The impact of breast density notification on psychosocial outcomes in racial and ethnic minorities: A systematic review

BACKGROUND

High breast density is an independent risk factor for breast cancer and decreases the sensitivity of mammography. This systematic review synthesizes the evidence on the impact of breast density (BD) information and/or notification on women's psychosocial outcomes among women from racial and ethnic minority groups.

METHODS

A systematic search was performed in March 2023, and the articles were identified using CINHAL, Embase, Medline, and PsychInfo databases. The search strategy combined the terms "breast", "density", "notification" and synonyms. The authors specifically kept the search terms broad and did not include terms related to race and ethnicity. Full-text articles were reviewed for analysis by race, ethnicity and primary language of participants. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias.

RESULTS

Of 1784 articles, 32 articles published from 2003 to 2023 were included. Thirty-one studies were conducted in the United States and one in Australia, with 28 quantitative and four qualitative methodologies. The overall results in terms of breast density awareness, knowledge, communication with healthcare professionals, screening intentions and supplemental screening practice were heterogenous across studies. Barriers to understanding BD notifications and intentions/access to supplemental screening among racial and ethnic minorities included socioeconomic factors, language, health literacy and medical mistrust.

CONCLUSIONS

A one-size approach to inform women about their BD may further disadvantage racial and ethnic minority women. BD notification and accompanying information should be tailored and translated to ensure readability and understandability by all women.

Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

INTRODUCTION

Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain.

METHODS AND ANALYSIS

NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time.

ETHICS AND DISSEMINATION

This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications.

TRIAL REGISTRATION NUMBER

ACTRN12623001000695.

New Frontiers in Health Literacy: Using ChatGPT to Simplify Health Information for People in the Community

BACKGROUND

Most health information does not meet the health literacy needs of our communities. Writing health information in plain language is time-consuming but the release of tools like ChatGPT may make it easier to produce reliable plain language health information.

OBJECTIVE

To investigate the capacity for ChatGPT to produce plain language versions of health texts.

DESIGN

Observational study of 26 health texts from reputable websites.

METHODS

ChatGPT was prompted to 'rewrite the text for people with low literacy'. Researchers captured three revised versions of each original text.

MAIN MEASURES

Objective health literacy assessment, including Simple Measure of Gobbledygook (SMOG), proportion of the text that contains complex language (%), number of instances of passive voice and subjective ratings of key messages retained (%).

KEY RESULTS

On average, original texts were written at grade 12.8 (SD = 2.2) and revised to grade 11.0 (SD = 1.2), p < 0.001. Original texts were on average 22.8% complex (SD = 7.5%) compared to 14.4% (SD = 5.6%) in revised texts, p < 0.001. Original texts had on average 4.7 instances (SD = 3.2) of passive text compared to 1.7 (SD = 1.2) in revised texts, p < 0.001. On average 80% of key messages were retained (SD = 15.0). The more complex original texts showed more improvements than less complex original texts. For example, when original texts were ≥ grade 13, revised versions improved by an average 3.3 grades (SD = 2.2), p < 0.001. Simpler original texts (< grade 11) improved by an average 0.5 grades (SD = 1.4), p < 0.001.

CONCLUSIONS

This study used multiple objective assessments of health literacy to demonstrate that ChatGPT can simplify health information while retaining most key messages. However, the revised texts typically did not meet health literacy targets for grade reading score, and improvements were marginal for texts that were already relatively simple.

Qualitative and Quantitative Evaluation of an Innovative Primary and Secondary Diabetes Clinic in Western Sydney

Introduction

Western Sydney Diabetes (WSD) established an innovative diabetes service in May 2020, using virtual and in-person care, linking primary care with the diabetes specialist team. This study evaluated the service's feasibility using qualitative and quantitative methods.

Method

Evaluation included: 1) thematic analysis of interviews and workshops with patients and health professionals (n = 28); 2) quantitative analysis of records of patients admitted July 2020-June 2021 (n = 110).

Results

Key themes related to 1) benefits: convenient location, access to integrated care, advantages of virtual care; 2) challenges: hard for patients to ask questions, technology issues; 3) confidence: shared care decision making, multidisciplinary team; and 4) future directions: additional multidisciplinary services, expanded insulin stabilisation service, promotion.Improvements between baseline and 3 months included 1.3% reduction in HbA1c (p < 0.05). Sulfonylurea dropped by 25% between initial appointment and follow-up, and GLP1RA/SGLT2i use increasing by 30% (p < 0.05). The clinic covered costs using Medicare billings and Nationally Weighted Activity Units.

Discussion

The findings suggest this integrated care model was feasible and perceived as beneficial by both patients and providers. The clinic offers a promising model of practice that could be developed further to roll out in other regions for rural delivery of care.

Helping patient educators meet health literacy needs: End-user testing and iterative development of an innovative health literacy editing tool

Objective

The Sydney Health Literacy Lab (SHeLL) Editor is an online text-editing tool that provides real-time assessment and feedback on written health information (assesses grade reading score, complex language, passive voice). This study aimed to explore how the design could be further enhanced to help health information providers interpret and act on automated feedback.

Methods

The prototype was iteratively refined across four rounds of user-testing with health services staff (N = 20). Participants took part in online interviews and a brief follow-up survey using validated usability scales (System Usability Scale, Technology Acceptance Model). After each round, Yardley's (2021) optimisation criteria guided which changes would be implemented.

Results

Participants rated the Editor as having adequate usability (M = 82.8 out of 100, SD = 13.5). Most modifications sought to reduce information overload (e.g. simplifying instructions for new users) or make feedback motivating and actionable (e.g. using frequent incremental feedback to highlight changes to the text altered assessment scores).

Conclusion

terative user-testing was critical to balancing academic values and the practical needs of the Editor's target users. The final version emphasises actionable real-time feedback and not just assessment.

Innovation

The Editor is a new tool that will help health information providers apply health literacy principles to written text.

Impact of COVID-19 on the capacity to self-manage health and chronic conditions

Objective

To investigate well-being, lifestyle behaviors, self-management capacity and healthcare utilization among adults with chronic conditions at the outbreak of the COVID-19 pandemic.

Methods

Data was collected from two interviewer-administered telephone surveys conducted between March 27 - May 22, 2020. Participants were patients at Chicago-area clinics. Self-report and validated measures were used for study-related outcomes.

Results

A total of 553 participants (age range 23-88) completed data collection at both timepoints. One in five (20.7%) participants experienced stress due to the coronavirus most or all the time and rates of negative well-being were high (WHO-5 Index mean = 58.7%). Almost a quarter (22.3%) engaged in hazardous drinking and 79.7% reported insufficient physical activity. Nearly one in four participants (23.7%) avoided seeking medical care due to worry about COVID-19. In multivariable analyses, greater COVID-19 related stress was associated with less physical activity, lower self-efficacy, greater difficulty managing health and medications, and delays in seeking medical care due to the coronavirus.

Conclusions

Mental well-being, lifestyle behaviors, self-management capacity, and healthcare utilization were impacted in the months following the COVID outbreak.

Innovation

These findings suggest health systems should implement proactive measures for detecting and treating emotional and behavioral COVID-related concerns.

Clinical Observation, Management and Function Of low back pain Relief Therapies (COMFORT): A cluster randomised controlled trial protocol

INTRODUCTION

Low back pain (LBP) is commonly treated with opioid analgesics despite evidence that these medicines provide minimal or no benefit for LBP and have an established profile of harms. International guidelines discourage or urge caution with the use of opioids for back pain; however, doctors and patients lack practical strategies to help them implement the guidelines. This trial will evaluate a multifaceted intervention to support general practitioners (GPs) and their patients with LBP implement the recommendations in the latest opioid prescribing guidelines.

