An international comparison of stakeholder motivation to implement liver cancer control.

BACKGROUND: The World Health Organization offers clear guidance on the development of national cancer control programmes based on a country's level of resources, yet the motivation to implement such programmes may be driven by factors other than resources. OBJECTIVES: To compare stakeholder motivation to implement a national liver cancer control programme and assess if variation in motivation was associated with stakeholder characteristics or with national indicators of need and resources. METHODS: Relevant stakeholders were purposively selected from 13 countries (Australia, China, France, Germany, Italy, Japan, Nigeria, South Korea, Spain, Taiwan, Thailand, Turkey and USA) to participate in a structured survey on liver cancer control. Respondents included 12 individuals working in clinical, 5 in policy and 3 in advocacy roles from each country. Stakeholders' motivation was measured using a scale grounded in expectancy theory and knowledge gained during previous qualitative interviews. Comparisons across countries and respondent characteristics were conducted using hierarchical regression. Country level motivation scores, holding constant individual level covariates, were correlated with indicators of need and resources and tested using Pearson's correlation coefficients. RESULTS: In total, 260 stakeholders, equally drawn from the study countries, completed the survey (45% response rate). At the national level, motivation was highest in Nigeria, Thailand and China (P < 0.001), and lowest in Italy (P < 0.001) and Germany (P = 0.003). Higher motivation was observed among stakeholders working at the international level relative to the local level (P = 0.017). Motivation was positively associated with a country's relative burden of liver cancer (P = 0.015) and negatively associated with their level of resources (P = 0.018). CONCLUSIONS: This study provides the first empirical evidence on the motivation of stakeholders to implement national cancer control programmes. Furthermore, we demonstrate that motivation is more clearly associated with a country's cancer control needs rather than resources.

Stakeholder perspectives on European priorities for comprehensive liver cancer control: a conjoint analysis.

BACKGROUND: As liver cancer incidence and mortality remain high in many parts of Europe, a more comprehensive response is required to reduce the burden. Expert stakeholders should be involved in the design of responses because they have important insights about potentially effective responses and will be affected by policy changes. We aimed to prioritize liver cancer control strategies based on European liver cancer stakeholders' views of which strategies would have the greatest impact in a comprehensive liver cancer control plan. METHODS: One hundred liver cancer clinical, policy and advocacy stakeholders from France, Germany, Italy, Spain and Turkey were surveyed. Respondents completed 12 conjoint choice tasks in which they chose which of two subsets of 11 strategies would have the greatest impact in their country. RESULTS: All strategies were considered likely to have a positive impact (P < 0.01). The highest priority strategy was monitoring of at-risk populations, followed by centres of excellence, clinical education, multidisciplinary management, national guidelines, measuring social burden, public awareness, risk assessment and referral, research infrastructure and access to treatments. CONCLUSIONS: Canvassing stakeholder views through a conjoint analysis survey provided a robust quantitative prioritization that can complement traditional qualitative consultation processes. The prioritized strategies provide a logical starting point for decision makers considering developing national plans or collaborative efforts to achieve comprehensive liver cancer control in Europe.

Prioritizing strategies for comprehensive liver cancer control in Asia: a conjoint analysis.

BACKGROUND: Liver cancer is a complex and burdensome disease, with Asia accounting for 75% of known cases. Comprehensive cancer control requires the use of multiple strategies, but various stakeholders may have different views as to which strategies should have the highest priority. This study identified priorities across multiple strategies for comprehensive liver cancer control (CLCC) from the perspective of liver cancer clinical, policy, and advocacy stakeholders in China, Japan, South Korea and Taiwan. Concordance of priorities was assessed across the region and across respondent roles. METHODS: Priorities for CLCC were examined as part of a cross-sectional survey of liver cancer experts. Respondents completed several conjoint-analysis choice tasks to prioritize 11 strategies. In each task, respondents judged which of two competing CLCC plans, consisting of mutually exclusive and exhaustive subsets of the strategies, would have the greatest impact. The dependent variable was the chosen plan, which was then regressed on the strategies of different plans. The restricted least squares (RLS) method was utilized to compare aggregate and stratified models, and t-tests and Wald tests were used to test for significance and concordance, respectively. RESULTS: Eighty respondents (69.6%) were eligible and completed the survey. Their primary interests were hepatitis (26%), hepatocellular carcinoma (HCC) (58%), metastatic liver cancer (10%) and transplantation (6%). The most preferred strategies were monitoring at-risk populations (p<0.001), clinician education (p<0.001), and national guidelines (p<0.001). Most priorities were concordant across sites except for three strategies: transplantation infrastructure (p=0.009) was valued lower in China, measuring social burden (p=0.037) was valued higher in Taiwan, and national guidelines (p=0.025) was valued higher in China. Priorities did not differ across stakeholder groups (p=0.438). CONCLUSIONS: Priorities for CLCC in Asia include monitoring at-risk populations, clinician education, national guidelines, multidisciplinary management, public awareness and centers of excellence. As most priorities are relatively concordant across the region, multilateral approaches to addressing comprehensive liver cancer would be beneficial. However, where priorities are discordant among sites, such as transplantation infrastructure, strategies should be tailored to local needs.

