Self-Efficacy Scale, the Decisional Conflict Scale, and questions regarding the prostate biopsy decision (post-test only). Data on prostate-specific antigen levels were collected from the patients' medical records.

RESULTS

A total of 110 patients participated in the study. At baseline, the intervention group had significantly higher knowledge scores than the control group. The analysis of the covariance model with the baseline score as a covariate was used to analyze the intervention effect. After controlling for the baseline scores, the mean differences (95% CI) between the two groups were 11.75 (11.17-12.32), 76.45 (72.52-80.37), and -23.53 (-26.31-20.20) for knowledge, decision self-efficacy, and decisional conflict, respectively. The between-group difference in willingness to accept prostate biopsy at the post-test was not statistically significant (χ²= 1.704).

CONCLUSIONS

The decision support intervention significantly reduced patients' decisional conflict while improving their knowledge and self-efficacy. However, the intervention did not affect patients' biopsy decision.

The impact of religiously tailored and ethically balanced education on intention for living organ donation among Muslim Americans

We tested the efficacy of religiously tailored and ethically balanced education upon living kidney organ donation intent among Muslim Americans. Pre-post changes in participant stage of change, preparedness, and likelihood judged efficacy. Among 137 participants, mean stage of change toward donation appeared to improve (0.59; SD ± 1.07, P < .0001), as did the group's preparedness to make a donation decision (0.55; SD ± 0.86, P < .0001), and likelihood to donate a kidney (0.39; SD ± 0.85, P < .0001). Mean change in likelihood to encourage a loved one, a co-worker, or a mosque community member with ESRD to seek a living donor also increased (0.22; SD ± 0.84, P = .0035, 0.23; SD ± 0.82, P = .0021, 0.33; SD ± 0.79, P < .0001 respectively). Multivariate ordered logistic regression models revealed that gains in biomedical knowledge regarding organ donation increased odds for positive change in preparedness (OR = 1.20; 95% CI 1.01-1.41, P = .03), while increasing age associated with lower odds of positive change in stage of change (OR = 0.98, 95% CI 0.96-0.998, P = .03), and prior registration as an organ donor lowered odds for an increase in likelihood to donate a kidney (OR = 0.22; 95% CI 0.08-0.60, P = .003). Our intervention appears to enhance living kidney donation-related intent among Muslim Americans [Clinicaltrials.gov number: NCT04443114].

Improving treatment decision-making in bipolar II disorder: a phase II randomised controlled trial of an online patient decision-aid

BACKGROUND

Many patients with bipolar II disorder (BPII) prefer to be more informed and involved in their treatment decision-making than they currently are. Limited knowledge and involvement in one's treatment is also likely to compromise optimal BPII management. This Phase II RCT aimed to evaluate the acceptability, feasibility, and safety of a world-first patient decision-aid website (e-DA) to improve treatment decision-making regarding options for relapse prevention in BPII. The e-DA's potential efficacy in terms of improving quality of the decision-making process and quality of the decision made was also explored.

METHODS

The e-DA was based on International Patient Decision-Aid Standards and developed via an iterative co-design process. Adults with BPII diagnosis (n = 352) were recruited through a specialist outpatient clinical service and the social media of leading mental health organisations. Participants were randomised (1:1) to receive standard information with/without the e-DA (Intervention versus Control). At baseline (T0), post-treatment decision (T1) and at 3 months' post-decision follow-up (T2), participants completed a series of validated and purpose-designed questionnaires. Self-report and analytics data assessed the acceptability (e.g., perceived ease-of-use, usefulness; completed by Intervention participants only), safety (i.e., self-reported bipolar and/or anxiety symptoms), and feasibility of using the e-DA (% accessed). For all participants, questionnaires assessed constructs related to quality of the decision-making process (e.g., decisional conflict) and quality of the decision made (e.g., knowledge of treatment options and outcomes).

RESULTS

Intervention participants endorsed the e-DA as acceptable and feasible to use (82.1-94.6% item agreement); most self-reported using the e-DA either selectively (51.8%; relevant sections only) or thoroughly (34%). Exploratory analyses indicated the e-DA's potential efficacy to improve decision-making quality; most between-group standardised mean differences (SMD) were small-to-moderate. The largest potential effects were detected for objective treatment knowledge (- 0.69, 95% CIs - 1.04, - 0.33 at T1; and - 0.57, 95% CIs - 0.99,-0.14 at T2), decisional regret at T2 (0.42, 95% CIs 0.01, 0.84), preparation for decision-making at T1 (- 0.44, 95% CIs - 0.81, - 0.07), and the Decisional Conflict Scale Uncertainty subscale (0.42, 95% CIs 0.08, 0.08) and Total (0.36, 95% CIs 0.30, 0.69) scores, with all SMDs favouring the Intervention over the Control conditions. Regarding safety, e-DA use was not associated with worse bipolar symptoms or anxiety.

CONCLUSION

The e-DA appears to be acceptable, feasible, safe and potentially efficacious at improving patients' decision-making about BPII treatment. Findings also support the future adoption of the e-DA into patient care for BPII to foster treatment decisions based on the best available evidence and patient preferences.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617000840381 (prospectively registered 07/06/2017).

Evaluation of the Decision Aid for Genital Surgery in Transmen

BACKGROUND

Multiple options of genital gender-affirming surgery are available to transmen. The transman should be able to weigh these options based on the outcomes, risks, and consequences that are most important to him. For this reason, a decision aid for genital surgery in transmen (DA-GST) was developed. It aims to support the transman in making thoughtful choices among treatment options and facilitate shared decision-making between the healthcare professionals and the transindividual.

AIM

The aim of this study was to evaluate the newly developed DA-GST.

METHODS

This was a cross-sectional study using mixed methods. Transmen considering to undergo genital surgery were eligible to partake in the study. The questionnaires used in this study were developed by adapting the validated Dutch translation of the "Decisional Conflict Scale," the "Measures of Informed Choice," and the "Ottawa Preparation for Decision-Making Scale." Qualitative interviews were conducted querying their subjective experience with the DA-GST. The data from the questionnaires were statistically analyzed, and the data from the interviews were thematically analyzed.