METHODS AND ANALYSIS

This is a cluster randomised controlled trial that will evaluate the effect of educational outreach visits to GPs promoting opioid stewardship alongside non-pharmacological interventions including heat wrap and patient education about the possible harms and benefits of opioids, on GP prescribing of opioids medicines dispensed. At least 40 general practices will be randomised in a 1:1 ratio to either the intervention or control (no outreach visits; GP provides usual care). A total of 410 patient-participants (205 in each arm) who have been prescribed an opioid for LBP will be enrolled via participating general practices. Follow-up of patient-participants will occur over a 1-year period. The primary outcome will be the cumulative dose of opioid dispensed that was prescribed by study GPs over 1 year from the enrolment visit (in morphine milligram equivalent dose). Secondary outcomes include prescription of opioid medicines, benzodiazepines, gabapentinoids, non-steroidal anti-inflammatory drugs by study GPs or any GP, health services utilisation and patient-reported outcomes such as pain, quality of life and adverse events. Analysis will be by intention to treat, with a health economics analysis also planned.

ETHICS AND DISSEMINATION

The trial received ethics approval from The University of Sydney Human Research Ethics Committee (2022/511). The results will be disseminated via publications in journals, media and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12622001505796.

Exploring human papillomavirus vaccination decision making through mother and adolescent dyad interviews

INTRODUCTION

The purpose of our research was to explore how parents and their adolescent children make decisions about the human papillomavirus (HPV) vaccine, and to inform future interventions that aim to facilitate inclusive decision-making processes.

METHOD

Purposive and snowball sampling strategies targeted parents and their adolescent children (ages = 11-13) in a large city in Australia. We conducted separate and joint semistructured interviews in 2013 with six mother-adolescent dyads (50% female adolescents and 50% male). Interviews were analyzed using a grounded theory approach.

RESULTS

Factors that both facilitate and impede decision making emerged, including: background knowledge, values, historical experiences, parenting style, and opinion weights.

DISCUSSION

New interventions, strategies, and tools that are informed by these decision-making factors can be used to aid productive, mutual decision making between parents and adolescents and support adolescent autonomy and self-sufficiency in health decision making. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Twitch Data in Health Promotion Research: Protocol for a Case Study Exploring COVID-19 Vaccination Views Among Young People

BACKGROUND

Social media platforms have emerged as a useful channel for health promotion communication, offering different channels to reach targeted populations. For example, social media has recently been used to disseminate information about COVID-19 vaccination across various demographics. Traditional modes of health communication such as television, health events, and newsletters may not reach all groups within a community. Health communications for younger generations are increasingly disseminated through social media to reflect key information sources. This paper explores a social media gaming platform as an alternative way to reach young people in health promotion research.

OBJECTIVE

This protocol study aimed to pilot-test the potential of Twitch, a live streaming platform initially designed for video gaming, to conduct health promotion research with young people. We used COVID-19 vaccination as a topical case study that was recommended by Australian health authorities at the time of the research.

METHODS

The research team worked with a Twitch Account Manager to design and test a case study within the guidelines and ethics protocols required by Twitch, identify suitable streamers to approach and establish a protocol for conducting research on the platform. This involved conducting a poll to initiate discussion about COVID-19 vaccination, monitoring the chat in 3 live Twitch sessions with 2 streamers to pilot the protocol, and briefly analyze Twitch chat logs to observe the range of response types that may be acquired from this methodology.

RESULTS

The Twitch streams provided logs and videos on demand that were derived from the live session. These included demographics of viewers, chat logs, and polling results. The results of the poll showed a range of engagement in health promotion for the case study topic: the majority of participants had received their vaccination by the time of the poll; however, there was still a proportion that had not received their vaccination yet or had decided to not be vaccinated. Analysis of the Twitch chat logs demonstrated a range of both positive and negative themes regarding health promotion for the case study topic. This included irrelevant comments, misinformation (compared to health authority information at the time of this study), comedic and conspiracy responses, as well as vaccine status, provaccine comments, and vaccine-hesitant comments.

CONCLUSIONS

This study developed and tested a protocol for using Twitch data for health promotion research with young people. With live polling, open text discussion between participants and immediate responses to questions, Twitch can be used to collect both quantitative and qualitative research data from demographics that use social media. The platform also presents some challenges when engaging with independent streamers and sensitive health topics. This study provides an initial protocol for future researchers to use and build on.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/48641.

Process evaluation of the implementation of an evidence-based model of care for low back pain in Australian emergency departments

BACKGROUND

The Sydney Health Partners Emergency Department (SHaPED) trial targeted ED clinicians and evaluated a multifaceted strategy to implement a new model of care. The objective of this study was to investigate attitudes and experiences of ED clinicians as well as barriers and facilitators for implementation of the model of care.

DESIGN

A qualitative study.

METHODS

The EDs of three urban and one rural hospital in New South Wales, Australia participated in the trial between August and November 2018. A sample of clinicians was invited to participate in qualitative interviews via telephone and face-to-face. The data collected from the interviews were coded and grouped in themes using thematic analysis methods.

RESULTS

Non-opioid pain management strategies (i.e., patient education, simple analgesics, and heat wraps) were perceived to be the most helpful strategy for reducing opioid use by ED clinicians. However, time constraints and rotation of junior medical staff were seen as the main barriers for uptake of the model of care. Fear of missing a serious pathology and the clinicians' conviction of a need to provide something for the patient were seen as barriers to reducing lumbar imaging referrals. Other barriers to guideline endorsed care included patient's expectations and characteristics (e.g., older age and symptoms severity).

CONCLUSIONS

Improving knowledge of non-opioid pain management strategies was seen as a helpful strategy for reducing opioid use. However, clinicians also raised barriers related to the ED environment, clinicians' behaviour, and cultural aspects, which should be addressed in future implementation efforts.

Women's views about current and future management of Ductal Carcinoma in Situ (DCIS): A mixed-methods study

Management of low-risk ductal carcinoma in situ (DCIS) is controversial, with clinical trials currently assessing the safety of active monitoring amidst concern about overtreatment. Little is known about general community views regarding DCIS and its management. We aimed to explore women's understanding and views about low-risk DCIS and current and potential future management options. This mixed-method study involved qualitative focus groups and brief quantitative questionnaires. Participants were screening-aged (50-74 years) women, with diverse socioeconomic backgrounds and no personal history of breast cancer/DCIS, recruited from across metropolitan Sydney, Australia. Sessions incorporated an informative presentation interspersed with group discussions which were audio-recorded, transcribed and analysed thematically. Fifty-six women took part in six age-stratified focus groups. Prior awareness of DCIS was limited, however women developed reasonable understanding of DCIS and the relevant issues. Overall, women expressed substantial support for active monitoring being offered as a management approach for low-risk DCIS, and many were interested in participating in a hypothetical clinical trial. Although some women expressed concern that current management may sometimes represent overtreatment, there were mixed views about personally accepting monitoring. Women noted a number of important questions and considerations that would factor into their decision making. Our findings about women's perceptions of active monitoring for DCIS are timely while results of ongoing clinical trials of monitoring are awaited, and may inform clinicians and investigators designing future, similar trials. Exploration of offering well-informed patients the choice of non-surgical management of low-risk DCIS, even outside a clinical trial setting, may be warranted.

Addressing Behavioral Barriers to COVID-19 Testing With Health Literacy-Sensitive eHealth Interventions: Results From 2 National Surveys and 2 Randomized Experiments

BACKGROUND

Polymerase chain reaction (PCR) testing for COVID-19 was crucial in Australia's prevention strategy in the first 2 years of the pandemic, including required testing for symptoms, contact with cases, travel, and certain professions. However, several months into the pandemic, half of Australians were still not getting tested for respiratory symptoms, and little was known about the drivers of and barriers to COVID-19 PCR testing as a novel behavior at that time.

OBJECTIVE

We aimed to identify and address COVID-19 testing barriers, and test the effectiveness of multiple eHealth interventions on knowledge for people with varying health literacy levels.

METHODS

The intervention was developed in 4 phases. Phase 1 was a national survey conducted in June 2020 (n=1369), in which testing barriers were coded using the capability-opportunity-motivation-behavior framework. Phase 2 was a national survey conducted in November 2020 (n=2034) to estimate the prevalence of testing barriers and health literacy disparities. Phase 3 was a randomized experiment testing health literacy-sensitive written information for a wide range of barriers between February and March 2021 (n=1314), in which participants chose their top 3 barriers to testing to view a tailored intervention. Phase 4 was a randomized experiment testing 2 audio-visual interventions addressing common testing barriers for people with lower health literacy in November 2021, targeting young adults as a key group endorsing misinformation (n=1527).