Using best-worst scaling in horizon scanning for hepatocellular carcinoma technologies.

OBJECTIVES: There is a growing need for efficient procedures for identification of emerging technologies by horizon scanning systems. We demonstrate the value of best-worst scaling (BWS) in exploring clinicians' views on emerging technologies that will impact outcomes in hepatocellular carcinoma (HCC) in the next 5 to 10 years. METHODS: Clinicians in Asia, Europe, and the United States were surveyed and their views about eleven emerging technologies relevant to HCC were explored using BWS (case 1). This involved systematically presenting respondents with subsets of five technologies and asking them to identify those that will have the most and least impact on HCC within 5 to 10 years. Statistical analysis was based on sequential best-worst and analyzed using conditional logistic regression. RESULTS: A total of 120 clinicians uniformly distributed across ten countries completed the survey (37 percent response rate). Respondents were predominately hepatologist (41 percent) who focused on HCC (65 percent) and had national influence in this field (39 percent). Respondents viewed molecular targeted therapy (p < .001) and early detection of HCC (p < .001) as having most potential, while improved surgical techniques (p < .001) and biopsy free HCC diagnostics (p < .001) were viewed upon negatively. CONCLUSIONS: We demonstrate that BWS could be an important research tool to facilitate horizon scanning and HTA more broadly. Our research demonstrates the value of including clinicians' preferences as a source of data in horizon scanning, but such methods could be used to incorporate the opinions of a broad array of stakeholders, including those in advocacy and public policy.

Identifying and prioritizing strategies for comprehensive liver cancer control in Asia.

BACKGROUND: Liver cancer is both common and burdensome in Asia. Effective liver cancer control, however, is hindered by a complex etiology and a lack of coordination across clinical disciplines. We sought to identify strategies for inclusion in a comprehensive liver cancer control for Asia and to compare qualitative and quantitative methods for prioritization. METHODS: Qualitative interviews (N = 20) with international liver cancer experts were used to identify strategies using Interpretative Phenomenological Analysis and to formulate an initial prioritization through frequency analysis. Conjoint analysis, a quantitative stated-preference method, was then applied among Asian liver cancer experts (N = 20) who completed 12 choice tasks that divided these strategies into two mutually exclusive and exhaustive subsets. Respondents' preferred plan was the primary outcome in a choice model, estimated using ordinary least squares (OLS) and logistic regression. Priorities were then compared using Spearman's Rho. RESULTS: Eleven strategies were identified: Access to treatments; Centers of excellence; Clinical education; Measuring social burden; Monitoring of at-risk populations; Multidisciplinary management; National guidelines; Public awareness; Research infrastructure; Risk-assessment and referral; and Transplantation infrastructure. Qualitative frequency analysis indicated that Risk-assessment and referral (85%), National guidelines (80%) and Monitoring of at-risk populations (80%) received the highest priority, while conjoint analysis pointed to Monitoring of at-risk populations (p < 0.001), Centers of excellence (p = 0.002), and Access to treatments (p = 0.004) as priorities, while Risk-assessment and referral was the lowest priority (p = 0.645). We find moderate concordance between the qualitative and quantitative methods (rho = 0.20), albeit insignificant (p = 0.554), and a strong concordance between the OLS and logistic regressions (rho = 0.979; p < 0.0001). CONCLUSIONS: Identified strategies can be conceptualized as the ABCs of comprehensive liver cancer control as they focus on Antecedents, Better care and Connections within a national strategy. Some concordance was found between the qualitative and quantitative methods (e.g. Monitoring of at-risk populations), but substantial differences were also identified (e.g. qualitative methods gave highest priority to risk-assessment and referral, but it was the lowest for the quantitative methods), which may be attributed to differences between the methods and study populations, and potential framing effects in choice tasks. Continued research will provide more generalizable estimates of priorities and account for variation across stakeholders and countries.

Identifying important breast cancer control strategies in Asia, Latin America and the Middle East/North Africa.