OUTCOMES

The main outcome measures were decisional conflict and decisional confidence measured via self-report items and qualitative data regarding the use of the DA-GST via interviews.

RESULTS

In total, 51 transmen participated in the questionnaires study, 99 questionnaires were analyzed, and 15 interviews were conducted. Although confident in their decision, most transmen felt responsible to collect the necessary information themselves. The ability to go through the decision aid independently aided the decision-making process by providing information and highlighting their subjective priorities. Suggested additions are pictures of postoperational outcomes and personal statements from experienced transmen.

CLINICAL TRANSLATION

The DA-GST could be implemented as an integral part of transgender health care. Clinicians could take the individual personal values into account and use it to accurately tailor their consult. This would ultimately improve the doctor-patient relationship and decrease decisional regret by enhancing effective shared decision-making.

STRENGTHS & LIMITATIONS

This mixed-method design study confirmed the use of the DA-GST while taking a broad range of decisional factors into account. Limitations include the absence of a baseline analysis and the limited power for the comparison of treatment groups.

CONCLUSIONS

This study suggests that the DA-GST helped transmen feel more prepared for their personal consult with the surgeon, reduced decisional conflict, and increased their decisional confidence. Mokken SE, Özer M, van de Grift TC, et al. Evaluation of the Decision Aid for Genital Surgery in Transmen. J Sex Med 2020;17:2067-2076.

Decision-making in HIV clinical trials: a study with patients enrolled in antiretroviral trials

OBJECTIVE

To explore the decisional process of people living with human immunodeficiency virus (HIV) currently enrolled in antiretroviral clinical trials.

METHOD

Cross-sectional retrospective study. Outcome variables were reasons to participate, perceived decisional role (Control Preference Scale), the Decisional Conflict Scale and the Decisional Regret Scale. Descriptive statistics were calculated, and associations among these variables and with sociodemographic and clinical characteristics were analyzed with non-parametric techniques.

RESULTS

Main reasons to participate were gratitude towards Fundación Huesped (47%), the doctor's recommendation (32%), and perceived difficulty to access treatment in a public hospital (28%). Most patients thought that they made their decision alone (54.8%) or collaboratively with the physician (43%). Decisional conflict was low, with only some conflict in the support subscale (median=16.67). Education was the only significant correlate of the total decisional conflict score (higher in less educated patients; p=0.018), whereas education, recent diagnosis, living alone, lower age, being man and doctor's recommendation to go to Fundación Huésped related to higher conflict in different subscales. Nobody regretted to participate.

CONCLUSIONS

The decision making regarding participation in HIV trials, from the perspective of participants, was made respecting their autonomy and with very low decisional conflict. Currently, patients show no signs of regret. However, even in this favorable context, results highlight the necessity of enhancing the decision support in more vulnerable patients (e.g., less educated, recently diagnosed or with less social support), thus warranting equity in the quality of the decision making process.

Efficacy of a Decision Aid Consisting of a Video and Booklet on Advance Care Planning for Advanced Cancer Patients: Randomized Controlled Trial

CONTEXT

Few randomized controlled trials of advance care planning (ACP) with a decision aid (DA) show an effect on patient preferences for end-of-life (EOL) care over time, especially in racial/ethnic settings outside the U.S.

OBJECTIVES

The objective of this study was to examine the effect of a decision aid consisting of a video and an ACP booklet for EOL care preferences among patients with advanced cancer.

METHODS

Using a computer-generated sequence, we randomly assigned (1:1) patients with advanced cancer to a group that received a video and workbook that both discussed either ACP (intervention group) or cancer pain control (control group). At baseline, immediately after intervention, and at 7 weeks, we evaluated the subjects' preferences. The primary outcome was preference for EOL care (active treatment, life-prolonging treatment, or hospice care) on the assumption of a fatal disease diagnosis and the expectation of death 1) within 1 year, 2) within several months, and 3) within a few weeks. We used Bonferroni correction methods for multiple comparisons with an adjusted P level of 0.005.

RESULTS

From August 2017 to February 2018, we screened 287 eligible patients, of whom 204 were enrolled to the intervention (104 patients) or the control (100 patients). At postintervention, the intervention group showed a significant increase in preference for active treatment, life-prolonging treatment, and hospice care on the assumption of a fatal disease diagnosis and the expectation of death within 1 year (P < 0.005). Assuming a life expectancy of several months, the change in preferences was significant for active treatment and hospice care (P < 0.005) but not for life-prolonging treatment. The intervention group showed a significant increase in preference for active treatment, life-prolonging treatment, and hospice care on the assumption of a fatal disease diagnosis and the expectation of death within a few weeks (P < 0.005). From baseline to 7 weeks, the decrease in preference in the intervention group was not significant for active treatment, life-prolonging treatment, and hospice care in the intervention group in the subset expecting to die within 1 year, compared with the control group. Assuming a life expectancy of several months and a few weeks, the change in preferences was not significant for active treatment and for life-prolonging treatment but was significantly greater for hospice care in the intervention group (P < 0.005).

CONCLUSION

ACP interventions that included a video and an accompanying book improved preferences for EOL care.

Knowledge of and attitudes toward clinical trials in Saudi Arabia: a cross-sectional study

OBJECTIVES

Clinical trials (CTs) are considered an important method for developing new treatments and providing access to potentially effective drugs that are still under investigation. Measuring the public's knowledge of and attitudes toward CTs is important for assessing their readiness for and acceptance of human drug testing, which has previously not been assessed in the Kingdom of Saudi Arabia (KSA). The objective of this study is to explore the Saudi public's knowledge of and attitudes toward CTs as well as participation in trials to test new or approved drugs.

DESIGN

Cross-sectional.

SETTING

The 2016 Al Jenadriyah cultural/heritage festival in Riyadh, KSA.

PARTICIPANTS

Participating booths and exhibition halls, as well as festival visitors, were approached to participate in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Knowledge of and attitudes toward CTs.

RESULTS

The final number of participants was 938. The responses were converted to a percentage mean score (out of 100) for each knowledge-related response and attitude. The total mean knowledge score was 56.8±24.8 and the attitude-related score was 61.5±28.0. Although most of the participants supported testing approved or off-label and new drugs on adult and paediatric patients, only a third (30.5%) agreed that new drugs could be tested on healthy volunteers. The results indicated that gender, educational level, income, medical background, age and health insurance were independently associated with the level of knowledge of CTs. In terms of attitudes toward CTs, the factors that were independently associated were gender, educational level and medical background.