RESULTS

In phase 1, barriers were identified in all 3 categories: capability (eg, understanding which symptoms to test for), opportunity (eg, not being able to access a PCR test), and motivation (eg, not believing the symptoms are those of COVID-19). Phase 2 identified knowledge gaps for people with lower versus higher health literacy. Phase 3 found no differences between the intervention (health literacy-sensitive text for top 3 barriers) and control groups. Phase 4 showed that a fact-based animation or a TikTok-style video presenting the same facts in a humorous style increased knowledge about COVID-19 testing compared with government information. However, no differences were found for COVID-19 testing intentions.

CONCLUSIONS

This study identified a wide range of barriers to a novel testing behavior, PCR testing for COVID-19. These barriers were prevalent even in a health system where COVID-19 testing was free and widely available. We showed that key capability barriers, such as knowledge gaps, can be improved with simple videos targeting people with lower health literacy. Additional behavior change strategies are required to address motivational issues to support testing uptake. Future research will explore health literacy strategies in the current context of self-administered rapid antigen tests. The findings may inform planning for future COVID-19 variant outbreaks and new public health emergencies where novel testing behaviors are required.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621000876897, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382318 ; Australian New Zealand Clinical Trials Registry ACTRN12620001355965, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380916&isReview=true.

Developing a patient decision aid for Achilles tendon rupture management: a mixed-methods study

OBJECTIVE

To develop and user-test a patient decision aid portraying the benefits and harms of non-surgical management and surgery for Achilles tendon ruptures.

DESIGN

Mixed methods.

SETTING

A draft decision aid was developed using guidance from a multidisciplinary steering group and existing patient decision aids. Participants were recruited through social media.

PARTICIPANTS

People who have previously sustained an Achilles tendon rupture and health professionals who manage these patients.

PRIMARY AND SECONDARY OUTCOMES

Semi-structured interviews and questionnaires were used to gather feedback on the decision aid from health professionals and patients who had previously suffered an Achilles tendon rupture. The feedback was used to redraft the decision aid and assess acceptability. An iterative cycle of interviews, redrafting according to feedback and further interviews was used. Interviews were analysed using reflexive thematic analysis. Questionnaire data were analysed descriptively.

RESULTS

We interviewed 18 health professionals (13 physiotherapists, 3 orthopaedic surgeons, 1 chiropractor, 1 sports medicine physician) and 15 patients who had suffered an Achilles tendon rupture (median time since rupture was 12 months). Most health professionals and patients rated the aid's acceptability as good-excellent. Interviews showcased agreement among health professionals and patients on most aspects of the decision aid: introduction, treatment options, comparing benefits and harms, questions to ask health professionals and formatting. However, health professionals had differing views on details about Achilles tendon retraction distance, factors that modify the risk of harms, treatment protocols and evidence on benefits and harms.

CONCLUSION

Our patient decision aid is an acceptable tool to both patients and health professionals, and our study highlights the views of key stakeholders on important information to consider when developing a patient decision aid for Achilles tendon rupture management. A randomised controlled trial evaluating the impact of this tool on the decision-making of people considering Achilles tendon surgery is warranted.

Early COVID-19 Attitudes and Behaviors and Their Associations With Later Infection: A Local Perspective From One U.S. City

BACKGROUND

At the onset of the pandemic, there was poor public awareness and inaction in response to COVID-19; it is less known whether this translated to subsequent infections.

OBJECTIVES

To explore whether adults who perceived COVID-19 as less of a threat and who were not taking early actions were more likely to become infected over the following year.

RESEARCH DESIGN

Survey data from the ongoing (COVID-19 & Chronic Conditions (C3) anonymized for review) cohort study.

PARTICIPANTS

Six hundred forty-two adults with a mean age of 63 and ≥1 chronic condition.

MEASURES

Self-reported attitudes and behaviors regarding COVID-19 were assessed from March 13 to April 3, 2020, and COVID-19 infection status was captured between May 2020 and January 2021. Bivariate and multivariable analyses examined associations between early perceptions and behaviors with later infection.

RESULTS

Approximately 7% reported infection with COVID-19 (N = 46). Adults who perceived the threat of COVID-19 less seriously at the initial outbreak were more likely to test positive over the following year [odds ratio (OR): 0.81, CI: 0.70-0.94; P = 0.006]. Those who were less likely to believe their actions would affect whether they would become infected were more likely to test positive (OR: 0.87, CI: 0.77-0.99; P = 0.03), as were adults who reported not changing their routines (OR: 0.45; CI: 0.24-0.85; P = 0.01).

CONCLUSIONS

Adults with delayed responses in acknowledging the threat of COVID-19 and in changing behaviors were more likely to contract the virus. This investigation provides insight into the consequences of inadequate public understanding and response to COVID-19, and it highlights the importance of promoting early awareness among high-risk groups during public health crises.

Evaluating an audit and feedback intervention for reducing overuse of pathology test requesting by Australian general practitioners: protocol for a factorial cluster randomised controlled trial

INTRODUCTION

Consistent evidence shows pathology services are overused worldwide and that about one-third of testing is unnecessary. Audit and feedback (AF) is effective for improving care but few trials evaluating AF to reduce pathology test requesting in primary care have been conducted. The aim of this trial is to estimate the effectiveness of AF for reducing requests for commonly overused pathology test combinations by high-requesting Australian general practitioners (GPs) compared with no intervention control. A secondary aim is to evaluate which forms of AF are most effective.

METHODS AND ANALYSIS

This is a factorial cluster randomised trial conducted in Australian general practice. It uses routinely collected Medicare Benefits Schedule data to identify the study population, apply eligibility criteria, generate the interventions and analyse outcomes. On 12 May 2022, all eligible GPs were simultaneously randomised to either no intervention control or to one of eight intervention groups. GPs allocated to an intervention group received individualised AF on their rate of requesting of pathology test combinations compared with their GP peers. Three separate elements of the AF intervention will be evaluated when outcome data become available on 11 August 2023: (1) invitation to participate in continuing professional development-accredited education on appropriate pathology requesting, (2) provision of cost information on pathology test combinations and (3) format of feedback. The primary outcome is the overall rate of requesting of any of the displayed combinations of pathology tests of GPs over 6 months following intervention delivery. With 3371 clusters, assuming no interaction and similar effects for each intervention, we anticipate over 95% power to detect a difference of 4.4 requests in the mean rate of pathology test combination requests between the control and intervention groups.

ETHICS AND DISSEMINATION

Ethics approval was received from the Bond University Human Research Ethics Committee (#JH03507; approved 30 November 2021). The results of this study will be published in a peer-reviewed journal and presented at conferences. Reporting will adhere to Consolidated Standards of Reporting Trials.

TRIAL REGISTRATION NUMBER

ACTRN12622000566730.