BACKGROUND: Breast cancer is the most frequent cause of cancer death in women worldwide, but global disparities in breast cancer control persist, due to a lack of a comprehensive breast cancer control strategy in many countries. OBJECTIVES: To identify and compare the need for breast cancer control strategies in Asia, Latin America and the Middle East/North Africa and to develop a common framework to guide the development of national breast cancer control strategies. METHODS: Data were derived from open-ended, semi-structured interviews conducted in 2007 with 221 clinicians, policy makers, and patient advocates; stratified across Asia (n = 97), Latin America (n = 46), the Middle East/North Africa (ME/NA) (n = 39) and Australia and Canada (n = 39). Respondents were identified using purposive and snowballing sampling. Interpretation of the data utilized interpretive phenomenological analysis where transcripts and field notes were coded and analyzed and common themes were identified. Analysis of regional variation was conducted based on the frequency of discussion and the writing of the manuscript followed the RATS guidelines. RESULTS: Analysis revealed four major themes that form the foundation for developing national breast cancer control strategies: 1) building capacity; 2) developing evidence; 3) removing barriers; and 4) promoting advocacy - each specified across five sub-ordinate dimensions. The propensity to discuss most dimensions was similar across regions, but managing advocacy was discussed more frequently (p = 0.004) and organized advocacy was discussed less frequently (p < 0.001) in Australia and Canada. CONCLUSIONS: This unique research identified common themes for the development of breast cancer control strategies, grounded in the experience of local practitioners, policy makers and advocacy leaders across diverse regions. Future research should be aimed at gathering a wider array of experiences, including those of patients.

Controlling liver cancer internationally: A qualitative study of clinicians' perceptions of current public policy needs.

BACKGROUND: Liver cancer is the fifth most common cancer in men and the seventh for women. Usually because of late diagnosis, the prognosis for liver cancer remains poor, resulting in liver cancer being the third most common cause of death from cancer. While some countries have treatment guidelines, little is known or understood about the strategies needed for liver cancer control internationally. OBJECTIVE: To explore leading liver cancer clinician's perceptions of the current public policy needs to control liver cancer internationally. METHODS: Key informant interviews were conducted with a range of liver cancer clinicians involved in policy in eleven countries. Interviews were digitally recorded, transcribed verbatim, translated (where necessary), de-identified and analyzed by two researchers using a constant comparative method. RESULTS: Twenty in-depth semi-structured interviews were conducted in: Australia, China, France, Germany, Italy, Japan, Spain, South Korea, Taiwan, Turkey and the United States. Nine themes were identified and cluster into three groups: 1) Promoting prevention via early risk assessment, focusing on viral hepatitis and other lifestyle factors; 2) Increasing political, public and medical community awareness; and 3) Improving funding for screening, liver cancer surveillance and treatment. CONCLUSION: This study is an important step towards developing an evidence-based approach to assessing preparedness for implementing comprehensive liver cancer control strategies. Evaluation mechanisms to assess countries' performance on the needs described are needed. Future research will concentrate of understanding how these needs vary across countries and the optimal strategies to improve the diagnosis and prognosis of patients with liver cancer internationally.

Needs for hepatocellular carcinoma control policy in the Asia-Pacific region.

BACKGROUND: Hepatocellular carcinoma (HCC) is particularly burdensome in the Asia-Pacific region, however, cross-country comparisons have been limited to somewhat unreliable epidemiological measures. We conducted a comparative needs assessment for HCC control policy to inform HCC control efforts in the Asia-Pacific region. The aims were to identify regional needs, to compare overall competence across the region, and to identify which needs were concordant across the region. METHOD: Using the self-explicated method, a stated-preference approach, clinical experts from Australia, China, Japan, Korea, Taiwan, and the United States valued ten previously identified dimensions of HCC control: clinical education; risk assessment; HBV strategy; HCV strategy; life-style risk factors; national statistics; funding for screening; funding for treatment; political awareness; and public awareness. Results were normalized and analyzed using Z-scores and ANOVA, with concordance of need across the region tested via the F-test. RESULTS: Seventy-two respondents, equally drawn from the study sites, completed the survey (response rate: 36%). Respondents were hepatologists (39%), oncologists (21%), radiologists (17%), surgeons (17%), and other specialists (7%) who were involved in liver cancer control at local/regional (35%) national (44%) or international (21%) levels. In aggregate, the most significant needs were political awareness, public awareness, and life-style risk factors (all p<0.001). Significant differences in aggregate competence were observed across the region (p<0.001), with better than expected competence reported by respondents from Taiwan (p<0.001), Japan (p=0.006), and Korea (0.041), and close to expected competence reported by respondents from Australia, China, and USA (all p>0.05). There were differences in the extent of needs across the region (p<0.05) on all dimensions except funding for screening, clinical education and life style risk factors. CONCLUSIONS: As the first comparative needs assessment for HCC for the Asia-Pacific region, our results can inform national and cross-national priorities for intervention and facilitate the identification of best practices. Regional efforts to control HCC should adopt as objectives the needs for greater political and public awareness and improved management of lifestyle risk factors because these are the most significant needs, and are shared concerns across the region.