CONCLUSIONS

The Saudi public has a low level of knowledge and a moderately positive attitude toward CTs. There is a moderate positive correlation between the two factors such that as knowledge of CTs increases, the Saudi public will hold more positive attitudes toward CTs.

An education intervention to improve decision making and health literacy among older Australians: a randomised controlled trial

Background

National policies seek to involve older Australian’s in decisions regarding their care; however, research has found varying levels of decision self-efficacy and health literacy skills. An increasing number of older Australians use complementary medicine (CM). We examined the effectiveness of a CM educational intervention delivered using a web or DVD plus booklet format to increase older adults’ decision self-efficacy and health literacy.

Methods

A randomised controlled trial was conducted. We recruited individuals aged over 65 years living in retirement villages or participating in community groups, in Sydney Australia. Participants were randomly allocated to receive a CM education intervention delivered using a website or DVD plus booklet versus booklet only. The primary outcome was decision self-efficacy. A secondary outcome included the Preparation for Decision-Making scale and health literacy. Outcomes were collected at 3 weeks, and 2 months from baseline, and analysed using an adjusted ANOVA, or repeated measures ANOVA.

Result

We randomised 153 participants. Follow up at 3 weeks and 2 months was completed by 131 participants. There was a 14% (n = 22) attrition rate. At the end of the intervention, we found no significant differences between groups for decision self-efficacy (mean difference (MD) 3.8, 95% confidence interval (CI) -2.0 to 9.6 p = 0.20), there were no differences between groups on nine health literacy domains, and the Preparation for Decision-Making scale. Over 80% of participants in both groups rated the content as excellent or good.

Conclusion

Decision self-efficacy improved for participants, but did not differ between groups. Decision self-efficacy and health literacy outcomes were not influenced by the delivery of education using a website, DVD or booklet. Participants found the resources useful, and rated the content as good or excellent. CM Web or DVD and booklet resources have the potential for wider application.

Trial registration

The trial was registered with the Australian New Zealand Clinical Trials Registry: ACTRN (ACTRN12616000135415). The trial was registered on 5 February 2016.

Decisional conflict among breast cancer patients considering contralateral prophylactic mastectomy

OBJECTIVES

The study's goals were to characterize decisional conflict and preparedness for making the decision about having CPM among breast cancer patients considering CPM who do not carry cancer-predisposing mutation and to evaluate correlates of decisional conflict and preparedness.

METHODS

93 women considering CPM completed a survey of decisional conflict and preparedness for the CPM decision, knowledge, perceived risk, self-efficacy, reasons for CPM, input from others and discussion with the doctor about CPM, and cancer worry.

RESULTS

Between 8% and 27% of women endorsed elevated decisional conflict. Most women were satisfied with preparatory information that they were provided. Knowledge was low. Top reasons for choosing CPM were the desire for peace of mind, lowering the chance of another breast cancer, and improving survival.

CONCLUSIONS

Decisional conflict is elevated in a subset of patients considering CPM. A more well-informed decision may be fostered by a comprehensive discussion about CPM with the patient's clinician, fostering self-efficacy in managing cancer worry, and helping patients understand their motivations for CPM.

PRACTICE IMPLICATIONS

Clinicians working with breast cancer patients considering CPM should discuss the CPM decision, foster self-efficacy in managing cancer worry, and help patients understand their motivations for the surgery.

Understanding Patients' Preferences: A Systematic Review of Psychological Instruments Used in Patients' Preference and Decision Studies

BACKGROUND

Research has been mainly focused on how to elicit patient preferences, with less attention on why patients form certain preferences.

OBJECTIVES

To assess which psychological instruments are currently used and which psychological constructs are known to have an impact on patients' preferences and health-related decisions including the formation of preferences and preference heterogeneity.

METHODS

A systematic database search was undertaken to identify relevant studies. From the selected studies, the following information was extracted: study objectives, study population, design, psychological dimensions investigated, and instruments used to measure psychological variables.

RESULTS

Thirty-three studies were identified that described the association between a psychological construct, measured using a validated instrument, and patients' preferences or health-related decisions. We identified 33 psychological instruments and 18 constructs, and categorized the instruments into 5 groups, namely, motivational factors, cognitive factors, individual differences, emotion and mood, and health beliefs.

CONCLUSIONS

This review provides an overview of the psychological factors and related instruments in the context of patients' preferences and decisions in healthcare settings. Our results indicate that measures of health literacy, numeracy, and locus of control have an impact on health-related preferences and decisions. Within the category of constructs that could explain preference and decision heterogeneity, health locus of control is a strong predictor of decisions in several healthcare contexts and is useful to consider when designing a patient preference study. Future research should continue to explore the association of psychological constructs with preference formation and heterogeneity to build on these initial recommendations.

Ready to Make A Decision: A Model of Informational Aids to Improve Informed Participation in Clinical Trial Research

Enrollment rates for cancer clinical trials remain low, affecting the generalizability of new treatments. Research shows that many patients face significant challenges in understanding basic clinical trial vocabulary and making informed decisions about participation. Informational aids (IA) are developed to address these challenges and support decision making of cancer clinical trial participation. The present study proposed and tested a structural path model to explain the efficacy of three (i.e., interactive, non-interactive, non-cancer control) IAs. The results revealed that clinical trial participation intention was associated with attitudes and social constructs (i.e., social norm, social sharing, and cues to action). Ease of use, rather than knowledge, was the primary communication feature of IA that influenced the outcome variables. The path relations linking messages features, mediators, and outcome variables were different across all three IAs. The results therefore provide theoretical and practical implications for the use and development of IAs to support clinical trial accrual.

The perceived severity of a disease and the impact of the vocabulary used to convey information: using Rasch scaling in a simulated oncological scenario

BACKGROUND

Healthcare staff should be aware of the importance that patients may attach to the words that are used to convey information. This is relevant in terms of the patients' understanding. Modeling how people understand the information conveyed in a medical context may help health practitioners to better appreciate the patients' approach.