Complex intervention to promote human papillomavirus (HPV) vaccine uptake in school settings: A cluster-randomized trial

Using a cluster-randomized trial design, we aimed to evaluate a complex intervention to increase uptake of human papillomavirus (HPV) vaccination in schools. The study was undertaken in high schools in Western Australia and South Australia between 2013 and 2015 with adolescents aged 12-13 years. Interventions included education, shared decision-making, and logistical strategies. The main outcome was school vaccine uptake. Secondary outcomes included consent forms returned and mean time to vaccinate 50 students. We hypothesised that a complex intervention would increase 3-dose HPV vaccine uptake. We recruited 40 schools (21 intervention, 19 control) with 6, 967 adolescents. There was no difference between intervention and control (3-dose mean 75.7% and 78.9%, respectively). Following adjustment for baseline covariates, absolute differences in coverage in favour of the intervention group were: dose 1, 0.8% (95% CI, -1.4,3.0); dose 2, 0.2% (95% CI, -2.7, 3.1); dose 3, 0.5% (95% CI, -2.6, 3.7). The percentage of returned consent forms in intervention schools (91.4%) was higher than in control schools (difference: 6%, 95% CI, 1.4, 10.7). There was a shorter mean time to vaccinate 50 students at dose 3. The difference for dose 3 was 110 min (95% CI, 42, 177); for dose 2, 90 min (95% CI, -15, 196); and dose 1, 28 min (95% CI, -71, 127). Logs revealed the inconsistent implementation of logistical strategies. The intervention had no impact on uptake. Inadequate resourcing for logistical strategies and advisory board reluctance toward strategies with potential financial implications impacted the implementation of logistical components. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12614000404628, 14.04.2014. The study protocol was published in 2015 before data collection was finalised (Skinner et al., 2015). THE HPV.EDU STUDY GROUP: We would like to acknowledge the contributions to this study by members of the HPV.edu Study Group, including: Professor Annette Braunack-Mayer: Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia; Dr. Joanne Collins: Women's and Children's Health Network and School of Medicine and Robinson Research Institute, University of Adelaide, SA, Australia; Associate Professor Spring Cooper: School of Public Health, City University of New York (CUNY), New York, NY, USA; Heidi Hutton: Telethon Kids Institute, University of Western Australia, WA, Australia; Jane Jones: Telethon Kids Institute, University of Western Australia, WA, Australia; Dr. Adriana Parrella: Women's and Children's Health Network and School of Medicine and Robinson Research Institute, University of Adelaide, SA, Australia; and South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia; Associate Professor David G. Regan: The Kirby Institute for Infection and Immunity in Society, Faculty of Medicine, UNSW Sydney, NSW, Australia; Professor Peter Richmond: Perth Children's Hospital, Child and Adolescent Health Service, Western Australia, Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, WA, Australia, and School of Medicine, University of Western Australia, Perth, WA, Australia; Dr. Tanya Stoney: Telethon Kids Institute, University of Western Australia, WA, Australia. Contact for the HPV.edu study group: Cristyn.Davies@sydney.edu.au or Rachel.Skinner@sydney.edu.au.

Integrating consumer perspectives into a large-scale health literacy audit of health information materials: learnings and next steps

BACKGROUND

Health information is less effective when it does not meet the health literacy needs of its consumers. For health organisations, assessing the appropriateness of their existing health information resources is a key step to addressing this issue. This study describes novel methods for a consumer-centred large-scale health literacy audit of existing resources and reflects on opportunities to further refine the method.

METHODS

This audit focused on resources developed by NPS MedicineWise, an Australian not-for-profit that promotes safe and informed use of medicines. The audit comprised 4 stages, with consumers engaged at each stage: 1) Select a sample of resources for assessment; 2) Assess the sample using subjective (Patient Education Materials Assessment Tool) and objective (Sydney Health Literacy Lab Health Literacy Editor) assessment tools; 3) Review audit findings through workshops and identify priority areas for future work; 4) Reflect and gather feedback on the audit process via interviews.

RESULTS

Of 147 resources, consumers selected 49 for detailed assessment that covered a range of health topics, health literacy skills, and formats, and which had varied web usage. Overall, 42 resources (85.7%) were assessed as easy to understand, but only 26 (53.1%) as easy to act on. A typical text was written at a grade 12 reading level and used the passive voice 6 times. About one in five words in a typical text were considered complex (19%). Workshops identified three key areas for action: make resources easier to understand and act on; consider the readers' context, needs, and skills; and improve inclusiveness and representation. Interviews with workshop attendees highlighted that audit methods could be further improved by setting clear expectations about the project rationale, objectives, and consumer roles; providing consumers with a simpler subjective health literacy assessment tool, and addressing issues related to diverse representation.

CONCLUSIONS

This audit yielded valuable consumer-centred priorities for improving organisational health literacy with regards to updating a large existing database of health information resources. We also identified important opportunities to further refine the process. Study findings provide valuable practical insights that can inform organisational health actions for the upcoming Australian National Health Literacy Strategy.

COVID-19 messages targeting young people on social media: content analysis of Australian health authority posts

Health authorities utilized social media during the COVID-19 pandemic to disseminate critical and timely health messages, specifically targeting priority groups such as young people. To understand how social media was used for this purpose, we investigated the content of COVID-19-related social media posts targeting young people (16-29 years old) shared by Australian health departments. Posts targeting young people with COVID-19 information were extracted from all eight Australian State and Territory health department Facebook, Instagram and TikTok accounts over 1 month of the Delta outbreak (September 2021) and analysed thematically. In total, 238 posts targeting young people were identified from 1059 COVID-19 posts extracted. All eight health departments used Facebook, five used Instagram and only one used TikTok. The majority of posts implicitly targeted young people; only 14.7% explicitly mentioned age or 'young people'. All posts included accompanying visuals; 77% were still images like photos or illustrations whilst 23% were moving images like videos and GIFs. Communication techniques included calls to action (63% of posts), responsive communication (32% of posts) and positive emotional appeal (31% of posts). Social marketing techniques catering to young people were used to varying extents despite receiving higher levels of engagement; 45% featured emojis whilst only 16% used humour, 14% featured celebrities and 6% were memes. Priority groups like ethnic/cultural groups and chronic health/disability communities were rarely targeted in this communication. The findings indicate a lack of health communication on social media directed towards young people, highlighting an opportunity for increased use of platforms like TikTok and trends popular with young people online.

Considering potential benefits, as well as harms, from the COVID-19 disruption to cancer screening and other healthcare services

Since 2020, hundreds of thousands of more deaths than expected have been observed across the globe. Amid the coronavirus 2019 (COVID-19) pandemic, current research priorities are to control the spread of infection and minimise loss of life. However, there may be future opportunities to learn from the pandemic to build a better healthcare system that delivers maximum health benefits with minimum harm. So far, much research has focused on foregone benefits of healthcare services such as cancer screening during the pandemic. A more balanced approach is to recognise that all healthcare services have potential harms as well as benefits. In this way, we may be able to use pandemic 'natural experiments' to identify cases where a reduction in a healthcare service has not been harmful to the population and some instances where this may have even been beneficial.

Interventions to support decision-making, health literacy and self-management in ethnic-minority adults living with chronic kidney disease: a systematic review

Optimal patient care is directed by clinical practice guidelines, with emphasis on shared decision-making. However, guidelines –and interventions to support their implementation– often do not reflect needs of ethnic minorities who experience inequities in CKD prevalence and outcomes. This review aims to describe what interventions exist to promote, decision-making, self-management and/or health-literacy for ethnic-minority people living with CKD, describe intervention development and/or adaptation processes, and explore the impact on patient outcomes. Six databases were searched (MEDLINE, PsychINFO, Scopus, EMBASE, CINAHL, InformitOnline) and two reviewers independently extracted study data and assessed risk of bias. Twelve studies (n = 291 participants), conducted in six countries and targeting nine distinct ethnic-minority groups were included. Intervention strategies consisted of: i) face-to-face education/skills training (3 studies, n = 160), ii) patient education materials (2 studies, n = unspecified), iii) cultural health liaison officer (6 studies, n = 106) or iv) increasing access to healthcare (3 studies, n = 25). There was limited description of cultural targeting/tailoring. Where written information was translated into languages other than English, the approach was exact translation without other cultural adaptation. Few studies reported on community-based research approaches, intervention adaptations requiring limited or no literacy (e.g. infographics; photographs and interviews with local community members) and the inclusion of Cultural Healthcare Workers as part of intervention design. No community-based interventions were evaluated for their impact on clinical or psychosocial outcomes. All interventions conducted in the hospital settings reported favorable outcomes (e.g. reduction in blood pressure) compared to routine care but were limited by methodological issues.

Beliefs about medicines and adherence to asthma medications during pregnancy

OBJECTIVE

Discontinuation of, and non-adherence to, inhaled corticosteroids (ICS) for asthma treatment is a significant issue in pregnancy. This study characterized beliefs about medicines in pregnant women with asthma and investigated associations with ICS adherence.

METHODS

Pregnant women with relatively mild asthma (n = 302) were grouped according to ICS use and self-reported adherence (≥80% doses taken). They completed questions about dislike of asthma medications and the validated Beliefs about Medicines Questionnaire (BMQ), which consists of ten questions about asthma medicines ("necessity" questions about maintaining health, or "concern" questions about adverse effects), and eight general medicine questions, scored on five-point Likert scales. The Necessity Concerns differential (N-C) was calculated, with positive scores indicating that the patient perceives the benefits of medicines to outweigh the risks.

RESULTS

ICS was used by 87 (29%) women, with 49 (56%) self-reporting adherence. Of the 22% who disliked taking asthma medications during pregnancy, 20% had the belief that the medication was unsafe. ICS users had a significantly higher BMQ necessity score and higher necessity-concern differential score than nonusers; when adjusted for covariates, ICS non-adherence was associated with a lower necessity score (p = 0.015). Women adherent to ICS were more likely to agree to "my health at present depends on my asthma medication" compared to non-adherent ICS users.

CONCLUSIONS

ICS non-adherence was not associated with having relatively more concerns about asthma medicines; however, ICS users were more likely to perceive that the benefits of medication use outweighed any risks. Interventions to improve asthma medication adherence in pregnancy are needed.

COVID-19 Testing and Vaccine Willingness: Cross-Sectional Survey in a Culturally Diverse Community in Sydney, Australia

Objective

The current study examined patterns in COVID-19 testing and vaccination intentions across multiple language groups in Greater Western Sydney, Australia.

Methods

Participants completed a cross-sectional survey available from March 21 to July 9, 2021 in Sydney, Australia. Surveys were available in English or translated (11 languages). Participants could complete surveys independently or with support from bilingual staff. Logistic regression models using poststratification weighted frequencies identified factors associated with testing and vaccination intentions.

Results

Most of the 708 participants (88%, n=622) were not born in Australia; 31% reported that they did not speak English well or at all (n=220); 70% had no tertiary qualifications (n=497); and 41% had inadequate health literacy (n=290). Half (53.0%) reported willingness to get a COVID-19 vaccine if recommended to them (n=375); 18% were unwilling (n=127), and the remainder unsure (29%, n=205). These proportions varied significantly by language group (p<0.001). Participants were more likely to be unwilling/hesitant if they were female (p=0.02) or did not use Australian commercial information sources (p=0.01). Concerns about side effects (30.4%, n=102) and safety (23.9%, n=80), were key reported barriers to vaccination. Most participants reported high testing intention (77.2%, n=546), with differences observed across language groups (p<0.001). The most frequently reported barrier to testing was concerns about infection at the clinic (26.1%) followed by concerns that testing was painful (25.3%).

Conclusion

Different language groups have unique and specific needs to support uptake of COVID-19 testing and vaccination. Health services must work collaboratively with culturally and linguistically diverse communities to provide tailored support to encourage COVID-19 testing and vaccination.

Comparison of Readability Scores for Written Health Information Across Formulas Using Automated vs Manual Measures

This cross-sectional study examines the variability of readability scores across widely used online calculators.

Embedding health literacy research and best practice within a socioeconomically and culturally diverse health service: A narrative case study and revised model of co-creation

BACKGROUND

Health literacy interventions and research outcomes are not routinely or systematically implemented within healthcare systems. Co-creation with stakeholders is a potential vehicle through which to accelerate and scale up the implementation of innovation from research.

METHODS

This narrative case study describes an example of the application of a co-creation approach to improve health literacy in an Australian public health system that provides hospital and community health services to one million people from socioeconomically and culturally diverse backgrounds. We provide a detailed overview of the value co-creation stages and strategies used to build a practical and sustainable working relationship between a University-based academic research group and the local health district focussed on improving health literacy.

RESULTS

Insights from our experience over a 5-year period informed the development of a revised model of co-creation. The model incorporates a practical focus on the structural enablers of co-creation, including the development of a Community of Practice, co-created strategic direction and shared management systems. The model also includes a spectrum of partnership modalities (spanning relationship-building, partnering and co-creating), acknowledging the evolving nature of research partnerships and reinforcing the flexibility and commitment required to achieve meaningful co-creation in research. Four key facilitators of health literacy co-creation are identified: (i) local champions, (ii) co-generated resources, (iii) evolving capability and understanding and (iv) increasing trust and partnership synergy.

CONCLUSION

Our case study and co-creation model provide insights into mechanisms to create effective and collaborative ways of working in health literacy which may be transferable to other health fields in Australia and beyond.

PATIENT AND PUBLIC CONTRIBUTION

Our co-creation approach brought together a community of practice of consumers, healthcare professionals and researchers as equal partners.

Effect of asthma management with exhaled nitric oxide versus usual care on perinatal outcomes

INTRODUCTION

Asthma exacerbations in pregnancy are associated with adverse perinatal outcomes. We aimed to determine whether fractional exhaled nitric oxide (F _ENO)-based asthma management improves perinatal outcomes compared to usual care.

METHODS

The Breathing for Life Trial was a multicentre, parallel-group, randomised controlled trial conducted in six hospital antenatal clinics, which compared asthma management guided by F _ENO (adjustment of asthma treatment according to exhaled nitric oxide and symptoms each 6-12 weeks) to usual care (no treatment adjustment as part of the trial). The primary outcome was a composite of adverse perinatal events (preterm birth, small for gestational age (SGA), perinatal mortality or neonatal hospitalisation) assessed using hospital records. Secondary outcomes included maternal asthma exacerbations. Concealed random allocation, stratified by study site and self-reported smoking status was used, with blinded outcome assessment and statistical analysis (intention to treat).

RESULTS

Pregnant women with current asthma were recruited; 599 to the control group (608 infants) and 601 to the intervention (615 infants). There were no significant group differences for the primary composite perinatal outcome (152 (25.6%) out of 594 control, 177 (29.4%) out of 603 intervention; OR 1.21, 95% CI 0.94-1.56; p=0.15), preterm birth (OR 1.14, 95% CI 0.78-1.68), SGA (OR 1.06, 95% CI 0.78-1.68), perinatal mortality (OR 3.62, 95% CI 0.80-16.5), neonatal hospitalisation (OR 1.24, 95% CI 0.89-1.72) or maternal asthma exacerbations requiring hospital admission or emergency department presentation (OR 1.19, 95% CI 0.69-2.05).

CONCLUSION

F _ENO-guided asthma pharmacotherapy delivered by a nurse or midwife in the antenatal clinic setting did not improve perinatal outcomes.

Women's reasons for taking complementary medicine products in pregnancy and lactation: Results from a national Australian survey

BACKGROUND

and purpose: Pregnant and breastfeeding women commonly use complementary medicine products (CMPs), including dietary supplements and herbal medicines. This study investigated women's reasons for use.

MATERIALS AND METHODS

A national, cross-sectional, online survey conducted between July-September 2019 investigated reasons for CMP use during pregnancy and lactation. Australian women who were currently pregnant and/or breastfeeding participated. Data analysis included descriptive statistics, Chi-square and principal component analyses.

RESULTS

Of the 810 women surveyed (n = 354 pregnant; n = 456 breastfeeding), most reported prior CMP use and felt that CMPs had been beneficial to maintaining and optimising their own and their children's health. However, when ill, they preferred medicines prescribed by doctors or pharmacists. Perceived benefits to their unborn or breastfeeding babies' health and their own health (both cohorts), the health of their pregnancy (pregnant participants), and benefits to the breastfeeding process and breastmilk supply (breastfeeding participants) were important reasons for women's CMP use.

CONCLUSION

Women's reasons for CMP use centred on perceived benefits to their own health and the health of their babies. Women's prior positive experiences with CMP use, combined with preferences for pharmaceutical use when ill, indicates their use of CMPs can be considered complementary, rather than alternative, to biomedical health care.

A systematic assessment of online international breast density information

Background

Breast density has become a topic of international discussion due to its associated risk of breast cancer. As online is often a primary source of women's health information it is therefore essential that breast density information it is understandable, accurate and reflects the best available evidence. This study aimed to systematically assess online international breast density information including recommendations to women.

Methods

Searches were conducted from five different English-speaking country-specific Google locations. Relevant breast density information was extracted from the identified websites. Readability was assessed using the SHeLL Editor, and understandability and actionability using the Patient Education Materials Assessment Tool (PEMAT). A content analysis of specific recommendations to women was also conducted.