PURPOSE

1) Analyze the participants' self-reported perception of the type of information provided in an oncological scenario in terms of three dimensions: impairment to their health, risks associated with the disease itself and commitment required to undergo the treatment; and 2) show the benefits of using Rasch scaling for the analysis of the data. Starting from a survey, Rasch scaling produces a unidimensional logit-interval scale relating to the extent to which each item conveys a latent dimension. These were related to structure, in particular concerning communication by means of opposite vs. unipolar language.

SUBJECTS AND METHODS

The participants rated 82 items of information in a questionnaire regarding their perception of impairment to their health (H) and the risks (R) and commitment relating to the treatment prescribed (T).

RESULTS

The scaling produced an item bank for healthcare staff to consult in order to estimate the importance the recipient would be likely to attach to the vocabulary used and the likely impact of the information in terms of the patient's condition. Furthermore, the use of opposites was generally associated with a clearer impression of whether the information given was generally only very negative or slightly negative, whereas 'neutral' information was often perceived as being very negative.

ACTUAL FINDINGS

Is possible to estimate people's understanding more precisely (in terms of H, R and T) which can help healthcare practitioners to modulate the way they convey information.

LIMITATIONS

The participants in the study were healthy volunteers and the context was simulated.

Patient reported measures of informed consent for clinical trials: A systematic review

INTRODUCTION

The subjective assessment of the adequacy of informed consent for clinical trials, and the potential difficulties associated with it, has led several studies to develop objective measures of informed consent for clinical trials. These objective measures of informed consent are often specific to a particular population or clinical condition and largely focus on understanding of (some or all of) the key elements of informed consent. Many of the developed tools are study-specific, but some validated measures exist. Of these validated measures, those which are reported by participants are of particular interest. Whether these objective tools conceptualize and measure informed consent in the same way is not known. As such, it is not clear whether meta-analyzing data from studies reporting different tools is worthwhile. The aim of this systematic review was to critically appraise the evidence on the overall conceptualisation and item content of validated patient reported measures of informed consent for clinical trials, and to identify core domains of potential importance for informed consent.

METHODS

A systematic search of the literature was conducted to identify relevant articles that described the development, and/or validation, of patient-reported measures of adequacy of informed consent for randomised controlled trials. Data was synthesised by classifying the items identified into domains and sub-domains which were determined by the nomenclature reported in included studies. Both for descriptions of included studies and of the instruments reported in those studies, descriptive statistics were used to describe general information and instrument detail. A narrative synthesis of the instruments and their inter-related domains and subdomains was conducted to identify areas of both convergence and divergence.

RESULTS

The search identified 8193 citations. After screening titles and abstracts, 29 full text articles were retrieved for further assessment. Of these 29, 14 complied with our pre-specified inclusion criteria with 15 not being eligible. Of the 14 instruments, three explicitly reported a theoretical or conceptual framework underpinning their development, a further three implicitly referred to the 'conceptual dimensions of informed consent' or 'principles of research ethics' as informing their development and eight reported no guiding theoretical framework. Only three of the 14 studies reported patient or public involvement in the development of the tool. One hundred and seventy nine items were included across the 14 instruments. The primary focus of the instruments was on understanding. Five core domains were identified which included: Autonomy; Consequences; Expectations; Purpose; and Individualisation. There was substantial variability in the coverage of different domains across measures.

CONCLUSIONS

This study demonstrated the variability in the theoretical underpinning, development and domain coverage of existing patient-reported measures of informed consent for clinical trials. The conceptualisation of informed consent could benefit from being extended from a narrow focus on understanding to include broader considerations of decision-making. Meaningful involvement of potential trial participants during development of measures critical for tool relevance is also lacking. The identification of the key domains relevant to all stakeholders which could be measured to assess the informed consent process for clinical trials is needed.

Decisional conflict in end-of-life cancer treatment among family surrogates: A cross-sectional survey

The aims of this study were to examine the extent of decisional conflict in end-of-life cancer treatments and to investigate the influences and predictors of decisional conflict among family surrogates. A cross-sectional, descriptive, correlational design was applied. Data were collected from a convenience sample of 102 family members who had participated in end-of-life cancer decision-making. We enrolled participants from inpatient oncology units at a university hospital in South Korea from May 2014 to January 2016. The results indicated that many family surrogates had high levels of decisional conflict and psychological stress after end-of-life cancer decision-making. Hierarchical multiple regression analyses demonstrated that decisional conflict had significant, substantial influences on decision regret and psychological stress after controlling for demographic variables. Family surrogates who were aware of the patients' wishes about end-of-life treatments and those who had good family functioning had less decisional conflict. To relieve decisional conflict regarding end-of-life cancer treatment among family surrogates, it is necessary to encourage patients to share their end-of-life treatment wishes with family members and to consider family functioning in the end-of-life decision-making process.

Attitudes towards mental health, mental health research and digital interventions by young adults with type 1 diabetes: A qualitative analysis

BACKGROUND

Young people with type 1 diabetes are at increased risk of mental disorders. Whereas treatment need is high, difficulty recruiting young people with type 1 diabetes into psychosocial studies complicates development, testing and dissemination of these interventions.

OBJECTIVE

Interviews with young adults with type 1 diabetes were conducted to examine attitudes towards mental health and mental health research, including barriers and motivators to participation in mental health studies and preferred sources of mental health support. The interviews were audio-taped, transcribed and evaluated via thematic analysis.

SETTING AND PARTICIPANTS

Young adults with type 1 diabetes were recruited via social media channels of 3 advocacy organizations. A total of 31 young adults (26 females and 5 males) with an average age of 22 years were interviewed between October 2015 and January 2016.

RESULTS

Participants were largely unaware of their increased vulnerability to common mental health problems and knew little about mental health research. Major barriers to participation included perceived stigma and lifestyle issues and low levels of trust in researchers. Opportunities to connect with peers and help others were described as key motivators. Psychological distress was considered normal within the context of diabetes. A need for some level of human contact in receiving psychosocial support was expressed.

DISCUSSION AND CONCLUSION

Findings provide valuable insights into the complex dynamics of engaging young adults with type 1 diabetes in mental health studies. Interviewees provided practical suggestions to assist investigation and delivery of psychosocial interventions for this vulnerable group.