Results

Forty-two eligible websites were identified and systematically assessed. The included informational content varied across websites. The average grade reading level across all websites was 12.4 (range 8.9–15.4). The mean understandability was 69.9% and the mean actionability was 40.1%, with 18/42 and 39/42 websites respectively scoring lower than adequate (70%). Thirty-six (85.7%) of the websites had breast density-related recommendation to women, with ‘talk to your doctor’ (n = 33, 78.6%) the most common.

Conclusions

Online information about breast density varies widely and is not generally presented in a way that women can easily understand and act on, therefore greatly reducing the ability for informed decision-making. International organisations and groups disseminating breast density information need to ensure that women are presented with health literacy-sensitive and balanced information, and be aware of the impact that recommendations may have on practice.

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First study to systematically assess online international breast density information.

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Information across the websites varies widely.

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Readability, understandability and actionability are low and poor.

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The most common recommendation to women is to ‘talk to your doctor’.

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More health literacy-sensitive online information about breast density is needed internationally.

Physiotherapists' attitudes, views, and beliefs about Choosing Wisely recommendations: A qualitative study

OBJECTIVE

Explore physiotherapists' attitudes, views, and beliefs towards the Australian Physiotherapy Association's (APA) Choosing Wisely recommendations.

DESIGN

Qualitative interview study.

METHODS

We conducted semi-structured interviews with physiotherapists who were registered to practise in Australia. We purposively recruited participants with different demographics, clinical backgrounds, and years of experience to achieve diversity in views and opinions. Interviews explored barriers and facilitators to adopting the APA's Choosing Wisely recommendations, and strategies to increase adoption. Interviews were recorded, transcribed verbatim and analysed thematically.

RESULTS

We interviewed 19 participants (79.2% of 26 who expressed interest to be interviewed). Mean (SD) age of participants was 33.4 (11.6), mean (SD) years of experience was 10 (11.4), 90% were male (n = 17) and 53% worked in private practice (n = 10). Most participants were slightly (42.1%, n = 8) or at least moderately familiar (42.1%, n = 8) with the recommendations. Barriers to adopting the recommendations included 1) clinicians' beliefs, experience, and knowledge, 2) patients' clinical presentation, their beliefs, and expectations, 3) workplace demands and culture, and 4) vague and restrictive language, and lack of awareness. Facilitators to adopting the recommendations included 1) physiotherapists' beliefs and practise patterns, 2) organisational support, and 3) clear and appropriate recommendations. Suggested strategies to increase adoption of the recommendations were 1) interventions targeting clinicians, 2) amendments to the recommendations and 3) increased awareness and access to the recommendations.

CONCLUSION

These findings will inform the development and dissemination of future Choosing Wisely recommendations, and development of strategies to replace low-value physiotherapy with high-value physiotherapy.

LEVEL OF EVIDENCE

IV.

Factors associated with women's supplemental screening intentions following dense breast notification in an online randomised experimental study

Controversy surrounding recommendations for supplemental screening (ultrasound and magnetic resonance screening) in women with dense breasts exists, as the long-term benefits from these additional modalities may not outweigh the harms. This study aimed to examine factors associated with supplemental screening intentions following a hypothetical breast density notification in a population of women who have not been routinely notified. Australian women of breast screening age participated in an online randomised experimental study where they were presented with one of two breast density notifications (with or without health literacy-sensitive information) and asked their screening intentions. After adjusting for covariates in multivariable analyses, women in both groups (n = 940) who indicated higher levels of breast cancer worry, had private health insurance, had a family history of breast cancer, and had a greater number of times previously attending mammography screening had higher intentions for supplemental screening. Understanding women's supplemental screening intentions following notification of dense breasts has important implications for health systems with breast screening considering the impacts of widespread notification. Personal, clinical and psychological factors should be considered when discussing both the benefits and harms of supplemental screening with women with dense breasts.

The impact of a patient decision aid on intention to undergo surgery for subacromial pain syndrome: An online randomised controlled trial

OBJECTIVE

To evaluate the effects of a patient decision aid for people considering shoulder surgery.

METHODS

Participants with shoulder pain considering shoulder surgery (n = 425) were recruited online and randomised to (i) a decision aid outlining the benefits and harms of shoulder surgery and non-surgical options (then randomised to a side-by-side vs. top-and-bottom display of options); and (ii) general information about shoulder pain from the NHS. Outcomes included treatment intention (primary), knowledge, attitudes, informed choice, and decisional conflict. Linear and logistic regression models were used to evaluate between-groups differences in outcomes.

RESULTS

409 participants (96%) had post-intervention data. Mean age was 41.3 years, 44.2% were female. There was no between-group difference in post-intervention treatment intention (MD -0.2, 95% CI: -3.3 to 2.8) and likelihood of intending to have shoulder surgery (OR 0.7, 95% CI: 0.3-1.5). The decision aid slightly improved knowledge (MD 4.4, 95% CI: 0.2-8.6), but not any other secondary outcomes. The display of options did not influence any outcome.

CONCLUSIONS

In this online trial, a co-designed patient decision aid had no effect on treatment intention, attitudes, informed choice, and decisional conflict, but a small effect on improving knowledge.

PRACTICE IMPLICATIONS

Research is needed to understand reasons for the lack of anticipated effects.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ACTRN12621000992808).

Testing behaviour may bias observational studies of vaccine effectiveness

BACKGROUND

Recent observational studies suggest that vaccines may have little effect in preventing infection with the Omicron variant of severe acute respiratory syndrome coronavirus 2. However, the observed effects may be confounded by patient factors, preventive behaviours, or differences in testing behaviour. To assess potential confounding, we examined differences in testing behaviour between unvaccinated and vaccinated populations.

METHODS

We recruited 1,526 Australian adults for an online randomized study about coronavirus disease 2019 (COVID-19) testing in late 2021, collecting self-reported vaccination status and three measures of COVID-19 testing behaviour: testing in past month or ever and test intention if they woke with a sore throat. We examined the association between testing intentions and vaccination status in the trial's baseline data.

RESULTS

Of the 1,526 participants (mean age 31 y), 22% had a COVID-19 test in the past month and 61% ever; 17% were unvaccinated, 11% were partially vaccinated (one dose), and 71% were fully vaccinated (two or more doses). Fully vaccinated participants were twice as likely as those who were unvaccinated (relative risk [RR] 2.2, 95% CI 1.8 to 2.8, p < 0.001) to report positive COVID testing intentions. Partially vaccinated participants had less positive intentions than fully vaccinated participants (RR 0.68, 95% CI 0.52 to 0.89, p < 0.001) but higher intentions than unvaccinated participants (RR 1.5, 95% CI 1.4 to 1.6, p = 0.002).

DISCUSSION

Vaccination predicted greater COVID-19 testing intentions and would substantially bias observed vaccine effectiveness. To account for differential testing behaviours, test-negative designs are currently the preferred option, but their assumptions need more thorough examination.

Australian General Practitioners' Current Knowledge, Understanding, and Feelings Regarding Breast Density Information and Notification: A Cross-Sectional Study

BACKGROUND

There is a lack of evidence around Australian general practitioners' (GPs) views of issues surrounding breast density. The current study aimed to quantitatively assess GPs' current knowledge, understanding, and feelings around breast density information and notification.

METHODS

This study involved a cross-sectional survey using an online platform to collect quantitative data from Australian GPs. Survey data were analysed with descriptive statistics.

RESULTS

A total 60 responses from GPs were analysed. Most (n = 58; 97%) had heard or read about breast density and nearly 90% (n = 52; 87%) have had discussions about breast density with patients. Three-quarters (n = 45; 75%) were supportive of making breast density notification mandatory for patients with dense tissue and a similar proportion (n = 45/58; 78%) felt they need or want more education on breast density.

CONCLUSIONS

There is strong support for notifying patients of breast density, and interest in further education and training among the surveyed GPs. As GPs play a central role in cancer prevention and control, their involvement in discussions related to breast density notification, evaluation and appraisal of evidence, development of communication strategies, and participation in ongoing research on the topic will be indispensable.

Adolescents' self-efficacy and digital health literacy: a cross-sectional mixed methods study

BACKGROUND

The internet and social media are increasingly popular sources of health information for adolescents. Using online health information requires digital health literacy, consisting of literacy, analytical skills and personal capabilities such as self-efficacy. Appraising trustworthiness and relevance of online health information requires critical health literacy to discriminate between sources, critically analyse meaning and relevance, and use information for personal health. Adolescents with poor digital health literacy risk using misinformation, with potential negative health outcomes. We aimed to understand adolescents' contemporary digital health literacy and compared self-efficacy with capability.

METHODS

Adolescents (12-17 years) completed an eHEALS self-report digital health literacy measure, a practical search task using a think-aloud protocol and an interview to capture perceived and actual digital health literacy. eHEALS scores were generated using descriptive statistics, search tasks were analysed using an observation checklist and interviews were thematically analysed based on Social Cognitive Theory, focussing on self-efficacy.

RESULTS

Twenty-one participants generally had high self-efficacy using online health information but perceived their digital health literacy to be higher than demonstrated. They accessed online health information unintentionally on social media and intentionally via search engines. They appraised information medium, source and content using general internet searching heuristics taught at school. Information on social media was considered less trustworthy than websites, but participants used similar appraisal strategies for both; some search/appraisal heuristics were insufficiently nuanced for digital health information, sometimes resulting in misplaced trust or diminished self-efficacy. Participants felt anxious or relieved after finding online health information, depending on content, understanding and satisfaction. They did not act on information without parental and/or health professional advice. They rarely discussed findings with health professionals but would welcome discussions and learning how to find and appraise online health information.

CONCLUSIONS

Whilst adolescents possess many important digital health literacy skills and generally feel self-efficacious in using them, their critical health literacy needs improving. Adolescents desire increased digital health literacy so they can confidently appraise health information they find online and on social media. Co-designed educational interventions with adolescents and health providers are required.

Effects of awareness of breast cancer overdiagnosis among women with screen-detected or incidentally found breast cancer: a qualitative interview study

OBJECTIVES

To explore experiences of women who identified themselves as having a possible breast cancer overdiagnosis.

DESIGN

Qualitative interview study using key components of a grounded theory analysis.

SETTING

International interviews with women diagnosed with breast cancer and aware of the concept of overdiagnosis.

PARTICIPANTS

Twelve women aged 48-77 years from the UK (6), USA (4), Canada (1) and Australia (1) who had breast cancer (ductal carcinoma in situ n=9, (invasive) breast cancer n=3) diagnosed between 2004 and 2019, and who were aware of the possibility of overdiagnosis. Participants were recruited via online blogs and professional clinical networks.

RESULTS

Most women (10/12) became aware of overdiagnosis after their own diagnosis. All were concerned about the possibility of overdiagnosis or overtreatment or both. Finding out about overdiagnosis/overtreatment had negative psychosocial impacts on women's sense of self, quality of interactions with medical professionals, and for some, had triggered deep remorse about past decisions and actions. Many were uncomfortable with being treated as a cancer patient when they did not feel 'diseased'. For most, the recommended treatments seemed excessive compared with the diagnosis given. Most found that their initial clinical teams were not forthcoming about the possibility of overdiagnosis and overtreatment, and many found it difficult to deal with their set management protocols.

CONCLUSION

The experiences of this small and unusual group of women provide rare insight into the profound negative impact of finding out about overdiagnosis after breast cancer diagnosis. Previous studies have found that women valued information about overdiagnosis before screening and this knowledge did not reduce subsequent screening uptake. Policymakers and clinicians should recognise the diversity of women's perspectives and ensure that women are adequately informed of the possibility of overdiagnosis before screening.

Evaluation of the SUCCESS health literacy app for Australian adults with chronic kidney disease: Study protocol for a pragmatic randomised controlled trial (Preprint)

Background

We developed a smartphone app—the SUCCESS (Supporting Culturally and Linguistically Diverse CKD Patients to Engage in Shared Decision-Making Successfully) app—to support Australian adults with kidney failure undertaking dialysis to actively participate in self-management and decision-making. The content of the SUCCESS app was informed by a theoretical model of health literacy that recognizes the importance of reducing the complexity of health information as well as providing skills necessary to access, understand, and act on this information.

Objective

The purpose of this study is to investigate the efficacy of the SUCCESS app intervention.

Methods

We designed a multicenter pragmatic randomized controlled trial to compare the SUCCESS app plus usual care (intervention) to usual care alone (control). A total of 384 participants receiving in-center or home-based hemodialysis or peritoneal dialysis will be recruited from six local health districts in the Greater Sydney region, New South Wales, Australia. To avoid intervention contamination, a pragmatic randomization approach will be used for participants undergoing in-center dialysis, in which randomization will be based on the days they receive hemodialysis and by center (ie, Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday). Participants undergoing home-based dialysis will be individually randomized centrally using simple randomization and two stratification factors: language spoken at home and research site. Consenting participants will be invited to use the SUCCESS app for 12 months. The primary endpoints, which will be assessed after 3, 6, and 12 months of app usage, are health literacy skills, evaluated using the Health Literacy Questionnaire; decision self-efficacy, evaluated using the Decision Self-Efficacy Scale; and rates of unscheduled health encounters. Secondary outcomes include patient-reported outcomes (ie, quality of life, evaluated with the 5-level EQ-5D; knowledge; confidence; health behavior; and self-management) and clinical outcomes (ie, symptom burden, evaluated with the Palliative care Outcome Scale–Renal; nutritional status, evaluated with the Patient-Generated Subjective Global Assessment; and intradialytic weight gain). App engagement will be determined via app analytics. All analyses will be undertaken using an intention-to-treat approach comparing the intervention and usual care arms.

Results

The study has been approved by Nepean Blue Mountains Human Research Ethics Committee (2020/ETH00910) and recruitment has begun at nine sites. We expect to finalize data collection by 2023 and publish the manuscript by 2024.

Conclusions

Enhancing health literacy skills for patients undergoing hemodialysis is an important endeavor, given the association between poor health literacy and poor health outcomes, especially among culturally diverse groups. The findings from this trial will be published in peer-reviewed journals and disseminated at conferences, and updates will be shared with partners, including participating local health districts, Kidney Health Australia, and consumers. The SUCCESS app will continue to be available to all participants following trial completion.

Trial Registration

Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000235808; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380754&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/39909

Implementing shared decision-making in Australia

Person-centred care (PCC) and shared decision-making (SDM) are part of national clinical standards for an increasing number of areas of health care delivery. In addition to existing standards for accrediting hospitals, day surgery facilities, public dental services and medical education in Australia, new standards governing primary health care and digital mental health services have been added. Implementation and measurement of PCC and SDM to comply with standards, and training of health professionals, remain challenges for the Australian health sector. Consumer involvement in health research, policy and clinical service governance continues to increase and the National Health and Medical Research Council has begun to encourage consumer and community involvement in health and medical research. This increased consumer engagement and moves towards more PCC provision is reflected in a focus on encouraging patients to ask questions during their clinical care and supports improvements in consumer health literacy. SDM support tools are now being culturally adapted whilst a need for more systemic approaches to their development and implementation persists. With increasing resources and tools for all aspects of PCC and SDM challenges to find sustainable solutions to ensure tools are kept up to date with the best available evidence remain.

Australian Women's Intentions and Psychological Outcomes Related to Breast Density Notification and Information: A Randomized Clinical Trial

IMPORTANCE

Whether the benefits of notifying women about breast density outweigh the potential harms to inform current and future mammogram screening practice remains unknown.

OBJECTIVE

To assess the effect of mammographic breast density notification and information provision on women's intention to seek supplemental screening and psychological outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A 3-arm online randomized clinical trial was conducted from August 10 to 31, 2021. Data analysis was conducted from September 1 to October 20, 2021. Participants included Australian residents identifying as female, aged between 40 and 74 years, with no history of breast cancer who were residing in jurisdictions without existing breast density notification with screening mammograms.