The effects of presenting oncologic information in terms of opposites in a medical context

BACKGROUND

An extensive body of literature has demonstrated that many patients who have been asked to participate in clinical trials do not fully understand the informed consent forms. A parallel independent study has demonstrated that opposites have a special status in human cognitive organization: they are common to all-natural languages and are intuitively and naturally understood and learnt.

PURPOSE

The study investigates whether, and how, the use of opposites impacts on doctor-patient communication: does using the terms "small-large" to describe a nodule (ie, bipolar communication) rather than speaking in terms of centimeters (ie, unipolar communication) affect a patient's understanding of the situation? And is it better to speak of "common-rare" side effects (ie, bipolar communication) instead of the number of people who have suffered from particular side effects (ie, unipolar communication)?

METHODS

Two questionnaires were created and used, one presenting the information in terms of opposites (ie, bipolar communication) and another using unipolar communication.

RESULTS

The participants' perception of their situation (in terms of feeling healthy-ill, being at high-low risk, and their treatment requiring high-low commitment) varied in the two conditions. Moreover, self-reported levels of understanding and satisfaction with how the information was communicated were higher when opposites were used.

LIMITATIONS

Since this is the first study that addresses the merits of using bipolar structures versus unipolar structures in doctor-patient communication, further work is needed to consolidate and expand on the results, involving not only simulated but also real diagnostic contexts.

CONCLUSION

The encouraging results imply that further testing of the use of opposites in informed consent forms and in doctor-patient communication is strongly advisable.

When Employment and Caregiving Collide: Predictors of Labor Force Participation in Prospective and Current Caregivers

OBJECTIVE

Female caregivers often reduce time spent at work to care for aging family members, which precipitates financial hardship and other adverse outcomes. Little is known about psychosocial correlates of labor force participation (LFP) among female caregivers. The theory of planned behavior posits that social norms, attitudes, and perceived control predict intentions and volitional behaviors, but also that the compelling influence of situational variables undermines enactment of behaviors consistent with one's intentions. The objective of this study was to employ the theory of planned behavior to examine how psychosocial characteristics predict willingness to reduce LFP among prospective caregivers and actual LFP reduction among active caregivers.

METHODS

Subsamples of 165 female prospective caregivers and 97 active female caregivers responded to a survey assessing filial beliefs and LFP.

RESULTS

Filial obligation and caregiver preparedness predicted intentions to reduce LFP among prospective caregivers, but did not predict actual reduction in LFP in active caregivers. Weekly care demands exceeding 20 hours emerged as the sole correlate of LFP among active caregivers.

CONCLUSIONS

Domains of the theory of planned behavior predict LFP intentions, but LFP decisions are subject to external pressures, specifically, time demands of the caregiving relationship. Prospective caregivers may benefit from proactive interventions aimed at reducing conflict between situational demands and filial beliefs.

A Data Capture Framework for Large-scale Interventional Studies with Survey Workflow Management

Capturing high-quality survey data is an arduous process for large-scale and extensive interventional studies. This paper presents the architecture, interface design, and an innovative form generation engine of a system called RE- Form: Refactorized Electronic Web Forms. REForm provides researchers the capability to design and manage surveys and the flexibility to organize them in a customizable workflow. REForm has been designed, implemented, pilot-tested and deployed for an NCI-funded interventional study IMPACT. It enables IMPACT to design and conduct a baseline survey of 95 questions with 662 options, a post-intervention survey of 82 questions with 574 options, six Ecological Momentary Assessment (EMA) surveys including four questions and 26 options each, and a follow-up survey con- taining 15 questions and 125 options. Feedback designed in the post-intervention survey showed that more than 94 percent of IMPACT participants highly endorsed the design and usability of the surveys created using REForm.

Conflict when making decisions about dialysis modality

AIMS AND OBJECTIVES

To explore decisional conflict and its influencing factors on choosing dialysis modality in patients with end-stage renal diseases. The influencing factors investigated include demographics, predialysis education, dialysis knowledge, decision self-efficacy and social support.

BACKGROUND

Making dialysis modality decisions can be challenging for patients with end-stage renal diseases; there are pros and cons to both haemodialysis and peritoneal dialysis. Patients are often uncertain as to which one will be the best alternative for them. This decisional conflict increases the likelihood of making a decision that is not based on the patient's values or preferences and may result in undesirable postdecisional consequences. Addressing factors predisposing patients to decisional conflict helps to facilitate informed decision-making and then to improve healthcare quality.

DESIGN

A predictive correlational cross-sectional study design was used.

METHODS

Seventy patients were recruited from the outpatient dialysis clinics of two general hospitals in Taiwan. Data were collected with study questionnaires, including questions on demographics, dialysis modality and predialysis education, the Dialysis Knowledge Scale, the Decision Self-Efficacy scale, the Social Support Scale, and the Decisional Conflict Scale.

RESULTS

The mean score on the Decisional Conflict Scale was 29.26 (SD = 22.18). Decision self-efficacy, dialysis modality, predialysis education, professional support and dialysis knowledge together explained 76.4% of the variance in decisional conflict.

CONCLUSIONS

Individuals who had lower decision self-efficacy, did not receive predialysis education on both haemodialysis and peritoneal dialysis, had lower dialysis knowledge and perceived lower professional support reported higher decisional conflict on choosing dialysis modality.

RELEVANCE TO CLINICAL PRACTICE

When providing decisional support to predialysis stage patients, practitioners need to increase patients' decision self-efficacy, provide both haemodialysis and peritoneal dialysis predialysis education, increase dialysis knowledge and provide professional support.

Clinical Trial Characteristics and Barriers to Participant Accrual: The MD Anderson Cancer Center Experience over 30 years, a Historical Foundation for Trial Improvement

Purpose: Slow-accruing clinical trials delay the translation of basic biomedical research, contribute to increasing health care costs, and may prohibit trials from reaching their original goals.Experimental Design: We analyzed a prospectively maintained institutional database that tracks all clinical studies at the MD Anderson Cancer Center (Houston, TX). Inclusion criteria were activated phase I-III trials, maximum projected accrual ≥10 participants, and activation prior to March 25, 2011. The primary outcome was slow accrual, defined as <2 participants per year. Correlations of trial characteristics with slow accrual were assessed with logistic regression.Results: A total of 4,269 clinical trials met inclusion criteria. Trials were activated between January 5, 1981, and March 25, 2011, with a total of 145,214 participants enrolled. Median total enrolment was 16 [interquartile range (IQR), 5-34], with an average enrolment rate of 8.7 participants per year (IQR, 3.3-17.7). There were 755 (18%) trials classified as slow accruing. On multivariable analysis, slow accrual exhibited robust associations with national cooperative group trials (OR = 4.16, P < 0.0001 vs. industry sponsored), time from trial activation to first enrolment (OR = 1.13 per month, P < 0.0001), and maximum targeted accrual (OR = 0.16 per log10 increase, P < 0.0001). Recursive partitioning analysis identified trials requiring more than 70 days (2.3 months) between activation and first participant enrolment as having higher odds of slow accrual (23% vs. 5%, OR = 5.56, P < 0.0001).Conclusions: We identified factors associated with slow trial accrual. Given the lack of data on clinical trials at the institutional level, these data will help build a foundation from which targeted initiatives may be developed to improve the clinical trial enterprise. Clin Cancer Res; 23(6); 1414-21. ©2017 AACR.

Relative contribution of genetic, individual, and self-efficacy factors to smoking cessation in a Chinese rural population

BACKGROUND AND OBJECTIVES

Nicotine dependence is influenced by genetic, individual, and psychological factors. We aimed to examine whether nicotinic acetylcholine receptor genes (CHRN) were associated with smoking cessation (SC) using genetic risk score and compare the relative contribution of genetic, individual and self-efficacy factors to SC.

METHODS

Eight hundred and nineteen male smokers (mean age: 59.62) were recruited from 17 villages of three counties in Shandong province, China. Thirty-two single nucleotide polymorphisms (SNPs) in seven CHRN genes were genotyped. Logistic regression was used to explore the relationship between genetic risk score and SC. Dominance analysis was performed to compare the relative contribution of genetic, individual, and self-efficacy factors on SC.

RESULTS

CHRNA3 genetic risk score was associated with SC. Dominance analysis showed that individual factor was the most important predictor for SC, followed by genetic and self-efficacy factors.

CONCLUSIONS

CHRNA3 was associated with successful SC. Individual factor had more contribution than genetic factor to SC.

SCIENTIFIC SIGNIFICANCE

Our findings provide support to the role of CHRN genes in the etiology of smoking cessation using genetic risk score. Individual factor should be particularly valued in smoking control intervention. (Am J Addict 2017;26:161-166).

Translation to Brazilian Portuguese, cultural adaptation and reproducibility of the questionnaire "Ankylosing Spondylitis: What do you know?"

CONTEXT AND OBJECTIVE:

Ankylosing spondylitis (AS) generates inflammation and pain in entheses, peripheral joints and the spine. Education regarding AS can improve patients' disability. Thus, it is important to assess patients' knowledge. There is no instrument in the literature for assessing knowledge of AS in Portuguese. The aim here was to translate to the Brazilian Portuguese language, culturally adapt and test the reliability of the questionnaire "Ankylosing Spondylitis: What do you know?" and to correlate the findings with other factors.

DESIGN AND SETTING:

Original article regarding validation of questionnaire, produced at the Federal University of Sao Paulo (Unifesp).

METHODS:

For translation and cultural adaptation, Guilleman methodology was used. After the first phase, the reliability was tested on 30 patients. Correlations between these scores and other factors were examined.

RESULTS:

In the interobserver assessment, the Pearson correlation coefficient and Cronbach's alpha were 0.831 and 0.895, respectively. In the intraobserver evaluation, the intraclass correlation coefficient and Cronbach's alpha were 0.79 and 0.883, respectively. At this stage, the score for area of knowledge A showed correlations with ethnicity and education; the score for area D, with age; the total score and scores for areas A and B with "social aspects" of SF-36; and the score for area D with "pain", "vitality" and "emotional aspects" of SF-36.

CONCLUSION:

The Brazilian version of the questionnaire "Ankylosing Spondylitis: What do you know?" was created. It is reproducible and correlates with education level, ethnicity and the SF-36 domains "social aspects" and "emotional aspects".

Financial Burden of Cancer Clinical Trial Participation and the Impact of a Cancer Care Equity Program

INTRODUCTION

Cancer clinical trial (CT) participation rates are low and financial barriers likely play a role. We implemented a cancer care equity program (CCEP) to address financial burden associated with trial participation. We sought to examine the impact of the CCEP on CT enrollment and to assess barriers to participation.

METHODS

We used an interrupted time series design to determine trends in CT enrollment before and after CCEP implementation. Linear regression models compared trial enrollment before and after the CCEP. We also compared patient characteristics before and after the CCEP and between CCEP and non-CCEP participants. We surveyed CCEP and non-CCEP participants to compare pre-enrollment financial barriers.

RESULTS

After accounting for increased trial availability and the trends in accrual for prior years, we found that enrollment increased after CCEP implementation (18.97 participants per month greater than expected; p < .001). A greater proportion of CCEP participants were younger, female, in phase I trials, lived farther away, had lower incomes, and had metastatic disease. Of 87 participants who completed the financial barriers survey, 49 CCEP and 38 matched, non-CCEP participants responded (63% response rate). CCEP participants were more likely to report concerns regarding finances (56% vs. 11%), medical costs (47% vs. 14%), travel (69% vs. 11%), lodging (60% vs. 9%), and insurance coverage (43% vs. 14%) related to trial participation (all p < .01).

CONCLUSION

CT participation increased following implementation of the CCEP and the program enrolled patients experiencing greater financial burden. These findings highlight the need to address the financial burden associated with CT participation.

IMPLICATIONS FOR PRACTICE

Financial barriers likely discourage patients from participating in clinical trials. Implementation of a cancer care equity program (CCEP) seeking to reduce financial barriers by assisting with travel and lodging costs was associated with increased trial accrual. The CCEP provided assistance to patients particularly in need, including those living farther away, those with lower incomes, and those reporting financial barriers related to trial participation. These findings suggest that financial concerns represent a major barrier to patient participation in clinical trials and underscore the importance of efforts to address these concerns.