INTERVENTIONS

Women were randomized to receive 1 of the following hypothetical breast screening test result letters: screening mammogram result letter without breast density messaging (control), screening mammogram result letter with breast density messaging and an existing density information letter taken from a screening service in Australia (intervention 1), and screening mammogram result letter with breast density messaging and a health literacy-sensitive version of the letter adapted for people with lower health literacy (intervention 2).

MAIN OUTCOMES AND MEASURES

Primary outcomes were intention to seek supplemental screening; feeling anxious (uneasy, worried, or nervous), informed, or confused; and having breast cancer worry.

RESULTS

A total of 1420 Australian women were randomized and included in the final analysis. The largest group consisted of 603 women aged 60 to 74 years (42.5%). Compared with the control cohort (n = 480), women who received density notification via intervention 1 (n = 470) and intervention 2 (n = 470) reported a significantly higher intention to seek supplemental screening (0.8% vs 15.6% and 14.2%; P < .001) and feeling anxious (14.2% vs 49.4% and 48.5%; P < .001), confusion (7.8% vs 24.0% and 23.6%; P < .001), and worry about breast cancer (quite/very worried: 6.9% vs 17.2% and 15.5%; P < .001). There were no statistically significant differences in these outcomes between the 2 intervention groups.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, breast density notification and information integrated with screening mammogram results increased women's intention to seek supplemental screening and made women feel anxious, confused, or worried about breast cancer. These findings have relevance and implications for mammogram screening services and policy makers considering whether and, if so, how best to implement widespread notification of breast density as part of mammography screening.

TRIAL REGISTRATION

ACTRN12621000253808.

Perceptions of Conflicting Breast Cancer Screening Recommendations Among Racially/Ethnically Diverse Women: a Multimethod Study

BACKGROUND

Conflicting breast cancer screening recommendations have the potential to diminish informed decision making about screening.

OBJECTIVE

We examined the knowledge, attitudes, and intentions related to divergent recommendations for breast cancer screening among racially/ethnically diverse women.

DESIGN

We used a multimethod study design employing focus groups and questionnaires. Focus groups included: (1) two 10-min presentations on the national screening recommendations and the potential benefits and harms of screening and (2) an interactive discussion. Data were collected: 8/3/2017 to 11/19/2019. Analysis occurred from 1/21/2019 to 7/24/2020.

PARTICIPANTS

Participants were (1) women 40-75 years; (2) English or Spanish speaking; (3)self-identified as Latina, Black, or non-Latina White; and (4) no known increased risk for breast cancer.

MAIN MEASURES

Main outcomes were participants' knowledge and perceptions of benefits and harms of screening mammography and their screening intentions. Focus groups were transcribed and analyzed using a qualitative descriptive approach. Quantitative data were summarized using descriptive statistics.

KEY RESULTS

One hundred thirty-four women (n=52, 40-49 years; n=82, 50-75 years) participated in 28 focus groups. Participants were Latina (n=44); Black (n=51); and non-Latina White (n=39). Approximately one-quarter (n=32) had limited health literacy and almost one-fifth (n=23) had limited numeracy. In the context of differing national screening recommendations, participants questioned the motives of the recommendation-making agencies, including the role of costs and how costs were considered when making screening recommendations. Participants expressed concern that they were not represented (e.g., race/ethnicity) in the data informing the recommendations. Immediately following the focus groups, most participants expressed intention to screen within the upcoming year (pre n=100 vs. post n=107).

CONCLUSIONS

Divergent breast cancer screening recommendations may lead to mistrust and paradoxically reinforce high overall enthusiasm for screening.

The impact of health literacy on psychosocial and behavioural outcomes among people at low risk of cardiovascular disease

This study aimed to explore the impact of health literacy on psychosocial and behavioural outcomes for people who were not at high risk of cardiovascular disease receiving a hypothetical blood pressure reading of 135/85 mmHg. We performed a secondary analysis of data from a national sample of Australians aged 40 to 50 years (n = 1318) recruited online. Health literacy was measured using the validated Newest Vital Sign (inadequate: 0-3; adequate: 4-6). Analysed outcomes included: willingness to increase exercise and accept medication; perceived severity; positive and negative affect; illness perceptions and impacts on life and motivation. Participants with inadequate levels of health literacy perceived a blood pressure reading of 135/85 mmHg to be less serious compared to individuals with adequate health literacy (Mean Difference [MD]:0.21; 95%CI 0.03-0.39; p = .024; d = 0.13), and reported less motivation to eat well (MD:0.44; 95%CI 0.31-0.58; p < .001; d = 0.38) and exercise (MD:0.43; 95%CI 0.31-0.58; p < .001; d = 0.36). However, they were more willing to accept medication (MD:0.20; 95%CI 0.07-0.34; p = .004; d = 0.17). Participants with inadequate health literacy also perceived the condition to have fewer negative impacts on aspects of life and work than individuals with adequate health literacy, but reported greater negative emotion and more negative illness perceptions (all p < .001). Tailored communication and behaviour change support may be needed when communicating blood pressure information to people with lower health literacy and not at high risk of cardiovascular disease given the differential impacts on medication (increased willingness) and healthy exercise and diet behaviours (decreased willingness) observed in this study.

"It's about our bodies… we have the right to know this stuff": A qualitative focus group study on Australian women's perspectives on breast density

OBJECTIVE

This study aimed to explore Australian women's current knowledge, perspectives and attitudes about breast density (BD); and information needs to inform effective evidence-based communication strategies.

METHODS

Fourteen online focus group sessions with a total of 78 women in New South Wales and Queensland, Australia aged 40-74 years without a personal diagnosis of breast cancer were conducted. Audio-recorded data was transcribed and analysed thematically.

RESULTS

Women had a very limited knowledge of BD. Overall, women expressed a preference for more frequent mammograms and/or supplemental screening should they be told they had dense breasts, despite being presented with information on potential downsides of additional testing. The majority of women were supportive of the notion of BD notification, often suggesting they had a 'right to know' and they would prefer to be educated and informed about it.

CONCLUSION

The potential of being informed and notified of BD is found to be of interest and importance to Australian women of breast screening age despite lacking current knowledge.

PRACTICE IMPLICATIONS

This study highlights that policy makers and screening services need to consider how to weigh up these views and preferences of women with current evidence surrounding BD in deciding about implementing population-based BD notification.

Demographics, health literacy and health locus of control beliefs of Australian women who take complementary medicine products during pregnancy and breastfeeding: A cross-sectional, online, national survey

Background

Pregnant and breastfeeding women's use of complementary medicine products (CMPs) is common, and possibly associated with autonomous health care behaviours. However, the health literacy levels and health locus of control (HLOC) beliefs of women who use CMPs in pregnancy and lactation have not been previously assessed in a large Australian sample.

Aim

The aim of this study is to determine the health literacy levels and HLOC beliefs of women who use CMPs in pregnancy and lactation and determine the types of CMPs used.

Methods

A cross‐sectional, national, online survey of Australian pregnant or breastfeeding women aged 18 years and older, and currently using CMPs was conducted.

Results

A total of 810 completed surveys (354 pregnant and 456 breastfeeding women) were analysed. Most had adequate functional health literacy levels (93.3%). Health care practitioners (HCPs) HLOC mean scores were the highest for the sample, followed by Internal HLOC beliefs mean scores. Almost all (n = 809) took at least one dietary supplement, the most popular being pregnancy and breastfeeding multivitamins, iron supplements and probiotics. Use was generally in line with clinical recommendations, except for low rates of iodine supplementation. Herbal medicine use was lower for the total sample (57.3%, n = 464), but significantly higher (p < .0001) for the breastfeeding cohort, with consumers taking one to four herbal medicines each. The most popular herbs were raspberry leaf, ginger, peppermint and chamomile (pregnant respondents) and chamomile, ginger and fenugreek (breastfeeding respondents).

Conclusions

Respondents were health literate, with high scores for Internal and HCP HLOC scales, suggesting that they are likely to demonstrate self‐efficacy, positive health behaviours and work well in partnership with HCPs. HCPs can facilitate discussions with pregnant and breastfeeding women using CMPs, while considering women's health literacy levels, health beliefs and goals.