Randomized Trial of a Web-Based Intervention to Address Barriers to Clinical Trials

PURPOSE

Lack of knowledge and negative attitudes have been identified as barriers to participation in clinical trials by patients with cancer. We developed Preparatory Education About Clinical Trials (PRE-ACT), a theory-guided, Web-based, interactive computer program, to deliver tailored video educational content to patients in an effort to overcome barriers to considering clinical trials as a treatment option.

PATIENTS AND METHODS

A prospective, randomized clinical trial compared PRE-ACT with a control condition that provided general clinical trials information produced by the National Cancer Institute (NCI) in text format. One thousand two hundred fifty-five patients with cancer were randomly allocated before their initial visit with an oncologist to PRE-ACT (n = 623) or control (n = 632). PRE-ACT had three main components: assessment of clinical trials knowledge and attitudinal barriers, values assessment with clarification back to patients, and provision of a video library tailored to address each patient's barriers. Outcomes included knowledge and attitudes and preparation for decision making about clinical trials.

RESULTS

Both PRE-ACT and control interventions improved knowledge and attitudes (all P < .001) compared with baseline. Patients randomly allocated to PRE-ACT showed a significantly greater increase in knowledge (P < .001) and a significantly greater decrease in attitudinal barriers (P < .001) than did their control (text-only) counterparts. Participants in both arms significantly increased their preparedness to consider clinical trials (P < .001), and there was a trend favoring the PRE-ACT group (P < .09). PRE-ACT was also associated with greater patient satisfaction than was NCI text alone.

CONCLUSION

These data show that patient education before the first oncologist visit improves knowledge, attitudes, and preparation for decision making about clinical trials. Both text and tailored video were effective. The PRE-ACT interactive video program was more effective than NCI text in improving knowledge and reducing attitudinal barriers.

Financial Concerns About Participation in Clinical Trials Among Patients With Cancer

PURPOSE

The decision to enroll in a clinical trial is complex given the uncertain risks and benefits of new approaches. Many patients also have financial concerns. We sought to characterize the association between financial concerns and the quality of decision making about clinical trials.

METHODS

We conducted a secondary data analysis of a randomized trial of a Web-based educational tool (Preparatory Education About Clinical Trials) designed to improve the preparation of patients with cancer for making decisions about clinical trial enrollment. Patients completed a baseline questionnaire that included three questions related to financial concerns (five-point Likert scales): "How much of a burden on you is the cost of your medical care?," "I'm afraid that my health insurance won't pay for a clinical trial," and "I'm worried that I wouldn't be able to afford the costs of treatment on a clinical trial." Results were summed, with higher scores indicating greater concerns. We used multiple linear regressions to measure the association between concerns and self-reported measures of self-efficacy, preparation for decision making, distress, and decisional conflict in separate models, controlling for sociodemographic characteristics.

RESULTS

One thousand two hundred eleven patients completed at least one financial concern question. Of these, 27% were 65 years or older, 58% were female, and 24% had a high school education or less. Greater financial concern was associated with lower self-efficacy and preparation for decision making, as well as with greater decisional conflict and distress, even after adjustment for age, race, sex, education, employment, and hospital location (P < .001 for all models).

CONCLUSION

Financial concerns are associated with several psychological constructs that may negatively influence decision quality regarding clinical trials. Greater attention to patients' financial needs and concerns may reduce distress and improve patient decision making.

Patients' knowledge and perceived understanding - Associations with consenting to participate in cancer clinical trials

Recruitment to clinical trials is essential. The aims of the study were to investigate associations between patients' informed consent to participate in a cancer clinical trial and knowledge and perceived understanding of the trial. Furthermore, associations between demographic factors and consent to participate and knowledge and perceived understanding of information about the trial were studied.

Methods

The patients were recruited in connection to a visit at the oncology clinic for information about a drug trial. The Quality of Informed Consent questionnaire was mailed to the patients after they had decided about participation in the trial. The associations of demographic factors and "knowledge" and "perceived understanding" were analysed using linear regression models.

Results

A total of 125 patients were included. Higher levels of "knowledge" and "understanding" were found to be associated with consent to participate in a clinical trial, both in the univariate and multivariate analyses (p = 0.001). None of the tested demographic factors were related to consent to participate. No statistically significant associations between any of the demographic factors and knowledge or perceived understanding scores were found.

Conclusion

The results indicate that interventions that increase patients' knowledge and perceived understanding might improve participation rates in clinical trials.

Decisional conflict in asthma patients: a cross sectional study

OBJECTIVE

This study aimed at determining the level of decisional conflict in asthmatic individuals facing recommendation-based decisions provided to improve asthma control.

METHODS

This was a cross-sectional study performed on a convenience sample of 50 adults aged between 18 and 65 years with a diagnosis of asthma. They completed a decisional conflict scale (possible range of 0-100%), asthma knowledge and control questionnaires (both 0% and 100%), and a general questionnaire on socio-demographic characteristics. A decisional conflict was considered clinically significant with a score greater than 37.5%. Simple descriptive statistics were used to investigate associations with decisional conflict.

RESULTS

Participants were mainly women (76%) and diagnosed with mild asthma (72%). The median age (1st and 3rd quartile) was 25 years (22 and 42). The median score (1st and 3rd quartile) of decisional conflict was 33% (24 and 44). A clinically significant score (>37.5%) was obtained in 36% of subjects. A statistically significant negative correlation between the knowledge score and the decisional conflict score (r(p) = -0.38; p = 0.006) was observed. The level of knowledge was the only statistically independent variable associated with the decisional conflict score (p = 0.0043).

CONCLUSIONS

A considerable proportion of patients with asthma have a clinically significant level of decisional conflict when facing decisions aimed at improving asthma control. Patients with poor knowledge of asthma are more at risk of clinically significant level of decisional conflict. These findings support the relevance of providing asthmatic patients with relevant information in decision aids.

Authentic caring occasions for patients in hairy cell leukemia clinical trials

BACKGROUND

Rare diseases present challenges for patients, healthcare providers, and researchers. Rare disease communities exist for collaboration, dissemination of information, and to promote support for all community members. Patients with a rare disease desire to be supported through a rare disease community. Hairy cell leukemia (HCL) is a rare adult B-cell lymphocytic cancer that currently has no cure.

OBJECTIVES

Patients with relapsed or refractory HCL may need to consider participation in a clinical trial. The research nurse can initiate a planned caring occasion based on Watson's Theory of Human Caring. The purpose of the planned caring occasion for patients with HCL in clinical trials is to establish authentic intentional caring encounters between the research nurse and patients and meaningful caring encounters between patients.

OBSERVATIONS

Relapsed or refractory patients enrolled in an HCL clinical trial identify the trial as a microcommunity and the research nurse as an advocate and liaison. Patients seek support, empowerment, and the opportunity to connect with other patients with HCL. The planned caring occasion has the potential to provide a healing environment and facilitate shared experiences of living with HCL. The potential outcome for patients is strengthened holistic wellness.

Making a decision about trial participation: the feasibility of measuring deliberation during the informed consent process for clinical trials

Background

Informed consent of trial participants is both an ethical and a legal requirement. When facing a decision about trial participation, potential participants are provided with information about the trial and have the opportunity to have any questions answered before their degree of ‘informed-ness’ is assessed, usually subjectively, and before they are asked to sign a consent form. Currently, standardised methods for assessing informed consent have tended to be focused on aspects of understanding and associated outcomes, rather than on the process of consent and the steps associated with decision-making.

Methods

Potential trial participants who were approached regarding participation in one of three randomised controlled trials were asked to complete a short questionnaire to measure their deliberation about trial participation. A total of 136 participants completed the 10-item questionnaire (DelibeRATE) before they made an explicit decision about trial participation (defined as signing the clinical trial consent form). Overall DelibeRATE scores were compared and investigated for differences between trial consenters and refusers.

Results

No differences in overall DelibeRATE scores were identified. In addition, there was no significant difference between overall score and the decision to participate, or not, in the parent trial.

Conclusions

To our knowledge, this is the first study to prospectively measure the deliberation stage of the informed consent decision-making process of potential trial participants across different conditions and clinical areas. Although there were no differences detected in overall scores or scores of trial consenters and refusers, we did identify some interesting findings. These findings should be taken into consideration by those designing trials and others interested in developing and implementing measures of potential trial participants decision making during the informed consent process for research.

Trial registration

International Standard Randomised Controlled Trial Number (ISRCTN) Register ISRCTN60695184 (date of registration: 13 May 2009), ISRCTN80061723 (date of registration: 8 March 2010), ISRCTN69423238 (date of registration: 18 November 2010)

Application of best practice approaches for designing decision support tools: the preparatory education about clinical trials (PRE-ACT) study

OBJECTIVE

This article describes the rigorous development process and initial feedback of the PRE-ACT (Preparatory Education About Clinical Trials) web-based- intervention designed to improve preparation for decision making in cancer clinical trials.

METHODS

The multi-step process included stakeholder input, formative research, user testing and feedback. Diverse teams (researchers, advocates and developers) participated including content refinement, identification of actors, and development of video scripts. Patient feedback was provided in the final production period and through a vanguard group (N=100) from the randomized trial.

RESULTS

Patients/advocates confirmed barriers to cancer clinical trial participation, including lack of awareness and knowledge, fear of side effects, logistical concerns, and mistrust. Patients indicated they liked the tool's user-friendly nature, the organized and comprehensive presentation of the subject matter, and the clarity of the videos.

CONCLUSION

The development process serves as an example of operationalizing best practice approaches and highlights the value of a multi-disciplinary team to develop a theory-based, sophisticated tool that patients found useful in their decision making process. Practice implications Best practice approaches can be addressed and are important to ensure evidence-based tools that are of value to patients and supports the usefulness of a process map in the development of e-health tools.

Knowledge, attitudes, and self-efficacy as predictors of preparedness for oncology clinical trials: a mediational model

OBJECTIVE

This study used the Ottawa Decision Support Framework to evaluate a model examining associations between clinical trial knowledge, attitudinal barriers to participating in clinical trials, clinical trial self-efficacy, and clinical trial preparedness among 1256 cancer patients seen for their first outpatient consultation at a cancer center. As an exploratory aim, moderator effects for gender, race/ethnicity, education, and metastatic status on associations in the model were evaluated.

METHODS

. Patients completed measures of cancer clinical trial knowledge, attitudinal barriers, self-efficacy, and preparedness. Structural equation modeling (SEM) was conducted to evaluate whether self-efficacy mediated the association between knowledge and barriers with preparedness.

RESULTS

. The SEM explained 26% of the variance in cancer clinical trial preparedness. Self-efficacy mediated the associations between attitudinal barriers and preparedness, but self-efficacy did not mediate the knowledge-preparedness relationship.

CONCLUSIONS

. Findings partially support the Ottawa Decision Support Framework and suggest that assessing patients' level of self-efficacy may be just as important as evaluating their knowledge and attitudes about cancer clinical trials.

Gene therapy researchers' assessments of risks and perceptions of risk acceptability in clinical trials

Although recent clinical trials have demonstrated the increasing promise of gene therapy, they have also illustrated the difficulties of assessing risks, given the inherent uncertainty of trial outcomes. An international survey was conducted to investigate gene therapy researchers' perceptions and assessments of risks in clinical trials. Data from respondents (n = 156) demonstrated researchers' perceptions of clinical context and the strength of preclinical evidence strongly influenced risk assessments and judgments of acceptable risk levels. Professional experience in clinical care, and particularly care of children, predicted favorable attitudes toward nonanimal preclinical models and trial initiation when sub-optimal treatments were available. The potential for adverse events to impact negatively on the gene therapy field and on public trust were relevant considerations when planning a trial. Decisions about clinical trials appear to be influenced not only by the clinical context and preclinical evidence, but also subjective factors reflecting the experience of researchers, value-judgments about risk and benefit, and attitudes toward preclinical models, uncertainty, adverse events, and the perceived needs of patients. It is clear that risk assessment in clinical research involves moral and scientific judgment. Identifying moral assumptions and qualitative assessments underpinning the design and conduct of research may facilitate future decision-making in clinical trials.